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: percocet / serax attending: chief complaint: sob, hypoxia major surgical or invasive procedure: none history of present illness: 75 f c cad s/p cabg, pvd, esrd on hd, sarcoid (seen by dr. . recently hospitalized () for ischemic l thumb and l subclavian vein stenosis with course complicated by fluid overload (tx c hd), hemodynamically unstable afib c rvr requiring 2 dccv + started on amiodarone. also complicated by b/l pleural effusions, underwent thoracentesis showing transudate. had angioplasty of l subclavian vein stenosis. also of note, had recent evaluation for temporal arteritis c negative biopsy; treated empirically with a course of prednisone (). . pt. reports 2 weeks of worsening sob and orthopnea. awoke significantly sob this morning. noted to be hypoxic at hd to 80s and sob c fever and cough at dialysis. also complained of pain, redness, swelling over r foot. at hd, concern expressed for nonhealing l shin ulcer, possible rle cellulitis. sent to . received 1 dose of 750 mg levofloxacin prior to transfer. . in ed, vs - 100.4, 108, 27, 93% 4l nc. bnp 30 k. recevied vancomycin, levofloxacin in ed. cxr concerning for new rll pna. admitted to micu. in micu, c/o mild orthopnea, mild pleuritic pain midline with exhalation, fatigue. past medical history: - cad s/p cabg () - dm ii: since age 47 with triopathy - hypercholesterolemia - htn - sarcoidosis with pulmonary involvement: followed by dr. - copd (fev1 93% in ; previously on home o2 but not now) - hypothyroidism - renal artery stenosis s/p bilateral stents () - esrd on hd (qmwf; due to renal artery stenosis) - chf (ef>55%) - atrial fibrillation, paroxysmal - pvd s/p left fem- , s/p right fem- , s/p angioplasty and stent - breast cancer s/p left mastectomy - h/o mesenteric ischemia s/p sma bypass - gastritis - s/p cholecystectomy - chronic anemia (baseline hct 28-30) - : lt sc angioplasty for necrotic l thumb - carpal tunnel syndrome bilaterally, with positive electromyogram - acute tubular necrosis secondary to dye nephropathy social history: general: retired postal worker. lives with husband. previously independent in her adls. has 3 adult children and grandchildren. tobacco: 25-50 pack year smoking history, quit etoh: denies recreational drugs: denies family history: one sister had lung cancer, one brother had lung cancer and leukemia, five of the patient's six siblings have diabetes. father died of myocardial infarction at age 66. there is a strong family history of hypertension. physical exam: vs- 98.7, 86/48, 106-111 (afib), 25-28, 100% ventimask 10 lpm heent- jvp flat at 20 degrees, dry mm, + skin tenting over forehead lungs- crackles r>l base, decreased fremitus r base, dullness to percussion over r/l bases. fine wheeze on inspiration. heart- irregularly irregular, tachycardic, no murmurs abdom- soft, nd, nt, bs+ extre- wwp, no edema, erythema over r/l shin + ulcer neuro- a*o*3, moving ext. pertinent results: labs: 01:40pm blood wbc-13.3* rbc-3.64* hgb-11.3* hct-34.9* mcv-96 mch-31.1 mchc-32.4 rdw-19.8* plt ct-333 01:40pm blood neuts-84.6* lymphs-7.9* monos-6.4 eos-0.8 baso-0.3 01:40pm blood hypochr-2+ anisocy-2+ poiklo-1+ macrocy-2+ 01:40pm blood pt-20.1* ptt-33.5 inr(pt)-1.9* 01:40pm blood plt ct-333 01:40pm blood glucose-300* urean-22* creat-2.3* na-136 k-4.2 cl-95* hco3-31 angap-14 01:40pm probnp-* 01:49pm lactate-2.6* 08:52pm pt-22.7* ptt-35.2* inr(pt)-2.2* 08:52pm wbc-9.9 rbc-3.07* hgb-9.8* hct-29.4* mcv-96 mch-31.9 mchc-33.3 rdw-20.1* 08:52pm albumin-2.2* calcium-7.2* phosphate-2.9 magnesium-1.7 08:52pm alt(sgpt)-11 ast(sgot)-12 alk phos-82 tot bili-0.3 08:52pm glucose-308* urea n-26* creat-2.6* sodium-137 potassium-4.2 chloride-100 total co2-29 anion gap-12 . cxr (): comparison is made to prior chest radiograph dated and prior ct dated . increased interstitial edema with more focal opacity within the right lower lung, likely representing alveolar edema with underlying consolidation less likely. recommend repeat radiographs to assess for resolution. stable appearance to small pleural effusions, left greater than right. . cxr (): 1. diffuse interstitial edema. 2. developing confluent asymmetric airspace opacity in right lower lobe. although possibly asymmetric edema, aspiration or infectious pneumonia should be considered. 