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: penicillins / vancomycin / oxycodone attending: chief complaint: chest pain - initial presenting complaint abdominal pain - developed during hospitalization major surgical or invasive procedure: cardiac catheterization -- exploratory laparotomy with resection of ischemic transverse and left colon and spleen -- history of present illness: per cardiology service: 78 yo woman with a pmh of cad, s/p cabg and pci, chf (systolic), s/p biv-icd, af, dm, htn, hc, hypothyroidism, ckd, and breast cancer s/p mastectomy in the 80's presents with chest pain. this morning she noticed that her vision was slightly blurry when she was directions on her cereal and her newspaper. she was dyspnic walking to her bathroom at home, an activity that does not typically cause dyspnea. later in the morning she was at clinic for a regular appointment when she noted sudden onset dull chest pain that radiated to her left arm and back. this was associated with mild sob and lightheadedness when pain was at its worst, but no nausea, vomiting, change in vision or diaphoresis. she affirms that this pain and lightheadedness is very similar to her prior presentations, including this . . of note, per her cardiologist, the patient has chronic chest discomfort, which awakens her at night and is always present. there is no exacerbation with her minimal physical activity and it can last for up to hours at a time. she does not note any exacerbation with food intake and differentiates this from her typical "heartburn," which is more of a burning sensation in the mid chest. she also notes that there is sometimes a sensation of food getting stuck when she is trying to swallow. . she was hospitalized in late with left-sided chest pain and black stool. troponins were negative, no ekg changes. during that admission egd revealed no bleeding but did show candidal esophageal infection. she was seen in the ed on for chest pain, again cardiac enzymes negative. pharmacologic stress test showed no change and she was d/c without admission. she last saw her cardiologist on for a post-discharge visit at which time she was noted to be volume overloaded. she also complained of chronic chest pain at that time, and anti-fungal treatment with fluconazole was recommended. the patient states that she used "some antibiotic" that completed its course "a while ago", but does not recall the name or timing. on she was switched from warfarin to dabigatran for anti-coagulation, although the patient believes that dabigatran was later stopped. per clinic notes, she reported chest pain in late (, ) and requested additional ntg tablets. by her report she uses these tablets perhaps once a week, 2-3 tablets per chest pain episode. she does not believe that the pace of her chest pain worsened over . on she complained of weakness and her vna noted she was pale; she also notes that about this time she started to have increased dyspnea on exertion, such that walking shorter distances caused her to be short of breath. prior to this time she could walk from her apartment to her car without dyspnea, but in the last week she could no longer do this. on her vna reported volume overload and her lasix was restarted at 40mg daily. . today she was given asa, ntg x2 at prior to presentation. in the ed, initial vitals were 97.8 81 135/55 16 100% ra. ekg showed st depressions in v1 and v2, troponin < 0.01. started on heparin gtt, nitro gtt, plavix loaded with 600mg, asa 325, morphine 5mg iv. . per report, her catheterization showed that 2 of her 3 cabg grafts are occluded. the svt to om graft remains patent. no intervention was performed. . on arrival to the floor, patient complains of a sensation of urinary urgency, but denies chest pain or dyspnea. . review of systems positive for orthopnea (wedge and pillow, unchanged), feeling cold, lightheadedness on standing. on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension 2. cardiac history: - cad status post inferoposterior wall mi, cabg in (lima-lad, svg-om, svg-pda, known svg to pda stenosis)--> taxus stent to svg - pda in --> stenting of anterograde limb of pda in . demonstration of svgsvg-rpda demonstrated 40%ostial lesion consistent with in-stent restenosis. - small - ischemic cm, ef 25-30% s/p biv upgrade on , ( cognis). lv lead revision . nyha class iii. - ventricular tachycardia status post icd placement; generator change 3. other past medical history: - hypertension/lvh - hyperlipidemia - type 2 diabetes (hba1c 8.2% in ), followed at the by . - mild as/ar - atrial fibrillation - hypothyroidism - irritable bowel syndrome/diverticulosis - chronic kidney