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: captopril attending: chief complaint: volume overload recalcitratnt atrial fibrillation chronic respiratory acidosis major surgical or invasive procedure: avr/maze intubation percutaneous jujenostomy tube placement percutaneous tracheostomy tube placement. history of present illness: 76 year old female with pmh of afib, h/o lbbb, cva-17 years ago, as- 0.7 cm mean gradient of 34 and decreased systolic function with ef of 30% in , presents for avr and maze. as has been diagnosed during ccu admission in which patient was transferred from osh after presenting in cardiogenic shock with afib. was cardioverted/ intubated/ hypotensive and transferred here on dopa/dobutaime. cath that adm showed normal coronaries with elevated blt filling pressures. ra 12 rv: 55/12 pa 55/26 mean: 38 pcwp: 31 co/ci: 5.2/3.0 svr: 1123. pt recovered was treated unsuccessfully with amio after dccv failed, was treated for pna, was found to have decreased platlets (- hits), had arf improving by time of dc, stage ii decubitus ulcer. upon admission on , patients cr was 2.1 delaying her surgery. arf was thought to be secondary to volume overload and decreased perfusion. treated with natrecor with improvement in volume status and serum creatinine. ultimately, patient had avr and maze done with placement of 19mm magna tissue valve. note taht echo prior to surgery showed valve area of 0.5 with mean gradient of 56 and markedly improved lv systolic function to 55-60%. 1+ mr and 2+tr. post-op patient reverted to afib, was initially diuresed with natrecor and lasix, restarted bb and ace and placed on amio drip and coumadin for afib. cr rose over teeh next week. swan on showed cvp: 19, pa 51/24 co: 2 svr: 2800 (by thermodilution) then on natrecor and lasix drip. repeat echos ruled out tamponade and showed again mildly decreased ef -45-50% on . patient re-intubated on for respiratory distress secondary to chf. milrinone added with good effect (ci- 3.2) with some improved renal perfusion. increased tsh t'ed with synthroid as recommended by . extubated . failed swallow study . met alk treated wuth diamox. dccv on to sinus. off all ionotropes and pressors as of . on natrecor. pt continues to go in and out of afib. on zosyn for resistent uto from . patient now transferred to ccu for further management of worsening renal function and afib. past medical history: see above social history: lives with family. denies smoking, alcohol or illicits. no tatoos. multiple blood transfusions. family history: +dm +cv negative for premature coronary disease. no other obvious etiology of cardiomyopathy per pt and family. physical exam: gen: nad, a&o x 4 heent: eomi, perrl, mmm neck: +jvd to 10cm. tracheostomy in place c/d/i. chest: sternotomy scar heart: irregular rate and rhythm. normal s1, decreased s2. +harsh systolic murmur at llsb with no radiation that varies with respiration. lungs: decreased, bronchiol breath sounds bibasilarly. decreased tactile fremitus bibasilarly. clear apically. abd: pej in place. soft, nt/nd. nabs. ext: stable 2+ pedal edema in arms and legs. l picc line in place c/d/i. neuro: cn 2-12 intact. motor and sensory grossly intact. able to ambulate with help, grossly ataxic. pertinent results: tte: the left atrium is mildly dilated and elongated. the right atrium is markedly dilated. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast (no maneuvers performed). late bubbles seen in the left atrium/ventricle suggestive of rapid pulmonary transit or av malformations. left ventricular wall thicknesses and cavity size are normal. overall, left ventricular systolic function is normal (ef > 55%). right ventricular chamber size and free wall motion are normal. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. a bioprosthetic aortic valve prosthesis is present. the transaortic gradient is normal for this prosthesis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. severe tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. aortic valve pathology: (aortic) valve leaflets with fibrosis, myxoid degenerative change and calcification. tte: mild spontaneous echo contrast is seen in the body of the left atrium. laa not visualized (excluded/oversewn during prior cardiac surgery). no thrombus/mass is seen in the body of the left atrium. the right atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). no masses or thrombi are seen in the left ventricle. the right ventricular free wall is hypertrophied. the right ventricular cavity is dilated. right ventricular systolic function is normal. there is abnormal (paradoxical) septal motion/position. there are complex (>4mm, non-mobile) atheroma in the descending thoracic aorta. a mechanical aortic valve prosthesis is present. the aortic prosthesis appears well seated, with normal leaflet/disc motion. no aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. a catheter is seen in the ra/rv/pa c/w a swan-ganz catheter. there is no pericardial effusion. tte: limited views obtained on this study. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. brief hospital course: 1. aortic stenosis: valve area 0.7cm squared with mean gradient 49. pt admitted to cardiac for avr. started on natrecor while waiting for avr (supratherapeutic inr) to decrease filling pressures. had maze/avr with 19 mm magnapericardial tissue heart valve with resolution of gradient post op. pt was anticoagulated with heparin during most of her hospitalizaiton for clot prevention, and will be sent out with coumadin with inr goal 2.0-3.0. 2. heart failure: pt with chronic nyha class 4 hf with preserved ef of 55%. thus, her heart failure is likely primarily diastolic failure with superimposed valvular disease also complicated by chronic af. pt remained fluid overloaded and often went into pulmonary edema. mrs. is negative 15 l for her length of stay and her discharge "dry weight" is 62kg. she required natrecor and iv lasix drips on and off during her admission. she also required milrinone for 2 weeks during this admission to maintain her blood pressure. she also had hypertension during this hospitalization and transiently required bp control with ace-inhibitors, beta-blockers, and prn hydralizine (mrs. did become quite hypotensive with ace-inhibitors and these medications should be avoided in her). her swan #'s revealed elevated filling pressures, with pulmonary arterial hypertension. interestingly, her pa pressures remained elevated even with correction of her pcwp, implying possible underlying primary lung disease. her most recent swan #'s: pap 41/22, pcwp 22, co/ci 6.5/3.76 and svr 679 (while on milrinone). mrs. was intubated and extubated 3 times during this hospitalization, mainly for pulmonary edema and hypoxic respiratory failure. she will be discharged with prn lasix to take in case of wieght gain, although this will now be less of an issue as she now is s/p tracheostomy and has access to positive-pressure ventilatory support. she will be d/c'd on coreg for increased lusotropy, rate control of af, and slight reduction in afterload. 3. cad: mrs. had no angiographic evidence of coronary disease as of . 4. rhythm: pt also had maze procedure with use of atricor system. unfortunately, she reverted to atrial fibrillation soon thereafter. she also is s/p numerous cardioversions that have failed to keep her in nsr. her rate during the first 3 weeks of her hospitalization was difficult to control, intermittently on amiodorone, digoxin and beta-blockers. the pt did not tolerate af with rvr secondary to her stiff, non-compliant ventricles, and this contributed to her recalcitrant hf. amiodorone was also used to increase likelihood of staying in sinus rhythm. she currently is off all av nodal blockers and her rate is 60's-70's. it should be noted that mrs. became very bradycardic (i.e. 30's-40's) with digoxin and this medication should be avoided in the patient. she did not need require pacing for this bradycardia. the patient was anticoagulated with heparin during her hospitalization and will be d/c'd on coumadin for stroke prophylaxis in a-fib. surface ecg also shows rbbb. 5. respiratory failure: the patient was intubated 4 times during this hospitalization, mainly for hypoxic resp failure due to pulmonary edema. each time she was weaned off the ventilator as she was diuresed. she also grew proteus from sputum cultures and was treated successfully for bronchitis with ceftriaxone. however, the last time extubated she did remain relatively euvolemic, but then developed hypercapnic respiratory failure, thought to be muscle deconditioning and as a compenasation to diuretic-induced metabolic alkalosis. the pt also had radiologic evidence of rul collapse thought to be due to mucus plugging. she had aggressive pulmonary toilet and chest pt, and she was able to mobilize most of her secretions. the patient would periodically tire and become hypercapnic at night, but could not tolerate bipap (used with the goal of nightime resp muscle rest) for more than one hour at a time due to discomfort/anxiety. pulmonary was consulted and the decision was made to use a tracheostomy for intermittent positive pressure ventilation. 