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: lisinopril / kefzol / sulfa (sulfonamide antibiotics) / shellfish derived attending: chief complaint: shortness of breath major surgical or invasive procedure: temporary hd line placement arterial line placement cvvh hemodialysis subclavean central line placement history of present illness: 63 y/o f with hx of severe diastolic chf, pulm htn, afib, ulcerative colitis, and recent lower gi bleed who is transferred from with acute dyspnea and hypoxia. per her daughter, she has been more dypsneic on exertion for the past week with episodes somewhat relieved with albuterol. the pt reports that she awoke at 3:15 am with acute shortness of breath and wheezing. she denies chest pain, palpitations, fevers, chills, night sweats. she denies cough. an albuterol inhaler did not help, so she went to the ed. . in the ed, she placed on bipap with o2sat 100%. her bp was initially 104/67, hr 55, rr13. cxr showed r pleural effusion. bnp was 1500, cardiac enzymes negative. hct was noted to be 24.9 (baseline 24-27). at 6am her blood pressures dropped to 83/44 and she was given a 125cc ns bolus. abg on bipap was 7.34/60/313/32. at 7:30am, levophed gtt was started. at 8am she was transitioned to a nrb and was satting 100%. her levophed was increased at 8:15am. . on arrival to the icu, she reports comfortable breathing ever since being placed on o2. ros is otherwise positive for more black stools over the past 2-3 days. . of note, she was recently admitted due to lower gi bleed and hct of 17. she required 6 units prbcs that admission and bleeding was felt to be due to lower gi angioectasia; colonoscopy was not done due to recent scope which showed many angioectasias throughout the colon. hct was stable at 24.7 on discharge and most recent hct was 27.4. she was also treated for congestive heart failure exacerbation and acute renal failure on that admission and was discharged on spironolactone, torsemide and metolazone still about 40 lbs above her dry weight. at her follow-up appointments, her weight was still stable, so spironolactone was increased on by dr. (weight 199 lbs) and her torsemide on by dr. (weight 196 lbs). the pt reports medication compliance (does sometimes take medications late) and general diet compliance although "ate more over ." she does recall an episode of left leg pain two days ago while trying to go up stairs and feels she may have been when she started feeling more short of breath, although the acute episode of dyspnea was not until later. . review of systems: (+) per hpi. ongoing occasional nausea, vomiting with emesis including medications at times. (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough. denies chest pain, chest pressure, palpitations, or weakness. diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: # diabetes # dyslipidemia (tg 53, chol 145 hdl 71 ldl 63 on ) # hypertension # atrial fibrillation off coumadin secondary to gi bleed # severe diastolic dysfunction w/ right sided heart failure # severe pulmonary hypertension # severe tricuspid regurg (eval by card , not op candidate) # etoh remote history # pfo closure () # ulcerative colitis # intermittent hyponatermia # elevated lfts # angioectasia of the entire colon seen on colonoscopy social history: -married, separated from husband who is mentally ill, living with son and his family currently (supportive) -tobacco history: no -etoh: +prior h/o heavy etoh use, current intermittent etoh use -illicit drugs: no family history: -father with mi at age 68 -mother breast cancer at age 52 no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: vitals: t 95.7, p 57, bp 104/71, rr 13, o2sat 100% 5l general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, very promiment ej, jvp elevated, no lad lungs: mild rales bilaterally, no wheezes, or ronchi cv: irregular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gi: trace guaiac positive hard very dark brown stool gu: foley in place ext: warm, well perfused, 2+ pulses, 3+ edema bilateral to knees and up posterior aspects to lower back, lle more erythematous with hematoma, calf tenderness bilaterally neuro: aaox3, mild asterixis b/l, otherwise nonfocal pertinent results: 09:32pm urea n-102* creat-2.4* 09:32pm ck(cpk)-32 09:32pm ck-mb-notdone ctropnt-<0.01 09:32pm hct-26.8* 03:32pm urine hours-random urea n-335 creat-27 sodium-84 03:32pm urine osmolal-348 03:32pm urine color-straw appear-clear sp -1.007 03:32pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 03:32pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 03:32pm urine rbc-0-2 wbc-* bacteria-few yeast-none epi-0-2 03:32pm urine eos-positive 12:00pm glucose-109* urea n-100* creat-2.5* sodium-134 potassium-4.5 chloride-92* total co2-26 anion gap-21* 12:00pm alt(sgpt)-9 ast(sgot)-44* ld(ldh)-283* ck(cpk)-39 alk phos-194* tot bili-1.4 12:00pm ck-mb-notdone ctropnt-0.01 probnp-6666* 12:00pm calcium-9.4 phosphate-6.5*# magnesium-2.4 12:00pm tsh-4.7* 12:00pm wbc-12.1*# rbc-3.33* hgb-8.9* hct-28.8* mcv-87 mch-26.9* mchc-31.0 rdw-16.3* 12:00pm neuts-94.4* lymphs-3.0* monos-2.2 eos-0.3 basos-0.1 12:00pm plt count-236 12:00pm pt-13.1 ptt-29.4 inr(pt)-1.1 : portable cxr indication: 63-year-old female with history of chf, shortness of breath. for pulmonary edema. comparison: chest radiograph and multiple priors. single portable semi-upright view of the chest: in comparison to the most recent chest radiograph as well as the recent ct, there has been an increase in a right pleural effusion. lung volumes are low, accentuating