disease - anemia - arthritis - breast ca, s/p r mastectomy and xrt - gastritis on egd, w/ hiatal hernia and candidal infection - chronic low back pain - obstructive sleep apnea - osteoarthritis social history: widowed. lives in apartment building across the hallway from her daughter and son-in-law. a 30-year-old granddaughter. previously owned toy stores with husband. lives independently at home in . independent for all adls. - tobacco history: never - etoh: never - illicit drugs: never lifetime nonsmoker and nondrinker. retired from toy wholesale business. family history: mother died at 53 of an mi, also had a stroke. brother died of mi at 40; sister died of mi in her 60s, another brother died of congenital heart defect at 32(valve). father died at 86. children both have diabetes. physical exam: admission physical examination: vs: 97.6 127/44 60 14 94% ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, mmm, op clear. no thrush. neck: supple with jvp of cm. chest: s/p mastecomy on right cardiac: rrr, normal s1 s2. 3/6 systolic crescendoing murmur best heard at rsb. no s3 or s4. lungs: resp were unlabored, no accessory muscle use. ctab, no rales, wheezes or rhonchi. abdomen: soft, non-tender, non-distended. no hsm. extremities: no cyanosis, clubbing. trace pedal edema b/l. cath site cdi, no eccymosis or hematoma, no bruit. neuro: tested with each eye, normal and not blurred. cn ii-xii tested and intact, strength 5/5 throughout, sensation grossly normal. gait not tested. pulses: right: carotid 2+ dp 1+ pt dopp left: carotid 2+ dp 1+ pt dopp pertinent results: admission labs: 10:30am blood wbc-7.7 rbc-3.11* hgb-8.9* hct-28.1* mcv-91 mch-28.6 mchc-31.6 rdw-13.8 plt ct-155 10:30am blood pt-14.8* ptt-46.4* inr(pt)-1.4* 10:30am blood neuts-81.8* lymphs-10.9* monos-5.5 eos-1.4 baso-0.3 10:30am blood glucose-250* urean-45* creat-1.7* na-135 k-4.2 cl-100 hco3-23 angap-16 10:30am blood calcium-10.4* phos-3.6 mg-2.0 cardiac labs: 10:30am blood ctropnt-0.01 07:30pm blood ck-mb-2 ctropnt-0.02* probnp-* 07:30pm blood ck(cpk)-40 09:40pm blood ck-mb-2 ctropnt-0.03* 09:40pm blood ck(cpk)-44 discharge labs: microbiology: 1:20 pm urine site: not specified **final report ** urine culture (final ): no growth. <br> imaging: cxr mild fluid overload and probable trace pleural effusions, new since prior exam cardiac cath 1. selective coronary angiography of this right dominant system demonstrated severe three vessel coronary disease. the lmca had moderate disease. the lad, lcx, and rca were 100% occluded. 2. selective arterial conduit angiography demonstrated patent lima to lad. 3. venous conduit angiography demonstrated a patent svg-om and a 100% occluded svg to d1 and svg to pda. 3. limited resting hemodynamics demonstrated normotension. final diagnosis: 1. three vessel coronary artery disease. 2. patent lima-lad. 3. two occluded svgs. <br> echo the left atrium is markedly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe regional left ventricular systolic dysfunction with inferior and inferolateral akinesis, as well as apical hypokinesis. there is mild hypokinesis of the remaining segments (lvef = 25-30%). no masses or thrombi are seen in the left ventricle. right ventricular chamber size is normal. with mild global free wall hypokinesis. tricuspid annular plane systolic excursion is depressed (1.1 cm) consistent with right ventricular systolic dysfunction. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: dilated left ventricle with severe regional and global left ventricular systolic dysfunction, most c/w multivessel cad. mild right ventricular systolic dysfunction. moderate mitral regurgitation. moderate tricuspid regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , left ventricular cavity size is larger. the other findings are similar. <br> kub the ascending colon is markedly distended, particularly the cecal region with maximal diameter of approximately 13 cm. additional loops of air-filled bowel are present beyond this region in the transverse and distal colon, measuring up to about 6.6 cm in greatest diameter. on the left lateral decubitus view, multiple air-fluid levels are present, but there is no evidence of free intraperitoneal air. a small amount of gas is also noted within the nondistended loops of small bowel. impression: markedly distended cecum, without evidence of distal colonic decompression. the possibility of intermittent cecal volvulus should be considered, and a ct of the abdomen has already been obtained for a more complete evaluation at the time of this dictation. <br> ct abdomen and pelvis impression: - no evidence to suggest cecal volvulus. fluid-filled