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: ambien / beta-blockers (beta-adrenergic blocking agts) attending: chief complaint: weakness, left ankle pain, swollen legs major surgical or invasive procedure: none history of present illness: 69 yo m with hx of systolic , 15-20%, s/p cabg x2, s/p mvr and tricuspid valve annuloplasty ring, paf, and itp who presents with increased weakness and difficulty ambulating due to left ankle pain. the patient states that he started to feel weak about four days ago. he rose from his bed and noticed that he felt very weak. of note, he had difficulty walking on his left ankle and it was very limited by pain. he did note increased swelling in his legs and abdomen, however, his scale did not show any weight gain. he claims that he's taking coumadin 5 mg only. he denies orthopnea, pnd, dyspnea, fevers, chills, cough, n/v, black tarry stools, bright red blood per rectum, headache, blurry vision. . he was recently admitted for a heart failure exacerbation. his inr at that time was elevated. he was diuresed aggressively and sent home. he presented once again to the hospital because he had an elevated inr>20 and in the er, he was also found to be in acute on chronic renal failure. his lasix and aldactone were held at the end of admission and he was given vitamin k to reverse his inr. he was sent home with a normal inr and had an inr check and f/u with cardiology. cardiology started him on lasix and aldactone and kept the rest of his medications the same. . since the patient could not walk, he came to the hospital. in the er, his vital signs were t: 99.5, bp: 116/77, hr: 96, rr: 18, o2 sat: 100% ra. the patient had a cxr which showed mild pulmonary vascular congestion with small bilateral pleural effusions and a retrocardiac opacity likely represents atelectasis, although underlying infection cannot be excluded. his inr was also found to be elevated >20. he had xrays of his left ankle and tibia which showed "no acute fracture." ekg showed atrial fibrillation at 98 bpm with lvh, intraventricular conduction delay and overall no changes from prior. the patient received lasix 20 mg iv and vitamin k 10 mg po and was transferred to the floors. . . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: -hypertension -coronary artery disease, cabg lima to lad, svg to rpda and svg sequential graft to om1 and om2; cabg svg to rpda -chronic systolic chf ef 15-20% -severe tricuspid regurgitation s/p tricuspid valve annuloplasty ring -severe mitral regurgitation s/p porcine mvr -paroxysmal atrial fibrillation on coumadin, s/p cardioversion , h/o bradycardia with beta blocker -pad s/p bilateral carotid endarterectomy -itp -pancreatic cysts (likely ipmn) -h/o cholestatic jaundice in (thought secondary to drug reaction, since resolved, had 2 liver biopsies) social history: divorced. lives alone. 2 children. tries to follow 2g na diet with 50 ounce fluid restriction. lives alone. he is retired. former etoh abuse and denies current etoh use and denies illicit drug use. family history: mother with hyperlipidemia and died of coronary artery disease in her 60s. there is no family history of premature coronary artery disease or sudden death. physical exam: admission physical exam: vitals: t: 97.7, bp: 114/75, hr: 83, rr: 20, o2 sat: 96% ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp elevated to ear, no lad lungs: clear to ausculatation bilaterally. no w/r/c. cv: irregular rhythm. normal rate. normal s1 + s2, loud systolic murmur at llsb. abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, 2+ peripheral edema to the knee bilterally. brusing on left ankle with tenderness to palpation. cool left foot, difficult to assess pulses due to edema in left foot. sensation intact. pertinent results: admission laboratories: 04:39pm blood wbc-7.3 rbc-4.47* hgb-12.2* hct-36.1* mcv-81* mch-27.3 mchc-33.7 rdw-17.8* plt ct-171 04:39pm blood neuts-86.5* lymphs-6.6* monos-5.6 eos-0.8 baso-0.5 04:39pm blood pt->150* ptt-55.3* inr(pt)->20.2* 12:05am blood fibrino-428*# 04:39pm blood glucose-97 urean-63* creat-2.2* na-126* k-5.3* cl-87* hco3-23 angap-21* 05:45am blood alt-84* ast-138* alkphos-107 totbili-3.1* dirbili-1.7* indbili-1.4 03:12pm blood calcium-8.8 phos-3.9 mg-2.6 --------------- cxr: impression: 1. mild pulmonary vascular congestion with small bilateral pleural effusions. 