the heart size, but even allowing for technique very stable moderate cardiomegaly. the bony thorax is unremarkable. impression: increased right and continued left pleural effusion. : portable cxr history: central line placement. findings: in comparison with the earlier study of this date, there has been placement of a right subclavian catheter that extends to the mid-to-lower portion of the svc. otherwise, little change. the study and the report were reviewed by the staff radiologist. : tte the left atrium is moderately dilated. the right atrium is moderately dilated. a septal occluder device is seen across the interatrial septum. the estimated right atrial pressure is 10-20mmhg. there is mild 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 low normal (lvef 50-55%). the right ventricular cavity is dilated with borderline normal free wall function. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is probably significant pulmonary hypertension although this could not be adequately quantified. significant pulmonic regurgitation is seen. there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. (echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures.) compared with the prior study (images reviewed) of , there is no significant change. : renal ultrasound indication: patient is a 63-year-old female with longstanding hypertension. for renal artery stenosis. examination: renal ultrasound with doppler. comparisons: comparison is made to ct from and renal ultrasound from . findings: the right kidney measures 9.2 cm. left kidney measures 8.7 cm. both kidneys are relatively normal in size for patient's stated age. both kidneys are unremarkable in appearance with no evidence of hydronephrosis, nephrolithiasis, or discrete masses. note is made of a small amount of pelvic free fluid. the bladder is collapsed about a foley catheter. doppler examination: both main renal arteries demonstrate a brisk upstroke and good diastolic flow. there is normal venous drainage with normal venous waveforms demonstrated. resistive indices were measured as ranging from 0.61 to 0.83 within the left and 0.68 to 0.81 on the right. this is compatible with mild to moderately elevated resistive indices. impression: 1. no son evidence of renal artery stenosis. mild to moderately and symmetrically elevated resistive indices bilaterally. 2. unremarkable appearance of the kidneys. 3. small amount of pelvic free fluid. : chest radiograph indication: chronic heart failure, shortness of breath, evaluation for interval change. comparison: . findings: as compared to the previous radiograph, there is no relevant change. unchanged moderate cardiomegaly with basal areas of atelectasis and a small right-sided pleural effusion. no newly occurred focal parenchymal opacity in the lung parenchyma. unchanged course and position of the two right-sided central venous access lines. no pneumothorax. brief hospital course: # dyspnea/hypoxia: pt presented with dyspnea and hypoxia; she was on bipap and transitioned to nrb. she appeared fluid overloaded clinically and on cxr with a bnp of 6666. acute onset raised concern for an inciting event, but no clear inciting factor apparent. she did have mild leukocytosis to wbc 12 but no fevers, cough, or clear consolidation suggestive of pneumonia. she is in chronic atrial fibrillation but is rate controlled. she had no chest pain to suggest acs; ekg was at her baseline and 2 sets of cardiac enzymes were negative. a pulmonary embolus was considered but given no chest pain or tachycardia (on beta blocker) this was not felt to be a concern. thyroid dysfunction unlikely to provoke acute decompensation. according to the patient's daughter, the presentation may have actually been more subacute over several days and there may have been a component of suboptimal dietary/medication compliance in this patient with baseline diastolic chf that has been very difficult to manage. she was begun on cvvh on and diuresis was begun. her admission weight was 87.6 kg and her maximum weight during admission prior to cvvh was 92 kg. she continued on cvvh with levophed as needed for pressure support until . she was transferred to the regular floor and continued to receive hemodialysis until discharge. she was discharged on her home regimen of metolazone, torsemide and spironalactone. permanent transiton to hemodialsis had been discussed with her in detail but she much preferred the option of an oral antidiuretic regimen which she committed to be compliant with. . # hypotension: the patient was hypotensive to the 80s systolic in the osh ed and she was started on levophed. she continued requiring levophed for pressure support here in the ed and micu and a central venous line was placed here in her right subclavian vein. the hypotension was felt to be cardiogenic in the setting of worsening diastolic chf. there was no evidence for sepsis although the patient was found to have a uti. her hematocrit did show a slight drop but blood loss and hypovolemia were not felt to be contributing to her hypotension. levophed was maintained as needed while diuresing aggressively with cvvh. . # hematochezia: the patient was recently admitted for anemia and thought to have recurrent lower gi angioectasia bleeding. during this admission she continued to have guaiac positive stools but her hematocrit was relatively stable since her last discharge. her hematocrit was monitored closely and she was transfused two units of packed red blood cells (one on and one on ) with an appropriate increase in her