loops of small bowel is suggestive of enteritis. evaluation of mesenteric ischemia is limited due to lack of iv contrast. - mild nonspecific thickening of the wall of the left colon which could be secondary to infectious/ ischemic colitis. - extensive vascular disease involving the vessels of the abdomen and pelvis. - trace perihepatic ascites. - small bilateral pleural effusions. <br> <br> post-op labs 03:01a ph 7.22 pco2 35 po2 56 hco3 15 basexs -12 type:central venous freeca:1.26 lactate:10.1 o2sat: 85 02:40a 144 108 40 83 agap=25 -------------< 4.3 15 2.6 comments: glucose: if fasting, 70-100 normal, >125 provisional diabetes ca: 11.4 mg: 2.2 p: 8.5 &#8710; alt: 218 ap: 34 tbili: 0.5 alb: ast: 314 ldh: dbili: tprot: : lip: 9.1 \ 8.6 / 65 / 27.7 \ n:43 band:32 l:15 m:9 e:0 bas:0 metas: 1 nrbc: 1 comments: plt-ct: verified hypochr: 3+ anisocy: 1+ poiklo: 1+ macrocy: 1+ burr: 2+ pappenh: 1+ plt-est: very low pt: 74.9 ptt: 126.0 inr: 7.6 brief hospital course: cardiology hospital course: 78 yo woman with a pmh of cad, s/p cabg and pci, chf (systolic), s/p biv-icd, af, dm, htn, hc, hypothyroidism, ckd, and breast cancer s/p mastectomy in the 80's presents with chest pain. . # coronaries: history of prior imi, cabg in , subsequent stenting to svg to pda and anterograde limb of pda. per prior cath records, the lima-lad graft has been occluded since . catheterization on showed occlusion of the svg-pda lesion, leaving only the svg-om patent. the chronicity of this occlusion is uncertain, and she had no cardiac enzyme elevation. she has a history of chronic chest pain, thought to be both of cardiac and non-cardiac origin. continued asa, statin, metoprolol. nitrate was uptitrated. lisinopril was held for two days due to acute kidney injury (see below). . # pump: chronic systolic heart failure, infarct mediated, ejection fraction 30% status post biventricular icd: nyha iii. cxr showed mild pulmonary edema and trace effusions. bnp was elevated, peripheral edema. tte was not significantly changed from prior. home lasix was initially continued, then held for two days due to acute kidney injury (see below). ranolazine was started in an attempt to reduce her chronic chest pain. . # rhythm: chronic afib, on anti-coagulation with dabigatran, recently switched from warfarin due to compliance concerns. per patient, she was told to d/c dabigatran last week, but this is not documented in the clinic notes. dabigatran was restarted, and it was emphasized to the patient to maintain this medication unless specifically instructed to stop it by her cardiologist. metoprolol continued to rate control, digoxin started . . # post-cath bleeding: when the sheath was pulled , the patient had a small hematoma and 50 cc blood loss. pressure was held and the hematoma pressed out, groin was soft without hematoma on . no hct loss, vss. no need for ultrasound given normal clinical appearance. . # enteritis: on the evening of at 2200 the patient was given a dose of kayexelate for k 5.5. at 0430 she suddenly developed explosive brown diarrhea with urgency, frequency, and associated abdominal pain. bowel sounds were hyperactive. at 0700 she began to have tachycardia to the low 100s (rate usually controlled to 60-70s). bp at 0600 was 115/43, dropped to 90s/40s by noon. diarrhea continued through the morning, patient became clinically dehydrated with bp down to 80s/40s. ivf boluses used to support fluid balance and pressure. stool guaiac positive, non-melanotic. kub showed sign of either cecal volvulus or ischemic colitis with distension, no sign of perforation. lactate elevated to 5.9, lactic acidosis with venous ph 7.32. surgery was consulted. due to the patient's hypotension, volume loss, and acidemia, she was transferred to micu for monitored resuscitation. . # candidial esophagitis and gerd: egd in showed no bleeding, but did find candidal infection causing esophagitis. patient also complains of chronic gerd. unclear if she completed fluconazole for candidial esophagitis, although at admission she had no thrush and no globus sensation. there is concern that this esophagitis may be contributing to her chest pain. her ppi was continued. . # blurred vision: the patient states that she noted slight blurring of her vision the morning of , but this has now resolved. no associated neuro signs. be due to hyperglycemia, but in case of embolic event her risk factors are being mitigated, dabigatran restarted. . # ua: ua showed trace leuks, few bacteria. patient complained of some urinary frequency and burning. urine culture negative. repeat ua showed sign of infection, cipro was started for 3-day course (4/6-8) . # aockd: baseline cr 1.6-1.8 with mild hypercalcemia due to renally-derived secondary hyperparathyroidism. on her cr increased to 2.0, then to 2.4 on . lisinopril and lasix were held. her home dexedrcalciferol was continued and all medications (including dabigatran and cipro) renally dosed. . inactive issues: # hyperlipidemia: continued statin as above, held fish oil (not available on formulary) # anemia: baseline hb 10. no evidence of bleeding. continued iron supplementation, vit b12 # hypothyroidism: last tsh 2.4 in , continued levothyroxine # t2dm: on insulin, recently started sitagliptan. while inpatient we used iss and held sitagliptan. # health maintenance: continued mvi . code: full emergency contact: . transitional issues: - monitor digoxin levels, particularly in light of renal failure - ongoing surveillance of renal function - continue to emphasize appropriate and continued medication use . . surgery hospital course: 78f with multiple medical/surgical comorbidities as described above. the acs service was consulted on for acute abdominal pain with distension and copious diarrhea that began hours after patient had received kayexalate for treatment of hyperkalemia on . her symptoms persisted and she was reportedly hypotensive and tachycardic briefly but responded to iv fluid boluses on morning of . her lactate was 5.9. a kub was done that demonstrated markedly distended cecum, without evidence of distal colonic decompression and raised the possibility of intermittent cecal volvulus. on physical exam at this time, her abdomen was soft but moderately distended and diffusely moderately tender, right abdomen greater than left but there was no rebound. she was stable hemodynamically at the time. she continued to have diarrhea that was heme positive but non-melanotic or grossly bloody. initial discussion of potential surgical intervention with the patient was met with indecision and the patient wanted to discuss this possibility with her son/family. the patient understood that she was a high-risk operative candidate for morbidity and mortality given her numerous comorbidities and poor cardiac and renal functions. in addition, she has been chronically anticoagulated with pradaxa. given the equivocal etiology of her abdominal symptoms, a non-contrast ct scan was recommended for further evaluation (no iv contrast given that her cr was 3.0). the scan demonstrated no evidence to suggest cecal volvulus but there were fluid-filled loops of small bowel suggestive of enteritis along with mild nonspecific thickening of the wall of the left colon which could be secondary to infectious causes or ischemic colitis. at this juncture, it was felt that this was possibly a pseudoobstructive picture of the colon and gi was consulted for colonoscopy for further evaluation of the colonic mucosa along with potential endoscopic decompression. chemical decompression was not attempted given the patient's significant history of cardiac dysrrhythmias. her lactate had improved to 2.9 after iv fluid boluses. however, she had some intermittent episodes of hypotension to sbp 90's along with tachycardia and was transferred to the micu (no available sicu beds) with surgery following closely. gi was unable to visualize colonic mucosa secondary to copious amounts of stool and attempted to decompression the colon with moderate effect. the patient tolerated the procedure well without complications. her exam post-procedure demonstrated a softer, less distended abdomen and mildly less tender. her hemodynamics remained stable and she was monitored closely. she continued to have copious amounts of diarrhea, now collected in a flexiseal system. a c. diff pcr was sent (eventually, this returned as negative). her stool started to appear more blood-tinged and her coagulation panel returned with markedly elevated inr 4.5 and ptt 150, which was not compatible with a picture of possible supratherapeutic pradaxa levels. this was confirmed with discussions with hematology. a concern for a comsumptive coagulopathy was raised and a dic panel was sent (which eventually returned normal). hematology reinforced the point that there was no adequate methods of reversing pradaxa effects. despite continued fluid resuscitation, she started to become hemodynamically unstable around 10pm on and vasopressors therapy was started along with arterial line placement. her son was earlier in the day to discuss his mother's condition and the possibility of surgical intervention if she did not improve or got worse. he had discussed this possibility with his mother and sister and they were all in agreement towards surgery if necessary. with the new