3. bilateral pleural effusions, left greater than right. . ekg (): atrial fibrillation with a rapid ventricular response. compared to the previous tracing of there is atrial fibrillation with a rapid ventricular response. the t waves appear less biphasic in leads v2-v3, which may reflect the change in rate. . pfts (): the fvc is mildly reduced. the fev1 is within normal limits. the fev1/fvc ratio is elevated. flow-volume loop: abrupt termination of exhalation with reduced volume excursion. volumes: the tlc is mildly reduced. the frc, rv and rv/tlc ratio are within normal limits. results suggest a mild restrictive ventilatory defect. however, fvc may be underestimated due to suboptimal test performance, and lung volumes are irreproducible. since , fvc has been reduced by 1.06 l (35%). since , there is no significant change in tlc or dsb. . echo (): left atrium is normal in size. no atrial septal defect is seen. left ventricular wall thickness, cavity size, and systolic function are normal (lvef 70%). no ventricular septal defect. the right ventricular cavity is dilated. right ventricular systolic function is borderline normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is a minimally increased gradient consistent with trivial mitral stenosis. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. moderate to severe tricuspid regurgitation is seen. there is at least moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. compared with the findings of the prior study (images reviewed) of , the mitral and tricuspid regurgitation are increased; there is now at least moderate pulmonary hypertension; and the right ventricle is now dilated and hypocontractile. brief hospital course: 75 yo female with cad s/p cabg, copd, esrd on hd, dm type ii, presents with worsening sob and hypoxia and admitted with probable rll pneumonia, volume overload, atrial fibrillation with rvr, and right le cellulitis. . # sob/hypoxia: when the patient was admitted, she was found to be volume overloaded with ekg demonstrating afib with rvr, and additionally had rll infiltrate on cxr. a copd flair was thought unlikely as she was not wheezing. she was initially treated for pneumonia with levofloxacin and vanco and then switched to zosyn and vanco because a long qt was noted on ekg. she was admitted to the micu for respiratory distress in the setting of rapid afib. she underwent hd with ultrafiltration with removal of 3l with improvement in symptoms. she was transferred back to regular medical floor with improvement in her symptoms, but again triggered on the floor when she was found to be experiencing palpitations, sob, lightheadedness, and was tachycardic 130-160s. an ekg demonstrated sustained wide-complex afib with rvr and exam demonstrated worsening pulmonary crackles. efforts to restore normal sinus rhythm failed with iv metoprolol and she was transferred back to the micu. in the micu, iv diltiazem was started with improved rate control. cardiology was consulted and felt that wide complex tachycardia was likely a. fib w/ aberrancy and unlikely vt. she was again loaded with amiodarone with maintenance of nsr and rate control established with metoprolol. during this time the patient has been dialyzed with uf removal to reduce the volume overload, and after each session she had improvement in her sob. as the sessions were being limited by hypotension, she was started on midodrine prior to each session. she will be discharged on 12.5mg metoprolol and amiodarone 400mg daily to be decreased to 200mg daily on . she has been requiring supplemental o2 which should be continued to maintain o2 saturations >93% and titrated off as possible with additional fluid removal at hd. . # leukocytosis: had significant bandemia of 10% on which has since resolved with wbc count trending downward from a max of 19.6, now 14 on day of discharge. admission cxr showed rll infiltrate that on subsequent imaging had resolved and then again reappeared in the setting of climbing wbc count. she was again started on levofloxacin with downward trend of her wbc count, however was changed to zosyn for concern of widening qt while on amiodarone. she previously had significant diarrhea during this hospitalization with repeated c. diff toxin a that were negative. her diarrhea has since resolved and c. diff toxin b is pending and should be followed up on. urine culture was negative. last day of zosyn for probable aspiration pneumonia is to complete a 7 day course. . # ckd on hemodialysis: she was continued on hemodialysis with goal to remove excess fluid with uf. her phoslo was discontinued as her phosphate had normalized, but this should be monitored and restarted if again climbs. additionally, she has been receiving 5mg midodrine prior to hd to maintain pressures during hd, as amount of fluid removed during her sessions had previously been limited by borderline blood pressures. as she remains fluid overloaded, the goal will be