hematocrit from 22.9 to 29.8. she continued taking her home pantoprazole, and sub-cutaneous heparin was avoided in the setting of her gi bleed. . # acute renal failure: the patient was found to have bun 100 and cr 2.5 (baseline 1.7). this was thought likely due to decreased renal perfusion in the setting of decompensated heart failure. creatinine began trending down as patient started on cvvh. medications were dosed for the patient's creatinine clearance, and the patient was followed by the renal consult team; dr. , the patient's nephrologist, saw her while in-house. she was begun on cvvh on and diuresis was begun. her admission weight was 87.6 kg and her maximum weight during admission prior to cvvh was 92 kg. she continued on cvvh with levophed as needed for pressure support until . she was transferred to the regular floor and continued to receive hemodialysis until discharge. she was discharged on her home regimen of metolazone, torsemide and spironalactone. permanent transiton to hemodialsis had been discussed with her in detail but she much preferred the option of an oral antidiuretic regimen which she committed to be compliant with. . # elevated lfts: the patient was noted to have mild ast and alkaline phosphate elevation with normal alt and total bilirubin. she had no abdominal pain and these values were felt to be due to congestive hepatopathy; they resolved with diuresis. . # nausea: the patient had intermittent nausea, possibly related to uremia. abdominal exam was benign and the patient was given zofran as needed. . # atrial fibrillation: the patient remained stable with a slow ventricular response. her home metoprolol was held in the setting of hypotension and she was not anticoagulated given her history of significant gi bleeding. . # diarrhea / ulcerative colitis: dr. , the patient's gastroenterologist, was made aware of the patient's admission. on admission, the patient had no abdominal symptoms such as pain or diarrhea, and she did not seem to be having an acute ulcerative colitis flare. she did develop diarrhea with antibiotic treatment of her uti that resolved when the antibiotics were stopped. she continued taking her asacol though had some difficulties tolerating the medication without vomiting due to the size of the pill. medications on admission: albuterol hfa 90 mcg 2 puffs po qid prn ammonial lactate 12% lotion dicloxacillin 500mg po qid folic acid 1 tab po qday gabapentin 200mg po qhs prn leg spasm mesalamine 800mg po tid metolazone 5mg po bid metoprolol tartrate 25mg po bid metronidazole 0.75% cream omeprazole 20mg po qday oxycodone 5mg po 5mg po q6h potassium chloride 20meq with meals promethazine 12.5-25mg po q6h prn spironolactone 50mg po qday torsemide 60mg po bid trazodone 25mg po qhs asa 81mg po qday ferrous sulfate 325mg po bid miconazole 2% cream discharge medications: 1. mesalamine 400 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po tid (3 times a day). 2. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. torsemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). 6. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 7. spironolactone 50 mg tablet sig: one (1) tablet po once a day. 8. metolazone 5 mg tablet sig: one (1) tablet po bid (2 times a day). 9. methyl salicylate-menthol ointment sig: one (1) appl topical qid (4 times a day) as needed for prn pain. 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation four times a day as needed for shortness of breath or wheezing. 11. gabapentin 100 mg capsule sig: two (2) capsule po qhs (once a day (at bedtime)) as needed for leg spasm. 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. 13. promethazine 12.5 mg tablet sig: 1-2 tablets po every six (6) hours. 14. aspirin 81 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: discharge diagnosis: primary acute on chronic diastolic heart failure. . secondary acute renal failure ulcerative colitis diabetes hypertension discharge condition: fully ambulatory with walker. alert and oriented to person, place and time. discharge instructions: you were admitted to the hospital because you were having difficulty breathing. this was due to your heart failure which also caused renal failure. you required dialysis to remove all the extra fluid. a decision was made between you and your nephrologist not to pursue permanent dialysis but to continue using the diuretics you had been using at home.it is very important that you minimize salt in your diet to less than 2g/day and that you drink less than 1.5l of fluid a day and take all your medications. we stopped your omeprazole as we think this lowered your platelets. we stopped the potassium for the time being. you can discuss with dr when you should restart this. we added iron sulphate 325mg daily. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: internal medicine when: wednesday at 10:30 am with: , md, mph building: (, ma) campus: off campus best parking: free parking on site md, procedure: venous catheterization, not elsewhere classified hemodialysis venous catheterization for renal dialysis diagnoses: anemia in chronic kidney disease unspecified pleural effusion 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 chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation acute on chronic diastolic heart failure other chronic pulmonary heart diseases hypotension, unspecified angiodysplasia of intestine with hemorrhage ulcerative colitis, unspecified diseases of tricuspid valve restless legs syndrome (rls) 

Answer: The patient is high likely exposed to