Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: penicillins attending: chief complaint: shortness of breath major surgical or invasive procedure: peritoneal dialysis history of present illness: mr. is a 58 year old male with history of hepatitis c with portal gastropathy, rcc s/p nephrectomy, esrd on pd, cad s/p nstemi with rca bms stent () now off plavix, chronic lgib presents with 1 day of non-productive cough and worsening shortness of breath at rest. at baseline he is able to ambulate approximately yards before getting fatigued, however over the past day he has been increasingly short of breath with minimal exertion and yesterday morning was short of breath at rest. he also reports one to two minutes of substernal chest pressure this afternoon which resolved spontaneously - notes that this was very different from cp in . no radiation or associated diaphoresis or nausea. in he describes more intense chest pressure with left arm numbness and vomiting. of note, he recently travelled to foxwoods and noted that he did not take his medications for 2 days (sunday/monday) and had many dietary indiscretions including all-you-can-eat buffets. he did do his pd manually which is how he normally does pd when he travels (at home uses a machine). . in the ed, the patient's vitals were t 100.0, bp 133/72, hr 94, rr 28, o2sat 87% on ra, 97% on 6l. labs notable for elevated white count at 12.5 and 90% neutrophils, troponin t 1.36, ck 173, ckmb 20, mb index 11.6. blood cultures were sent. he was given levofloxacin for possible pna and lasix 80mg iv. cxr read as likely pulmonary edema, consider atypical infection. ecg unchanged, first degree av block. he was given aspirin, beta blocker. cards consult in ed felt that elevated troponins were related to demand ischemia with chf exacerbation in setting of dietary indiscretion and medication non-compliance. . review of systems on admission is positive for orthopnea, dyspnea on exertion, pnd, le edema and occasional chest pain. he also notes dysuria but is unsure if discomfort with urination began prior to or following placemtn of the urinary catheter. negative for fevers, chills. past medical history: - renal cell carcinoma s/p r nephrectomy - esrd after failing of l kidney, now on peritoneal dialysis, undergoing renal transplant eval - htn - chronic hep c: found during kidney transplant eval, currently being followed by dr. in liver clinic and was being evaluated for cirrhoisis with liver bx on - cad s/p mi in , bare metal stent to rca - hemorrhoids: s/p surgical correction , with subsequent decrease in brbpr but still gets on occasion. on surveillence cscope , noted to have grade 2 internal hemorrhoids - pvd: chronic symptoms of claudication but yet to undergo workup - capsule endoscopy showed fresh blood in the duodenum - gastric antral vascular ectasia by egd, s/p apc coag on social history: he is married. he has 3 kids. he works as a painter. he has history of chronic smoking at 1.5 packs for 30 years. he quit 5 years ago. he has history of intravenous drug abuse when he was in his 20s. his alcohol history before his surgery was two 6 packs per week for about 5-6 years. family history: his father is deceased with cirrhosis. his mother has diabetes. he has 1 sister who is healthy. physical exam: vs t 97.6, hr 87, bp137/85, rr28, o2sat 90% 4l nc gen: sitting up in bed, dyspneic with conversation. heent: dry mm neck: elevated jvp to 8cm cv: regular rhythm, nl s1 s2, no m/r/g appreciated chest: crackles r>l base, diffuse wheezing. abd: soft, obese, nt, nd, +bs ext: 1+ edema at the ankles, warm bilaterally. rectal: trace guaiac positive (in ed) skin: multiple excoriations over lower extremities, abdomen. pertinent results: 08:20pm lactate-1.2 08:15pm glucose-123* urea n-101* creat-15.5*# sodium-140 potassium-4.7 chloride-99 total co2-20* 08:15pm alt(sgpt)-24 ast(sgot)-44* ld(ldh)-527* ck(cpk)-173 alk phos-50 tot bili-0.4 08:15pm ck-mb-20* mb indx-11.6* ctropnt-1.36* 08:15pm calcium-8.3* phosphate-7.5*# magnesium-1.6 08:15pm wbc-12.5* rbc-3.03* hgb-9.8* hct-28.7* mcv-95 mch-32.4* mchc-34.3 rdw-17.5* 08:15pm neuts-90.2* bands-0 lymphs-6.1* monos-2.4 eos-1.1 basos-0.2 08:15pm hypochrom-normal anisocyt-1+ poikilocy-occasional macrocyt-1+ microcyt-normal polychrom-normal ovalocyt-occasional 08:15pm plt smr-low plt count-141* 08:15pm pt-13.5* ptt-26.6 inr(pt)-1.2* . . 