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: no known allergies / adverse drug reactions attending: chief complaint: icd placement, dyspnea major surgical or invasive procedure: icd implantation history of present illness: this is a 77 year old gentleman with a history of known coronary artery disease, s/p stent to the left circumflex in and cabg in with a lima to the lad, svg to diagonal, sequential svg to the ramus/om, svg to the pda. he also has a history of hypertension, hyperlipidemia, diabetes, systolic and diastolic chf (ef 35-40%) and atrial fibrillation on coumadin, and presented for placement of icd for primary prevention of sudden cardiac death. patient noted several weeks of worsening dyspnea on exertion, in that previously he was able to walk around the mall without getting symptomatic, but lately cannot ascend a flight of stairs without having to stop to catch his breath. he also had not been sleeping well and is occasionally waking with dyspnea. he admitted to two-pillow orthopnea, which is not new. there had also been worsening lower extremity edema over the last few weeks. he had gone a week or two without taking many of his medications, including plavix, lasix, and metoprolol, due to him not sending away for his supply of pills. . patient went for icd placement on the day of admission, and patient appeared fluid overloaded on presentation. he received 80 mg iv lasix x 1 after icd placement, and was transferred to the floor. he was on 3 liters of o2 upon presenting to the cardiology floor. . on review of systems, he denied any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, black stools or red stools. he denied recent fevers, chills or rigors. he denied exertional buttock or calf pain. all of the other review of systems are negative. . cardiac review of systems was notable for absence of chest pain, palpitations, syncope or presyncope. . at the time of arrival to the floor, patient complained of dyspnea mostly when he dozes off and falls asleep. he reported no chest pain, palpitations, or syncope. . past medical history: cardiac risk factors: +diabetes +dyslipidemia +hypertension . cardiac history: cad s/p ptca to lcx and cabg in - cabgx5 (lima->lad, vein->diagonal, vein->ramus sequentialed to obtuse marginal, vein->posterior descending artery) . other past history: hypertension hyperlipidemia aortic stenosis diabetes mellitus type 2 hx of pleural effusions, s/p left thoracentesis chronic renal insufficiency atrial fibrillation s/p treatment with amiodarone and cardioversion in colon cancer s/p resection in probable gerd tonsillectomy social history: he is a widower with six adult children. he lives with his daughter and grandson. is retired. prior to retiring he worked as a design draftsman. he quit smoking over 20 years ago, reports social alcohol use and denies illicit drug use. family history: father reportedly died of a myocardial infarction at the age of 39. physical exam: on admission: vs: t= 96.9 bp= 137/100 hr= 104 rr= 18 o2 sat= 97%3l o2 bs= 191 general: wdwn obese male in nad. oriented x 3. mood, affect appropriate. pleasant and cooperative heent: ncat. sclera anicteric. perrl, eomi. conjunctiva are pink, mm slightly dry, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 6 cm above the clavicle. cardiac: tachycardic, regular rhythm, normal s1, s2. no m/r/g audible. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, moderate kyphosis. respirations are unlabored, no accessory muscle use. ctab, bibasilar rales, no wheezes or rhonchi audible. abdomen: soft nt, obese and distended, + shifting dullness. mild pitting edema present. no hsm. extremities: 3+ pitting edema up to above the knee, warm and well-perfused. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ on discharge: vs: tm/tc 98.7/97.8 bp 119/72 (111-139/67-86) p 88 (82-94) r 18 sat 96%ra bs 166-196 i/o: 1715/1800 wt: 87.9-->79.8 kg general: wdwn obese male in nad. oriented x 3. mood, affect appropriate. pleasant and cooperative. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva are pink, mm slightly dry, no pallor or cyanosis of the oral mucosa. neck: supple with jvp elevated to 4 cm above clavicle. cardiac: irregularly irregular, normal s1, s2. ii/vi sem indicative of tr, iii/vi blowing holosystolic murmur at apex indicative of mr. chest: no swelling of icd placement site, no erythema, no pain to palpation around site. lungs: no chest wall deformities, moderate kyphosis. respirations are unlabored, no accessory muscle use. ctab, no rales present, no wheezes or rhonchi audible. abdomen: soft nt, obese, less distended than previous. no hsm. extremities: wwp, no c/c/e present. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: admission labs -------------- 07:15am blood wbc-8.9 rbc-4.97 hgb-11.6* hct-37.8* mcv-76* mch-23.3* mchc-30.7* rdw-20.3* plt ct-373 07:15am blood neuts-84.1* lymphs-8.3* monos-5.1 eos-1.3 baso-1.1 07:15am blood pt-21.3* inr(pt)-2.0* 07:15am blood glucose-164* urean-34* creat-2.0* na-143 k-4.4 cl-103 hco3-27 angap-17 07:10am blood calcium-8.8 phos-4.4 mg-2.4 discharge labs -------------- 07:31am blood wbc-8.4 rbc-3.47* hgb-8.8* hct-26.7* mcv-77* mch-25.4* mchc-32.9 rdw-19.7* plt ct-237 07:31am blood pt-18.2* ptt-78.9* inr(pt)-1.6* 07:31am blood glucose-132* urean-72* creat-3.2* na-140 k-4.6 cl-103 hco3-27 angap-15 07:31am blood calcium-9.5 phos-4.0 mg-2.1 microbiology ------------ 07:14pm urine color-yellow appear-clear sp -1.009 07:14pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 01:03pm urine hours-random urean-389 creat-54 na-53 k-50 cl-59 10:51am urine blood-mod nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg imaging ------- ecg on admission: artifact is present. probable sinus tachycardia, although baseline abnormality precludes definitive assessment of the rhythm. left axis deviation. non-specific intraventricular conduction delay. there is a late transition with q waves in the anterior leads consistent with prior myocardial infarction. non-specific st-t wave changes. compared to the previous tracing of the rhythm has probably changed. cxr on admission: current study demonstrates mild degree of pulmonary edema, significantly improved when compared to the radiograph. the pacemaker defibrillator was newly inserted with its lead terminating in the expected location of the right ventricle. there is no evidence of pneumothorax. there are still present bibasilar areas of atelectasis and right basal interstitial changes that potentially might represent interstitial lung disease underlying pulmonary congestion. if clinically warranted, further evaluation of the patient with hrct at some point may be reasonable for precise characterization of the lung findings to differentiate between the interstitial lung disease and superimposed part of pulmonary edema. tte : the left atrium is dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (lvef= 25 %) secondary to severe hypokinesis of the inferior free wall, interventricular septum and anterior free wall, extensive apical akinesis with focal dyskinesis. a large apical thrombus is seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. the right ventricular free wall thickness is normal. the right ventricular cavity is dilated with depressed free wall contractility. there are focal calcifications in the aortic arch. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. the main pulmonary artery is dilated. the branch pulmonary arteries are dilated. the pulmonary artery is not well visualized. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , there has been a major further reduction of left ventricular ejection fraction as well as significant increase in the mitral and tricuspid regurgitation. a large apical thrombus is now present in the left ventricle. the right ventricle is now dilated and hypocontractile. . renal ultrasound : impression: normal renal son . cardiac catheterization : comments: 1. coronary angiography in this right dominant system demonstrated three vessel disease. the lmca had no angiographically apparent disease. the lad was occluded in its mid-portion. the lcx was occluded at om1. the rca was not engaged as it was known to be occluded. 2. resting hemodynamics revealed normal right sided filling pressures with rvedp 8mmhg and a normal pulmonary capillary wedge pressure of 13mmhg. there was mild pulmonary arterial systolic hypertension with pasp 35mmhg. the cardiac index was preserved at 3 l/min/m2. the systemic and pulmonary vascular resistances were normal at 973 dynes-sec/cm5 and 80 dynes-sec/cm5 respectively. the systemic arterial blood pressure was normal with sbp 100mmhg and dbp 61mmhg. 3. arterial conduit angiography revealed the lima-lad, svg-om, svg-diag, and svg-pda to be patent. 4. supravalvular aortography revealed no significant aortic regurgitation. final diagnosis: 1. three vessel coronary artery disease. 2. patent bypass grafts. 3. normal filling pressures. . tte : the left atrium is mildly dilated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal third of the left ventricle, mid to distal inferior wall, and true apex. large thrombus is seen in the left ventricle. the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular systolic function has improved. the severity of mitral and tricuspid regurgitation is reduced. brief hospital course: 77 year-old man with ischemic cardiomyopathy and an lvef of 30% referred for icd implantation, presenting with weeks of worsening dyspnea on exertion secondary to medication noncompliance. . course ------------- # systolic congestive heart failure, acute on chronic: patient presented with symptoms of worsening dyspnea on exertion and at rest, and peripheral and pulmonary edema, in the setting of medication noncompliance. initially, patient received boluses of iv furosemide, but urine output was not optimal, so he was switched to an iv furosemide drip. urine output was still not optimal and metolazone was added. his home dose of spironolactone and lisinopril were initially continued, but then the medication was discontinued due to worsening renal function. he was continued on his home dose of metoprolol. echocardiography was initially performed, showing an ejection fraction of 25% and worsening mitral and tricuspid regurgitation. patient was started on milrinone drip, and initially required pressor support but was quickly weaned. he was able to maintain good urine output, achieving net -1.5 - 2.0 l fluid balance per day. he was restarted on home spironalactone 25 mg qd, kept on milrinone gtt, and transferred