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: history of present illness: the patient is a 77 year old man with a history of atrial fibrillation and aortic valve replacement, who presented to his primary care physician's office on the day of admission with one to two weeks of progressive dyspnea. it has evolved to the point where the patient is only able to walk two to three steps before he must sit down. over the last week, the patient has also been taking sublingual nitroglycerin with these episodes three to four times per day. this has not given him any relief. the patient denies chest pain, nausea, vomiting or diaphoresis with these events. he sleeps on three pillows. he describes difficulty sleeping over the last several weeks, but denies paroxysmal nocturnal dyspnea. he does not note increased swelling of his lower extremities. he describes an occasional productive cough with yellow sputum but denies fevers. he has had a decrease in his appetite recently. the patient has a history of gastrointestinal bleed. he notes a small amount of blood on the toilet paper over the past weeks. he denies bright red blood per rectum as well as hematemesis. past medical history: 1. status post aortic valve replacement secondary to rheumatic heart disease in . 2. atrial fibrillation. 3. type 2 diabetes mellitus. 4. status post gunshot wound to left leg. 5. history of left lower extremity cellulitis. 6. history of gastrointestinal bleeding attributed to gastritis, requiring over 20 units of blood transfusions earlier this year. 7. chronic renal failure. 8. history of colonic adenoma. 9. history of diverticulosis. medications on admission: protonix 40 mg p.o.q.d., coumadin 10 mg p.o.q.d., glucotrol xl 5 mg p.o.b.i.d., digoxin 0.125 mg p.o.q.d., lasix 40 mg p.o.q.d., prozac 20 mg p.o.q.d., zestril 20 mg p.o.q.d., zocor 20 mg p.o.q.d., iron 325 mg p.o.b.i.d. allergies: the patient has no known drug allergies. social history: the patient lives with his wife of 50 years. he has a remote history of tobacco and alcohol use. physical examination: on physical examination on admission, the patient had a temperature of 98.9, blood pressure 126/59, heart rate 81, respiratory rate 25 and oxygen saturation 96% on two liters. general: patient in no acute distress, alert and oriented times three, speaking in complete sentences. head, eyes, ears, nose and throat: pupils equal, round, and reactive to light and accommodation, positive left cataract, extraocular movements intact, anicteric sclerae, oropharynx clear. neck: no lymphadenopathy, jugular venous pressure at 9 cm, supple. lungs: bilateral crackles two-thirds of the way on the left, one-half of the way on the right, moving air in all segments. cardiovascular: mechanical click, irregularly irregular rhythm, ii/vi systolic ejection murmur at right upper sternal border. abdomen: soft, nontender, nondistended, positive bowel sounds. rectal: normal tone, no masses, heme positive brown stool, no hemorrhoids, no fissures. genitourinary: scrotal edema, reportedly unchanged per patient. extremities: no cyanosis, clubbing or edema in upper extremities, hyperemia of venous stasis in lower extremities with some edema of right lower extremity, 2+ pitting edema mid-calf and below in left lower extremity, no ulcers. neurologic examination: alert and oriented times three, cranial nerves ii through xii intact, motor and sensation grossly intact. laboratory data: admission white blood cell count was 7.9, hematocrit 28.6, platelet count 208,000, inr 1.8, partial thromboplastin time 32.4, sodium 139, potassium 5.1, chloride 106, bicarbonate 22, bun 66, creatinine 2.2, glucose 110, alt 12, ast 25, alkaline phosphatase 214, amylase 100, lipase 71, total bilirubin 0.5, ck/mb 3 and troponin-i less than 0.3. chest x-ray: no evidence of congestive heart failure, no infiltrate. electrocardiogram: atrial fibrillation, unchanged from prior tracing except for inverted t waves in v4 and v5. right lower extremity doppler: preliminary read negative. hospital course: 1. gastrointestinal: of note, the patient has a history of presenting with shortness of breath when he has had anemia secondary to gastrointestinal bleeding. his stool was guaiac positive on admission. the patient was transfused one unit of blood, with an appropriate increase in his hematocrit to 32.1 and his heparin was continued for aortic valve replacement related anticoagulation. the patient was transfused another unit of blood on for a hematocrit of 28.9, again with an appropriate increase to 32.8. at this time, he continued to have guaiac negative stools and no melena. when the patient had another drop in his hematocrit to 29.1 on , the gastroenterology service was contact regarding possible endoscopy. at this time, they declined endoscopy because the patient has had multiple upper endoscopies and an colonoscopy earlier this year, which revealed gastritis. on , the patient's protonix was increased to 40 mg every 12 hours. on the afternoon of , the patient noted melena. on , his hematocrit decreased to 27.5. on , the gastroenterology service was consulted for occult gastrointestinal bleed evaluation. the gastroenterology service opted to do an endoscopy to evaluate the status of his gastritis and possible arteriovenous malformation. on , the patient's hematocrit decreased to a level of 24.7. the patient was transferred to the medical intensive care unit for more intensive monitoring in