05:09am - cpk isoenzymes ctropnt-4.54 complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:39am 9.0 2.85* 9.1* 25.8* 91 31.9 35.2* 16.2* 146* 07:56am pt-12.4 ptt-30.7 inr-1.1 . miscellaneous hematology esr 06:39am 71* . 05:54am inhibitors & anticoagulants aca igg-6.41 aca igm-10.81 . 06:39am renal & glucose glucose-85 urean-120 creat-14.9 na-133 k-4.2 cl-91 hco3-22 . . studies: echo: conclusions: the left atrium is elongated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef 60%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the ascending aorta is moderately dilated. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (area 1.2-1.9cm2). moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is no mitral valve prolapse. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the findings are similar. . echo: conclusions: the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with focal mid to distal septal hypokinesis (branch disease?). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly to moderately thickened. there is a moderate-sized, mobile echodensity on the aortic valve (0.7 cm mobile echodensity on the lv side of the non-coronary cusp) suggestive of a vegetation. there is no significant valvular aortic stenosis (at most trivial). the increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is moderate to severe mitral annular calcification (involving the chordal structures). there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the prior study (images reviewed) of , no change (aortic valve vegetation was present but not reported. mild regional lv hypokinesis was present but not reported). reviewing the tte from , the regional dysfunction and aortic vegetation are now new. impression: mild regional lv hypokinesis (overall preserved lvef of 55%) c/w cad. moderate-sized aortic valve vegetation of unclear significance. moderate ai. if clinically indicated, a tee may better assess the valvular vegetation. tee: conclusions: no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular systolic function is normal. there are simple atheroma in the aortic arch. there are complex (>4mm) atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. there is a moderate-sized (0.8 mm x 0.5 mm) vegetation on the noncoronary cusp of the aortic valve. no aortic valve abscess is seen. moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are severely thickened/deformed with focal areas of increased thickening. a possible vegetation is noted on the posterior mitral valve leaflet. no mitral valve abscess is seen. there is severe mitral annular calcification without overt mitral stenosis. mild (1+) mitral regurgitation is seen. there is no abscess of the tricuspid valve. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: vegetation on the noncoronary cusp of the aortic valve with moderate aortic regurgitation. possible vegetation on the posterior leaflet of the mitral valve with mild mitral regurgitation. complex atheroma is in the descending aorta. no definite perivalvular abcess. brief hospital course: mr. is a 58 year old male with multiple medical problems including esrd on pd who presents with one day of cough, shortness of breath due concerning for acute coronary syndrome, transferred to the micu and found to have aortic valve vegetation on tte as an incidental finding. . micu course: he was admitted to the micu for further care of his shortness of breath and positive cardiac enzymes. the troponin levels remained elevated due to poor renal clearance, whereas ck-mb trended down and was no longer tracked on transfer from micu. cardiology followed the patient closely and decided not to puruse cath options since the patient is not an anticoagulation candidate due to history of gi bleeds. cardiology felt that ischemia was due to demand in the setting of decompensated chf. he had transient episodes of rvr secondary afib, with beta blockade held once during a transient episode of hypotension on (micu day 6). otherwise, the patient was hemodynamically stable for most of his micu course. . the patient was also transiently short of breath, with o2 saturations in the low 90s while on 4lnc. his respiratory status improved with nebulizers and fluid-balance control with his peritoneal dialysis. on transfer from the micu, he saturated well on room air. of note, a tte () was revealing of an aortic valve vegetation that was not present as seen in an echo from . a subsequent tee confirmed the aortic vegetation, and revealed a