continued removal of fluid with hd/uf and, thus, midodrine should be continued prior to hd as needed. she is next due for hemodialysis on with goal, as above, to continue fluid removal. . # atrial fibrillation and wide complex tachycardia: as above, she was admitted due to hypoxia in the setting of a-fib w/ rvr. she is now in nsr on amiodarone and hr consistently in the low 60s on 12.5mg metoprolol . rate controlled and in sinus rhythm s/p amio load. her inr is therapeutic on 1mg coumadin qhs and should be monitored especially while on antibiotics and amiodarone. she should be continued on amiodarone 400mg po daily and should be decreased to 200mg daily on . . # epistaxis: on hospital day 10 () the patient experienced an uncontrollable nose bleed that failed to respond to pressure, afrin, and packing in the micu. her inr at the time was therapeutic (2.6). ent was called and an anterior perforation was seen. the patient was decongested with afrin/lidocaine and the nasal cavity was cleared. surgicell was packed into the r-nare (anterior and posterior) and l-nare anteriorly and has since dissolved. coumadin was temporarily held and has since been restarted and remains therapeutic without any subsequently nose bleeds. . # brbpr: occurred in the setting therapeutic inr (2.6) and severe epistaxis as above. of note, has h/o ugib in ischemic necrosis of transverse duodenum after aorto-sma bypass. gi evaluated and, as her hct has since remained stable, egd and colonoscopy can be pursued as an outpatient. hct remained stable in the 24-27 and she is hd stable without evidence of further bleeding. . # anemia: although hct fluctuates, bl recently prior to this admission appears to be in the low 30s. hct during this stay has been 24-29 and is likely ckd and gi bleed and iron-deficiency. recent iron studies reveals iron saturation of 11% (iron 15, tibc 129, ferritin 428). she was continued on epogen per renal recs and was started on iron supplemenation which should be held 1 week to colonoscopy when scheduled. . # hypertension: blood pressure remained well controlled during her stay with the exception of bp dips during hd as discussed above. she will be discharged on 12.5mg metoprolol with midodrine prn prior to hd. . # cad: s/p cabg. she was without signs of active ischemia during her stay. she was continued on asa, statin, betablocker. . # right lower extremity cellulitis: surrounding superficial ulcer with erythema. treated x 8 days with vanco (and was on zosyn for pneumonia #1) with resolution of surrounding erythema and tenderness. superficial ulcer remains scabbed/dry without evidence of persistent infection. this exam should be monitored. . # pvd: patient with dry gangrenous left thumb tip without any e/o infection. no intervention currently as dry gangrene. thus, dry gauze dressings should be applied daily and exam monitored. . # copd: remained stable without e/o significant bronchospasm on exam. she was continued on tiotropium, advair, prn albuterol. . # dm: her blood glucose was challenging to control during her admission. her lantus was up-titrated somewhat with better overall control. she demonstrated some tendancy to become hypoglycemic in the morning hours and so her bedtime sliding scale was reduced with good effect. the humalog iss and lantus will need to be titrated according to her ss requirements. . # hypothyroidism: an initial tsh during the hospitalization was elevated and on re-check it was still elevated. free t4 was checked and was normal. she was continued on her home dose synthroid. . # fen: cardiac, diabetic, renal diet. as there was some concern for aspiration with thin liquids (okay with food), speech and swallow evaluated her at bedside. she is to use chin tuck maneuver when drinking thin liquids and head of bed should be upright when eating. . # access: dialysis line placed , peripheral ivs . # ppx: therapeutic from coumadin, ppi, hob elevation, pt consult . # code: dnr/dni as discussed with patient medications on admission: asa 81 qd nephrocaps qd salmeterol 1 spray spiriva 1 cap qd prednisolone 1 gtt r eye daily colace/senna/dulcolax prn insulin regular sliding scale amiodarone 200 daily darepoetin eucerin cream atorvastatin 40 daily nexium 40 daily becaplermin gel daily caco3 1000mg tid lopressor 25-50 insulin 12 u nph diluy vancomycin po 250 mg tid linezolid 600 mg vicodin prn albuterol prn ambien prn discharge medications: 1. nephrocaps 1 mg capsule sig: one (1) capsule po once a day. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po once a day. 3. atorvastatin 40 mg tablet sig: one (1) tablet po once a day. 4. levothyroxine 200 mcg tablet sig: one (1) tablet po once a day. 5. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) inhalation once a day. 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) inhalation twice a day. 8. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. insulin glargine 100 unit/ml solution sig: seventeen (17) units subcutaneous in the morning. 10. insulin regular human 100 unit/ml solution sig: sliding scale subcutaneous injection four times a day. 11. metoprolol tartrate 25 mg tablet sig: one-half tablet po twice a day. 12. amiodarone 200 mg tablet sig: two (2) tablet po once a day: last dose of 400mg daily will be on . 13. amiodarone 200 mg tablet sig: one (1) tablet po once a day: please start this dose on after finishing 400mg daily dose on . 14. coumadin 1 mg tablet sig: one (1) tablet po at bedtime. 15. prednisolone acetate 1 % drops, suspension sig: one (1) drop in right eye ophthalmic once a day. 16. nystatin 100,000 unit/ml suspension sig: five (5) ml po four times a day as needed. 17. senna 8.6 mg tablet sig: one (1) tablet po twice a day. 18. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 19. sodium chloride 0.65 % spray, non-aerosol sig: nasal three times a day as needed. disp:*1 bottle* refills:*2* 20. camphor-menthol 0.5-0.5 % lotion sig: one (1) application topical once a day as needed for as needed for affected areas. disp:*1 tube* refills:*2* 21. midodrine 5 mg tablet sig: one (1) tablet po on mornings of hemodialysis: please give before hemodialysis sessions. 22. zosyn 2.25 g recon soln sig: one (1) intravenous every twelve (12) hours for 7 days. 23. piperacillin-tazobactam 2.25 g recon soln sig: 2.25 g intravenous q12h (every 12 hours) for 7 days: to be completed on . 24. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: tcu - discharge diagnosis: primary diagnosis: 1. rll pneumonia 2. rle cellulitis 3. hypoxia from volume overload due to esrd 4. afib with rvr 5. guiaic positive stools 6. anemia due to ckd, gib 7. diabetes type 2 8. dry gangrene of left thumb . secondary: 1. chronic obstructive pulmonary disease 2. hypothyroidism 3. peripheral disease 4. ischemic left thumb 5. healing right shin ulcer 6. hypercholesterolemia 7. hypertension 8. coronary artery disease discharge condition: afebrile with improving white blood cell count, stable hematocrit and o2 requirement, currently on 4l nc. discharge instructions: you were diagnosed with atrial fibrillation with rapid heart rate as well as excessive fluid that led to your shortness of breath. please continue to go to hemodialysis as needed to help remove more fluid. please take medications as below. if you develop worsening shortness of breath, increasing weight gain, chest pain, palpitations, cough, fevers, or any other worrisome symptoms, please contact your facility doctor or report to the nearest er. followup instructions: please follow up with your doctor within 1-2 weeks of your discharge, dr. . please call his office for an appointment. . you have an appointment with dr. , a gastroenterologist, on at 4pm. his office is at , . for questions regarding scheduling or other issues, his phone number is . the purpose of this visit is follow-up regarding the bleeding episode you had during your hospitalization. . please follow up with previously scheduled appointments as below: 1. provider: scan phone: date/time: 10:15 2. provider: function lab phone: date/time: 12:00 md, procedure: hemodialysis control of epistaxis by anterior nasal packing diagnoses: pneumonia, organism unspecified anemia in chronic kidney disease end stage renal disease pure hypercholesterolemia urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute posthemorrhagic anemia unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified atrial fibrillation aortocoronary bypass status personal history of malignant neoplasm of breast sarcoidosis paroxysmal ventricular tachycardia atherosclerosis of renal artery cellulitis and abscess of leg, except foot blood in stool family history of ischemic heart disease diarrhea atherosclerosis of native arteries of the extremities with gangrene diastolic heart failure, unspecified epistaxis hypotension of hemodialysis lung involvement in other diseases classified elsewhere diabetes with neurological manifestations, type ii or unspecified type, uncontrolled family history of diabetes mellitus family history of malignant neoplasm of trachea, bronchus, and lung diabetes with renal manifestations, type ii or unspecified type, uncontrolled diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled family history of leukemia 

Answer: The patient is high likely exposed to