hemodynamic instability, her son was again, informed of the situation and the need for surgery. informed consent was obtained from him given that the patient was somewhat somnolent from recent pain medications. the great likelihood of death associated with surgery was reinforced and her son understood this risk. the patient became increasingly unstable and was transferred to the operating room emergently where she underwent an exploratory laparotomy, resection of ischemic transverse and left colon and spleen. she was coagulopathic despite pre-op/intra-op ffp and required multiple units of blood and albumin. please see operative note for more details. at the conclusion of the case, the patient had cardiovascular collapse despite maximal vasopressor and iv fluid support. acls protocol was initiated and eventually a perfusing cardiac rhythm was recovered. the sicu intensivist was called to the or for further critical care support. at this time, dr. had already been in contact with the patient's son and she explained to him his mother's critical condition and her son wished to continue resuscitation as needed. the patient was briefly stabilized for transfer to the sicu but shortly after arrival, she went into vtach with loss of bp, acls protocol was initiated again and a blood pressure was recovered. however, this was unable to be maintained and after mutliple unsuccessful rounds of acls and further discussions with her son who eventually agreed to stop active resuscitation, she expired at 03:12am on . the medical examiner's office was and the case was declined. her son also declined an autopsy due to personal/religious reasons. her pcp's office was notified as well. medications on admission: medications: from omr, patient does not have list dabigatran 75 mg *** per patient, stopped last week *** doxercalciferol 1.0 mcg furosemide 40 mg daily insulin glargine 5 units qam isosorbide mononitrate 30 mg daily levothyroxine 100 mcg daily lisinopril 5 mg daily metoprolol succinate 100 mg daily nitroglycerin 0.3 mg sl q 5 min x 3 prn chest pain omeprazole 20 mg 1/2 hr prior to breakfast and dinner rosuvastatin 20 mg qhs sitagliptin 50 mg daily aspirin 81 mg daily cyanocobalamin 100 mcg daily ferrous sulfate 325 mg (65 mg iron) daily loperamide 2 mg prn loose stool multivitamin-minerals-lutein 1 tablet daily omega-3 fatty acids-vitamin e 1,000 mg daily pyridoxine 100 mg daily fluconazole 400mg daily for 14 days rx discharge medications: expired discharge disposition: expired discharge diagnosis: sepsis bowel ischemia coronary artery disease s/p cabg and stent chronic systolic heart failure chronic atrial fibrillation on pradaxa chronic kidney disease discharge condition: expired discharge instructions: expired followup instructions: expired procedure: coronary arteriography using two catheters left heart cardiac catheterization open and other left hemicolectomy flexible sigmoidoscopy total splenectomy cardiopulmonary resuscitation, not otherwise specified diagnoses: other primary cardiomyopathies acidosis hyperpotassemia other iatrogenic hypotension obstructive sleep apnea (adult)(pediatric) abnormal coagulation profile anemia, unspecified coronary atherosclerosis of native coronary artery esophageal reflux intermediate coronary syndrome congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism coronary atherosclerosis of autologous vein bypass graft hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation hematoma complicating a procedure personal history of malignant neoplasm of breast percutaneous transluminal coronary angioplasty status accidental puncture or laceration during a procedure, not elsewhere classified chronic kidney disease, unspecified paroxysmal ventricular tachycardia cardiac arrest cardiogenic shock long-term (current) use of insulin cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure chronic systolic heart failure automatic implantable cardiac defibrillator in situ secondary hyperparathyroidism (of renal origin) urinary complications, not elsewhere classified acute vascular insufficiency of intestine unspecified gastritis and gastroduodenitis, without mention of hemorrhage diverticulosis of colon (without mention of hemorrhage) nephritis and nephropathy, not specified as acute or chronic, with other specified pathological lesion in kidney irritable bowel syndrome other drugs and medicinal substances causing adverse effects in therapeutic use candidal esophagitis accidental cut, puncture, perforation or hemorrhage during surgical operation acute kidney failure with other specified pathological lesion in kidney 

Answer: The patient is high likely exposed to