back to service. diuresis was continued upon coming back to the cardiology service, but was stopped when he was found to be euvolemic and his creatinine started to rise. prior to catheterization on , all diuresis was discontinued, patient was given intravenous hydration, but milrinone was continued. fluid restriction and a low sodium diet were employed and strict ins and outs and daily weights were recorded. diuresis was resumed with torsemide after returning from catheterization, and milrinone was discontinued. his creatinine continued to rise, so torsemide was discontinued upon discharge and more iv fluid was given, to which his creatinine downtrended. he is being discharged without further diuresis at this time. he will likely need torsemide dosing in the future as an outpatient.n echocardiography was performed again after diuresis, and showed improvement in ejection fraction and valvular function. he is scheduled to follow up with dr. , his new heart failure doctor on the day after discharge, who will determine when to resume diuresis. he is being discharged on metoprolol for therapy. his lisinopril and spironolactone are currently being held due to elevated creatinine level. . # status post icd placement: patient initially presented for the placement of an icd, for primary prevention due to low ejection fraction. he underwent the procedure without complication. he is scheduled for follow-up at the device clinic for post-procedure evaluation. . # left ventricular thrombus: patient was noted on echocardiogram to have a left ventricular thrombus present. he was started on a heparin drip and also started on coumadin. at the time of his discharge, his inr was 1.6. he will continue coumadin therapy and see dr. on the day after discharge for further management of anticoagulation. . # acute kidney injury on chronic kidney disease: baseline creatinine approximately 1.7, in the setting of likely diabetic nephropathy. on admission, patient creatinine was 2.0 compared to baseline of 1.7, which peaked at 3.5 after initiation of milrinone drip. urine lytes showed feurea 37.5%, which was not consistent with prerenal etiology. etiology was likely from the milrinone drip and fluid overload. it was subsequently exacerbated by likely overdiuresis and dye load during catheterization. creatinine should continue to be monitored as outpatient. patient's medications were renally dosed and nephrotoxins were avoided. due to patient's creatinine levels, his home doses of lisinopril and spironolactone were discontinued. they may be added back in the future if his creatinine returns towards baseline. patient should have his creatinine checked three times per week at rehab to evaluate status of kidney function. his discharge creatinine was 3.2. . # microcytic anemia, acute on chronic: patient's hematocrit slowly trended down during his hospital stay. he was provided with one unit blood transfusion on the day before discharge. patient has had a colonoscopy within the last two years that was reported to be free of polyps or cancer, reported by the patient, but this is not in our records system. he was noted to be guaiac positive while admitted and on heparin iv. patient should have his cbc checked three times per week at rehab to evaluate status of anemia. his discharge hematocrit level was 26. . inactive issues --------------- # coronary artery disease: s/p cabg, patient reported no chest pain during his hospitalization. he was continued on his home dose of clopidogrel as well as low-dose aspirin. he was also continued on his home dose of metoprolol. since patient is on amiodarone, his rosuvastatin dose was decreased to 10 mg daily. he was continued on his home dose of plavix. he is being discharged on metoprolol for therapy. his lisinopril is currently being held due to elevated creatinine level. catheterization was performed during his stay and showed no new lesions in the coronary arteries. patient will follow up with both his general cardiologist and heart failure specialist upon discharge. . # atrial fibrillation/flutter: patient is on coumadin and amiodarone, as well as metoprolol for rate control, all of which were given during his hospitalization. his coumadin was held prior to admission for icd placement, and then later for catheterization. it was restarted after the procedures and inr trended up until the time of discharge. he was monitored on telemetry during this admission. he stayed in normal sinus rhythm during his hospital stay. he is being discharged on his home dose of warfarin, metoprolol and amiodarone. patient should have his inr checked two times per week at rehab to evaluate status of therapeutic coumadin dosing. . # hypertension: patient remained normotensive on his home medications. his metoprolol succinate was continued, and he will continue taking this as an outpatient. his imdur was discontinued since he was normotensive during his stay. his lisinopril and spironolactone was held when his potassium and creatinine level rose above 2.5. . # hyperlipidemia: patient's statin dose was decreased to rosuvastatin 10 mg daily due to being on amiodarone, and he will continue this dosage upon discharge. . # diabetes mellitus type 2: patient has a history of diabetic retionopathy with likely nephropathy