2. retrocardiac opacity likely represents atelectasis, although underlying infection cannot be excluded. ankle/tibia xray: impression: no acute fracture. brief hospital course: # acute exacerbation of systolic heart failure: the patient presents with fluid overload, especially in the lower extremities. he has been compliant with his lasix and aldactone. he noticed his legs swelling, but he said his weight hasn't increased. he has been keeping to his fluid restriction. the patient was started on his home lisinopril. the patient was started on lasix boluses, however his hypotension limited his diuresis. since he was hypotensive to sbp: 80s-90s, his lisinopril was decreased to 2.5 mg. he was started on a lasix drip for more gentle diuresis, which proved ineffective with even i&os. he was admitted to the ccu with the intention of ionotrope assisted diuresis in the setting of persistent hypotension. vigorous diuresis was achieved with aggressive lasix drip without the need for ionotropes with the patient found to be asymptomatic from stable blood pressures in the 90s systolic. his lisinopril was held as this worsened his hypotension. the patient was transferred out of the ccu to the cardiac floor. his lasix drip was continued with further diuresis. the patient's weight plateaued, so metalozone was started which assisted with his diuresis. low dose captopril (3.125 mg tid) was added. any attempt to uptitrate the captopril caused hypotension. the was switched to lasix iv pushes and then to torsemide in which the patinet continued to gain weight. since there was difficulty in diuresing the patient, the patient was transferred to the ccu for ionotropic assisted diuresis. in the ccu, his lasix gtt was increased, and his urine output subsequently increased. he was subsequently transfered back to the cardiology floor were lasix gtt was continued with good response. once his weight reached his dry weight of <140 lbs, lasix gtt and metolazone were stopped, he was started on torsemide 40 mg and continued on spironolactone 25 mg . his weight on discharge was 138 lbs. . # acute on chronic renal failure: the patient presented with a creatinine of 2.2, higher than his baseline of 1.2. was on aldactone 25 and lasix 40 mg po at home. this was thought to represent pre-renal azotemia given his low ejection fraction and chf exacerbation. with aggressive diuresis (as above), his creatinine improved to baseline. on the floor, the patient was continued on the lasix drip and again developed acute renal failure with his cr increasing to 1.5-1.6 and stabilizing in that range. . # coagulopathy: the patient presented with an inr above 20.2. his elevated inr was likely due to hepatic congestion secondary to chf. the patient was given vitamin k 10 mg iv in the er and his inr corrected to 1.8. he continued his warfarin for a goal of thereafter. . # bioprosthetic mitral valve: the patient presented with an elevated inr to 20.2. he was given vitamin k 10 mg in the emergency room and his inr corrected to 1.8. at that point, he was started on a heparin drip along with warfarin. since a heparin gtt was not indicated, it was stopped and he continued coumadin for a goal inr of . . # hypervolemic hyponatremia: hyponatremia in the setting of chf, likely high adh state given low cardiac output. the patient was fluid restricted and diuresis was achieved (as above). his na continued to be low ranging from 126-130 but the patient remained asymptomatic. . # left lower extremity pain: the patient presented with lle pain in the setting of an elevated inr. xrays of the ankle and tibia were negative. ortho evaluated the patient and felt his pain was likely related to cellulitis (though no leukocytosis or fever) and possibly a hematoma. he had no signs of compartment syndrome. he was started on cefazolin on for treatment of cellulitis. his leg pain did not improve while on cefazolin, so it was discontinued on . with time, his lower extremity pain resolved, so it was likely related to a hemarthrosis vs. lower extremity edema. . # runs of vtach: the patient has a long history of runs of vtach and pvcs. patient has been refusing pacer since has pancreatic mass which needs to be followed by . he continued to have runs of vtach but all non-sustained. . # clot in nose: patient with bilateral nose clots in the setting of anticoagulation and thrombocytopenia. the patient had a nosebleed earlier during his admission and was prescribed affrin. he continued to use the affrin over three days and the primary team was unaware. once the primary team realized that the patient