6. renal: the pt developed arf with a peak cr level of 3.0 thought to be secondary to pre-renal azotemia due to decreased renal perfusion in setting of low forward-flow heart failure. her uti was considered complicated since it was associated with indwelling foley, but did not contribute to her arf. her cr improved to 1.6 on discharge, which is near her baseline of 1.2. her discharge gfr is 46 ml/min by the mdrd equation. her discharge meds will be renally dosed. 7. diabetes: pt was maintained on lantus 8-10u qpm with humalog sliding scale. her capillary blood glucose's were relatively well controlled usually 120's-180's. she did not develop hyperosmolar coma nor did she become symptomatically hypoglycemic during this hosptilaztion. consult was obtained to help with her regimen. she will be discharged on this same regimen of lantus 10u qpm with humalog ss. 8. hypothyroidism: pt's home regimen of levothyroxine was 50micrograms/day. her tsh was noted to be elvated to 24 early in the admission, so her thyroid replacement was increased to 75micrograms/day levothyroxine. her tsh was rechecked and revealed a level of 50, so levothyroxine was then increased to 100micrograms/day with the thought that hypothyroidism may be complicating her clinical presentation and perpetuating her hypotension late in the hospital course. medications on admission: dig 0.125 mg po dialy lasix 60 mg po daily coumadin 7.5mg po mo-fr glyburide 5mg po twice daily metformin 500 mg po twice daily protonix 40mg po daily lopressor 50mg po twice daily lisinopril 10mg po dialy discharge medications: 1. timolol maleate 0.25 % drops sig: one (1) drop ophthalmic qd (once a day). disp:*qs * refills:*2* 2. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 3. levothyroxine sodium 100 mcg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 4. warfarin sodium 5 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 5. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. furosemide 80 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 7. insulin glargine 100 unit/ml solution sig: 10 units subcutaneous at bedtime: 10u subcutaneous qpm. disp:*qs * refills:*2* 8. bimatoprost 0.03 % drops sig: two (2) ophthalmic every twelve (12) hours. disp:*qs * refills:*2* 9. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 10. humalog 100 unit/ml cartridge sig: one (1) subcutaneous once a day: quantity sufficient for sliding scale (see attached sliding scale). disp:*5 * refills:*2* 11. promote with fiber liquid sig: one (1) po once a day: tubefeeding: promote w/ fiber full strength; starting rate: 10 ml/hr; advance rate by 10 ml q4h goal rate: 50 ml/hr residual check: q4h hold feeding for residual >= : 100 ml flush w/ 150 ml water q8h disp:*qs * refills:*2* discharge disposition: extended care facility: - discharge diagnosis: heart failure from diastolic dysfunction chronic atrial fibrillation diabetes discharge condition: good discharge instructions: call your doctor or go to the er if you have these symptoms: 1. weight gain 2. leg swelling 3. fevers 4. shaking chills 5. dizziness or fainting 6. palpitations you must be weighed daily. your discharge weight is 62. weigh yourself immediately when you arrive at rehabilitation. if your weight increases by more than 2#, take an extra dose of lasix 80mg and if your weight does not return to normal, or continues to increase, call your doctor. followup instructions: please call dr office and schedule follow up in 14-21days md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more extracorporeal circulation auxiliary to open heart surgery diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances excision or destruction of other lesion or tissue of heart, open approach atrial cardioversion temporary tracheostomy open and other replacement of aortic valve with tissue graft percutaneous [endoscopic] gastrojejunostomy transfusion of packed cells injection or infusion of nesiritide diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation aortic valve disorders cardiogenic shock pressure ulcer, buttock diastolic heart failure, unspecified 

Answer: The patient is high likely exposed to