the setting of his gastrointestinal bleed. the patient received an upper endoscopy on , which revealed a single nonbleeding arteriovenous malformation in the pylorus of the stomach, which was electrocauterized, as well as a single small arteriovenous malformation with stigmata of recent bleeding in the jejunum, which was also electrocauterized. the patient continued to have a low hematocrit, with blood transfusion requirements and a tagged red blood cell scan was performed, which was negative for evidence of active bleeding. the patient also underwent a colonoscopy on , which revealed two nonbleeding polyps in the ascending and descending colon as well as multiple nonbleeding, not diverticula, in all portions of the colon. after this, the patient maintained his hematocrit in response to the red blood cell transfusions and he was called out of the medical intensive care unit on . from this time until the time of dictation (), the patient had a stable hematocrit in the range of 32 to 34. he has had guaiac negative stools and no evidence of gastrointestinal bleeding. he has continued on a twice a day proton pump inhibitor. 2. cardiovascular: both heart failure and cardiac ischemia were felt to be in the differential diagnosis for the patient's shortness of breath on presentation. on , the patient underwent a pharmacological stress test, which was negative for evidence of ischemia. he received an echocardiogram on , which revealed a left ventricular ejection fraction of about 40%, depressed right ventricular function with evidence of right greater than left heart failure. the patient was continued on his captopril, isordil, zocor, digoxin and lasix. while in the medical intensive care unit, the patient became hypotensive, requiring fluid boluses and, briefly, a dobutamine drip. in response to the fluids he received, the patient developed evidence of heart failure on physical examination and on chest x-ray. he was successfully diuresed and, at the time of dictation, had much improved oxygen saturation and ease of breathing. after the patient's stay in the micu, the patient was noted to have a substantial amount of ventricular ectopy. he had one 18 beat run of nonsustained ventricular tachycardia. the electrophysiology service was consulted and they recommended that he be continued on rate control for atrial fibrillation (metoprolol) without a recommendation for an icd or amiodarone. the patient was anticoagulated for his prosthetic aortic valve except when he had evidence of active gastrointestinal bleeding. after his endoscopy and electrocauterization procedure, the patient was placed on heparin again and eventually on coumadin until his inr became therapeutic at a left between 2.5 and 3.5. 3. pulmonary: at the time of the patient's admission to the intensive care unit, the patient was in respiratory distress and was intubated without complications. on , the patient was placed on pressure support ventilation. he continued to improve with diuresis. he was extubated on and has not had significant respiratory difficulties on minimal oxygen from nasal cannula since then. 4. infectious disease: while in the intensive care unit, the patient had a chest x-ray which was suggestive of possible ventilator associated pneumonia. he was also noted to have substantial erythema of the left lower extremity, possibly consistent with cellulitis. the patient was placed on unasyn to complete a 14 day course. on , the patient was noted to have a large quantity of loose stool. his stool test for clostridium difficile toxin was positive and the patient was started on a 14 day course of flagyl. the patient did not grow any organisms from his blood or urine cultures throughout admission. 5. renal: the patient has chronic renal failure with a baseline creatinine in the vicinity of 2. his creatinine increased to a level of around 3 at the time of his admission to the micu. at the time of discharge, the patient had improvement back to his baseline level. 6. musculoskeletal: on the evening of , the patient was noted to have severe pain in the left popliteal region. a lower extremity doppler ultrasound was performed, which was negative for deep vein thrombosis but positive for a ruptured cyst. the patient was treated with analgesic medications for the pain from this cyst. an orthopedic consult did not recommend any intervention and did not feel that the patient had any evidence of compartment syndrome. 7. neurologic: the patient was noted to have delirium after his stay in the medical intensive care unit. sedating medications were avoided and the patient's mental status gradually improved to the point where he is currently oriented to his location, the month and year, and his reason for admission to the hospital. the above is a dictation of the hospital course through . please refer to a discharge addendum for discharge medications and additional discharge information. , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube arterial catheterization colonoscopy endoscopic control of gastric or duodenal bleeding aspiration of bursa diagnoses: pneumonia, organism unspecified congestive heart failure, unspecified other pulmonary insufficiency, not elsewhere classified atrial fibrillation intestinal infection due to clostridium difficile hyperosmolality and/or hypernatremia drug-induced delirium angiodysplasia of stomach and duodenum with hemorrhage 

Answer: The patient is high likely exposed to