possible mitral valvle abnormality. of note, no abscesses were found. all blood cultures have been negative to date. a presumptive diagnosis of culture-negative endocarditis was made on . broad antibiotic coverage was started with iv vancomycin and levofloxacin. a picc line was placed on to allow proper iv access for treatment. on transfer to the medicine service, he did not complain of new chest pains or shortness of breath. he continued to get peritoneal dialysis throughout his micu stay. his micu los was 7 days. *** . # cardiac: **ischemia: on this admission, cardiac enzymes were positive in the ed and likely due to demand ischemia. an ekg showed 1st degree av block, nondiagnostic q waves in inferior and lateral leads, and 0. depressions in v4-v6. troponin continued to remain elevated likely due to poor clearance and less likely related to ongoing ischemia. the ck-mb was flat. anticoagulation was held due to his history of gi bleeding. he was maintained on beta-blockers, and aspirin. upon transfer from the micu to the medicine floor, he was hemodynamically stable. on two occasions he complained of chest discomfort that was responsive to a gi cocktail. on discharge, he no longer had angina or dyspnea. **pump: he had an ejection fraction of 55% on tte. he was kept on bete blockers and kept euvolemic for his stay. he had mild bilateral edema to his ankles that diminished by the day of discharge. **rhythm: in the micu, he had transient episodes of atrial fibrillation with rapid ventricular response. on transfer to the medicine floor, he remained in normal sinus rhythm while being monitored on telemetry. he did have a borderline prolonged qt interval of 450 that was closely monitored on serial ekgs in the setting of levofloxacin which is known to prolong qt intervals. . # aortic valve vegetation: he was treated for culture-negative endocarditis. on admission, the patient had a low grade temperature, and elevated white blood cell count with neutrophil predominance. there were no clear sources of infection, and urine, blood cultures, and chest x-ray were all negative. however, the presentation was concerning for endocarditis based on vegetation on his aortic valve (with a possible vegetation on the mitral valve as well) on tee imaging. he also had an elevated esr, and crp. gentamicin was not started due to poor renal function and concerns for eigth cranial nerve damage. he was continued on levofloxacin (po) and iv vancomycin. morning trough levels were used to find an optimal dosing regimen (500 mg every 72 hours). he should continue to complete a 6 week course of levofloxacin and vancomycin. a picc was inserted to allow a visiting nurse vancomycin as needed. by the day of discharge, all cultures and seroligies were negative or pending. . # hypoxia: on admission he was oxygenating well on 5l nc, however he became tachypneic in the micu, and he was tried on cpap with some improvement. his chest x-ray on admission showed volume overload with no signs of infiltrate. peritoneal dialysis was initiated at higher concentration to remove fluid. on transfer to the medicine floor, he oxygenated well on room air and was given atrovent and albuterol nebulizers as needed. . # esrd on pd/rcc s/p nephrectomy: he was followed by the renal team throughout his hospitalization. he was given a dose of lasix 40mg iv x 2 in ed, and responded with only minimal urinary output. he was continued with pd - 1.5%, 1.5% and 2.5% every 6 hours. his phosphate levels continued to be elevated and he was started on phoslo with good effect. medications were renally dosed. he was given an outpatient appointment to be followed by a nephrologist here as well as nutritionist from the transplant center. erythropoetin was restarted prior to discharge but no change in hematcrit was observed. . # chronic lgib: he has a history of grade 2 internal hemorrhoids, and a capsule endoscopy from showed fresh blood in the duodenum. an egd showed gastric antral vascular ectasia s/p apc coag on . during this hospitalization, his hematocrit was stable at 26-28. anticoagulants were held. . code: dnr/dni medications on admission: aspirin 325mg daily lanthanum 500 mg tablet po tid w/meals ferrous sulfate 325 mg tablet b-complex with vitamin po daily nitroglycerin 0.3 mg tablet, sublingual prn chest pain cinacalcet 60 mg po daily simvastatin 40 mg tablet daily docusate sodium 100 mg capsule po bid metoprolol tartrate 25 mg tablet po bid pantoprazole 40 mg tablet, delayed release po q12h quinine sulfate 260 mg tablet po at bedtime epoetin alfa 10,000 unit/ml solution mwf discharge medications: 1. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 2. cinacalcet 30 mg tablet sig: two (2) tablet po daily (daily). 3. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po bid (2 times a day). 6. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed). 7. lanthanum 500 mg tablet, chewable sig: four (4) tablet, chewable po tid w/meals (3 times a day with meals). 8. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). 10. maalox 1,000 mg tablet, chewable sig: one (1) ml po tid (3 times a day) as needed. 11. epoetin alfa 10,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 13. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). disp:*2700 ml(s)* refills:*0* 14. b complex tablet sig: one (1) tablet po once a day. 15. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). disp:*100 capsule(s)* refills:*0* 16. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 32 days. disp:*16 tablet(s)* refills:*0* 17. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) inhalation twice a day as needed. disp:*2 inhaler* refills:*0* 18. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 19. vancomycin 500 mg recon soln sig: one (1) intravenous every seventy-two (72) hours for 35 days: please follow up with the outpatient infectious disease clinic to have your vancomycin level checked. . disp:*12 * refills:*0* 20. outpatient lab work cbc, na, k, cl, bun, cr, ast, alt, alkaline phosphatase, bilirubin, vancomycin trough on . please fax results to dr. at 21. outpatient lab work cbc, na, k, cl, bun, cr, ast, alt, alkaline phosphatase, bilirubin, vancomycin trough on . please fax results to dr. at 22. picc line care please perform picc line care per ccs protocol discharge disposition: home with service facility: homecare discharge diagnosis: primary: endocarditis primary: end-stage renal disease primary: myocardial ischemia secondary: atrial fibrillation secondary: shortness of breath discharge condition: afebrile, hemodynamically stable, normal vital signs, chest-pain free, on peritoneal dialysis discharge instructions: you have been admitted for shortness of breath and chest discomfort. on this admission, an incidental finding of endocarditis (bacterial infection of your heart valves) was found. you are being discharged with antibiotics that you should continue to take as instructed for approximately the next 5 weeks. . you should take all medications as instructed. . you will need a weekly cbc, electrolytes, bun, creatinine, lfts, and vancomycin trough drawn by your pcp. make sure to have these labs drawn. . you should continue with the peritoneal dialysis schedule that you have been given. . if you begin to experience symptoms of worsening chest pains, shortness of breath, loss of consiousness, high fevers, blood in your stools, sudden increased weight gains, worsening swelling in your feet, pain or swelling around your peritoneal dialysis line, high fevers, or any other concerning signs, please contact a physician . . please follow up with all appointments that have been made for you. followup instructions: please follow up with your pcp to have weekly cbc, electrolytes, bun, creatinine, liver function tests, and vancomycin trough drawn. we have given you a prescription for this labwork to be done on and . these results can be faxed to her office at . . several follow-up appointments have been made for you: provider: . md, , 3pm provider: md, am, . phone: provider: , md phone: date/time: 9:30 provider: , md phone: date/time: 10:00 *** please call transplant center to make an appointment with nutritionist . ph# procedure: venous catheterization, not elsewhere classified peritoneal dialysis transfusion of packed cells diagnoses: end stage renal disease subendocardial infarction, initial episode of care anemia, unspecified coronary atherosclerosis of native coronary artery congestive heart failure, unspecified unspecified viral hepatitis c without hepatic coma atrial fibrillation peripheral vascular disease, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease old myocardial infarction acute and subacute bacterial endocarditis hypoxemia personal history of malignant neoplasm of kidney diastolic heart failure, unspecified other specified hypotension 

Answer: The patient is high likely exposed to