had been using affrin longer than the prescribed amount, it was discontinued. the patient was found to have bilateral ulcerated septums. ent recommended refraining from affrin use and the nasal mucosa should heal. in addition, ent recommended gentle irrigation with saline and saline mist hydration, and this was done. after this episode he had no more issues with epistaxis. . # microcytic anemia: patient with falling hct from admission. the patient was guiaic negative x 3. he most likely had an anemia due to bone marrow suppression and continued phlebotomy. there were no signs of bleeding. his hct remained stable ranging from 25-28. . # thrombocytopoenia: the patient has a history of itp was noted to have thrombocytopenia on admission. the patient had heparin during this admission and a prior admission to the hospital. both heparin induced thrombocytopenia and itp were ruled out. his thrombocytopenia likely related to bone marrow supporession. it remained stable ranging from 130-160's. . # cholestatic transaminitis: this was thought to be due to hepatic congestion, as a result of chf exacerbation. it resolved after diruesis. had no ruq tenderness or epigastric discomfort. medications on admission: 1. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet sublingual prn as needed for chest pain: take one tablet for chest pain. can repeat up to 2 times. at that point, call your doctor. :*30 tablets* refills:*0* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). 4. calcium oral 5. cholecalciferol (vitamin d3) 400 unit tablet oral 6. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 7. lasix 40 mg po 8. aldactone 25 mg po discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 4. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 5. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm. 6. spironolactone 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 10. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily) as needed for constipation. 11. captopril 12.5 mg tablet sig: 0.25 tablet po tid (3 times a day). 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 13. torsemide 20 mg tablet sig: two (2) tablet po daily (daily). discharge disposition: extended care facility: extended care facility discharge diagnosis: primary: -acute on chronic systolic heart failure -atrial fibrillation -acute on chronic renal failure secondary: -ventricular arrhythmias -thrombocytopenia -anemia discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure taking care of you at . you came into the hospital because your left leg hurt. you were found to have a worsening of your heart failure (increased water), acute kidney failure and a high inr (coumadin level). . while on lasix, you had low blood pressures, so you needed closer monitoring. you were transferred to the cardiac intensive care unit so that we could keep a closer eye. you did well while in the intensive care unit and were subsequently transfered to the cardiology floor where you continued with your diuresis. once you reached your goal weight of less than 140 pounds the lasix drip was stopped and you were transitioned to oral diuretics. you continued to do well and you weight was 138 on discharge. your inr reached the goal of once we increased your coumadin to 4 mg daily. your kidney function improved with treatement of your chf but this never returned to your previous baseline. please have your pcp follow up your renal function once you are discharged from the rehabilitation facility. . since you have a history of congestive heart failure, you should weigh yourself every morning. call your doctor if weight goes up more than 3 lbs. you should only drink 1.5 liters of fluid per day and stick to a 2 gram ( mg) salt/sodium diet. followup instructions: appointment #1 md: dr specialty: cardiology date/ time: at 3pm location: , , phone number: provider: , md phone: date/time: 2:35 provider: , md phone: date/time: 2:00 procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnoses: thrombocytopenia, unspecified congestive heart failure, unspecified acute kidney failure, unspecified hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status chronic kidney disease, unspecified paroxysmal ventricular tachycardia cellulitis and abscess of leg, except foot long-term (current) use of anticoagulants iron deficiency anemia, unspecified heart valve replaced by transplant acute on chronic systolic heart failure 

Answer: The patient is high likely exposed to