as well. patient's glyburide was held and sliding scale insulin was begun. blood sugar levels were well controlled throughout this hospitalization. patient is being discharged on glipizide for further diabetic management instead of glyburide due to his renal function. . # gerd: patient was continued on his home dose pantoprazole during hospitalization. . transition of care ---------------- # code status: patient is confirmed full code. . # follow-up: patient will follow up with his general cardiologist and a heart failure specialist. he needs follow-up of his inr levels due to being subtherapeutic on coumadin upon discharge. he also needs follow-up of his kidney function and anemia, since both were active issues upon discharge. he may need a colonoscopy due to noted guaiac positive stools. his inr, cbc and chem7 should be checked at rehab as described above. medications on admission: furosemide 80 mg po bid imdur 60 mg po daily warfarin 3 mg po daily plavix 75 mg po daily lisinopril 20 mg po daily metoprolol succinate 200 mg po daily amiodarone 200 mg po daily spironolactone 25 mg po bid rosuvastatin 20 mg po daily allopurinol 200 mg po daily ventolin aerosol 2 puffs ih qid prn protonix 40 mg po daily spiriva 18 mcg ih daily glyburide 5 mg po bid coenzyme q10 200 mg po daily multivitamin po daily fish oil - dose uncertain discharge medications: 1. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual q5min () as needed for chest pain. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q6h (every 6 hours) as needed for wheeze. 4. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 6. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. metoprolol succinate 200 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. warfarin 1 mg tablet sig: three (3) tablet po daily (daily). 10. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 11. glipizide 5 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 12. coenzyme q10 200 mg capsule sig: one (1) capsule po once a day. capsule(s) 13. multivitamin tablet sig: one (1) tablet po once a day. tablet(s) 14. fish oil oral 15. rosuvastatin 10 mg tablet sig: one (1) tablet po once a day. 16. outpatient lab work please perform inr check twice per week starting on and 17. outpatient lab work please perform chem7 and cbc three times a week and fax results to md on call discharge disposition: home with service facility: discharge diagnosis: primary diagnosis: systolic congestive heart failure, acute on chronic acute on chronic renal insufficiency left ventricular thrombus microcytic anemia, acute on chronic secondary diagnosis: coronary artery disease atrial fibrillation hypertension hyperlipidemia diabetes mellitus type 2 gastroesophageal reflux disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you at the . you came for placement of a defibrillator (icd), but were found to have increased fluid and decompensation of your heart failure. further tests showed that you had worsening heart function on echocardiogram, and you were given medications to help take this fluid off. your kidneys were also found to not be working optimally. a cardiac catheterization showed no problems with the blood vessels of your heart. your kidneys are still not working like they used to, and this will need follow-up. it is important that you continue to take your medications and follow up with the appointments listed below, one of which is with dr. on the day after your discharge, monday . weigh more than 3 lbs. the following changes have been made to your medications: we stopped your furosemide, lisinopril and spironolactone we stopped your glyburide, which is given for diabetes, and added glipizide, which is better for this condition given your kidney function. we decreased your rosuvastatin dose due to your kidney function we stopped your isosorbide mononitrate (imdur), since your blood pressure appears to be controlled. we decreased your dose of allopurinol, to adjust for your kidney function followup instructions: department: cardiac services when: monday at 9:00 am with: dr. building: sc clinical ctr campus: east best parking: garage name: , w. location: internal medicine associates address: , , , phone: appt: please call dr office to book a follow up appt from your hospital stay in the next two weeks. procedure: venous catheterization, not elsewhere classified coronary arteriography using two catheters left heart cardiac catheterization implantation or replacement of automatic cardioverter/defibrillator, total system [aicd] diagnoses: coronary atherosclerosis of native coronary artery esophageal reflux acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation aortocoronary bypass status aortic valve disorders other chronic pulmonary heart diseases atrial flutter chronic kidney disease, unspecified other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia long-term (current) use of anticoagulants personal history of malignant neoplasm of large intestine iron deficiency anemia, unspecified acute myocardial infarction of unspecified site, initial episode of care acute on chronic systolic heart failure diseases of tricuspid valve diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled background diabetic retinopathy 

Answer: The patient is high likely exposed to