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: patient recorded as having no known allergies to drugs attending: chief complaint: palpitations and chest pressure major surgical or invasive procedure: placement of tunneled hd catheter () placement of temporary internal jugular central venous line *2 placement of tunneled ij central venous line left sided thoracentesis ir guided picc placement history of present illness: 85 year old female status post coronary artery bypass grafts x 3 and mitral valve annuloplasty on , chronic systolic chf (ef 30%), htn, and ckd presents with chest pain and palpitations. the patient was discharged to rehab from on after cabg for 3v cad. on the day prior to admission she experienced a fluttering sensation in her chest and "heaviness" in her legs while walking around. she has had lower extremity swelling bilaterally, but did not have chest pain until the morning of admission. on the day of admission she awoke with sub-sternal chest pain radiating to the left arm and back, associated with palpitations but not with sob. the pain was not positional. she noted a stable cough with clear sputum attributed to a new medication started post-op. she also noted some difficulty with swallowing since leaving the hospital. she has not had fever, chills, uri symptoms, dizziness, light-headedness, diaphoresis, orthopnea, or pnd. she did not experience chest pain when she had her prior mi. she was taken from rehab to - by ambulance and subsequently transferred to for further evaluation and management. pre-hospital vital signs: hr 79 bp 159/78 rr 20 o2sat 100% 2l nc. in ed, t 95.5 hr 76 bp 138/76 rr 16 o2sat 99%ra. bedside revealed small pericardial effusion. given asa 324 mg po, morphine 2 mg iv, sl ntg x 3, lasix 40 mg iv and admitted to the floor. past medical history: -coronary artery disease with coronary artery bypass graft x 3 on (lima-lad, svg-om, svg-pda) -mitral valve annuloplasty -systolic chf (lvef 30% on tte ) -ckd (b/l cr 3.3) -anemia of ckd - b/l hct ~30 -hyperlipidemia -htn -gerd -gout -diverticulosis -gastroparesis -depression -status post choleycystectomy -status post hernia repair -status post hip fracture repair social history: she is a retired travel . she quit smoking one month prior to admission and denies alcohol use. she lives with her spouse when he is not also a patient in . she has two grown children who are very involved in her care. family history: mother: htn father: htn and cva physical exam: <u>on admission:</u> v/s - wt 90.8 kg hr 72 bp 126/57 rr 18 o2sat 100% 2l gen: elderly obese female in nad heent: normocephalic, atraumatic; sclerae anicteric, perrl, eomi, conjunctiva pale; op clear with mmm neck: supple with jvp at angle of jaw with head of bed at 30 degrees cv: regular rate and rhythm, nl s1s2, +s3 without murmurs or rubs; sternal incision tender to palpation but clean, dry, and intact pulm: crackles to mid-lung fields bilaterally, diffuse wheezes, no rhonchi abd: soft, nontender, nondistended, normoactive bs ext: warm, dry 2+ pitting edema le bilat; calves nt; lle venous graft dressing clean, dry, and intact <u>on discharge:</u> vs: t 97.5, bp 100/63, hr 80, rr 18, o2 sat 98% on 3l by nc neck: jvp at 2cm above clavicle at 30 degrees cv: rrr, no murmurs, rubs, or gallops, +s3, sternal incision scabbed over in areas, staples removed, less tender pulm: scattered crackles bilaterally w/o whezes or rhonchi abd: obese, soft, nt, nd, bs+ extremities: warm, 2+ pitting edema bilaterally, venous graft harvest sites w/o erythema or signs of infection pertinent results: <b><u>laboratory results</b></u> on admission: wbc-7.0 rbc-3.57* hgb-10.6* hct-31.9* mcv-89 plt ct-162 -----neuts-82.3* bands-0 lymphs-7.7* monos-3.8 eos-6.0* baso-0.2 pt-14.2* ptt-28.7 inr(pt)-1.2* glucose-83 urean-64* creat-3.3* na-135 k-4.7 cl-100 hco3-23 angap-17 calcium-8.0* phos-4.6* mg-2.1 cardiac enzymes: cpk: 37- 39- 20 ck-mb: nd- nd- nd tropt: 1.20- 1.17- 1.13 on discharge: wbc 7.5, rbc 2.70*, hb 8.5*, hct 26.7*, mcv 99*, plt 148* pt 19.3*, ptt 38.1*, inr 1.8* glu 77, bun 24*, cr 3.0*, na 141, k 4.5, cl 110*, hco3 25 brief hospital course: this is an 85 y.o. female with past medical history significant for chf, cad s/p cabg, and ckd presenting with chf exacerbation complicated by on ckd requiring initiation of hemodialysis. 1) acute on chronic systolic and diastolic chf - initial search for dangerous etiologies of decompensation was negative. serial ck's were negative, making an ischemic event an improbable precipitant of chf exacerbation and tte didn't show any acute mr, which was a concern given recent mv annuloplasty. it was inferred that the most likely etiology of her exacerbation was an inadequate home diuresis regimen. therefore the patient was placed on a 1l fluid restriction and started on aggressive diuresis. she was treated with iv lasix boluses followed by lasix gtt when her creatinine increased from baseline. eventually, when pt was nearly 7 liters negative from admission urine output slowed despite increasing furosemide drip rate (max at 30 mg/hr) and the patient went into anuric atn. at this point patient stopped making urine and further medical diuresis impossible (see below). patient had bilateral pleural effusions (l>r) at this point and complaining of subjective dyspnea though o2 requirement not dramatically worsened (saturations in upper 90's on 4l by nc). interventional pulmonology was consulted and decided to do therapeutic thoracentesis on left. this resulted in some minimal improvement in subjective dyspnea. the patient continued to appear quite fluid overloaded and had diminished breath sounds over the ensuing days. eventually, with initiation of dialysis patient began to have slightly improved lung exam. despite this and better oxygen saturations (consistently 99-100% on 4l) patient continued to complain of subjective dyspnea, which was relieved somewhat by morphine. eventually, after longer dialysis course and consistent fluid removal with dialysis patient began to complain of less dyspnea and o2 requirements dropped to 3l by nc. 2)cad s/p cabg x 3 - although the patient presented with chest pain, ekg was unchanged from prior and ck was wnl. troponins were elevated but the patient had cabg days prior to admission and has ckd so there was a very low index of suspicion for acute coronary syndrome. after her first few days in the hospital her chest pain did not recur. did not reveal any new wall motion abnormality. she was continued on her aspirin, clopidogrel, and statin throughout her hospitalization. staples from midline chest incision were removed by the ct surgery team while the patient was in the hospital. 3) afib - the patient had recurrence of this arrhythmia during this hospitalization, which had initially occurred during her post-op course following cabg. initially, she was quite symptomatic with this rhythm, so after being rate controlled with metoprolol she was loaded on amiodarone and then put on oral maintenance therapy. later in her hospitalization she switched back to afib with reasonable rates (80's to 90's) and seemed to have no additional distress from this rhythm. she always reverted back to sinus over a period of hours and then stayed more consistently in nsr in the days preceding discharge. systemic anticoagulation was initially begun with coumadin and a heparin gtt bridge, but she was later switched back to heparin and this was then discontinued in order to facilitate necessary procedures. she was restarted on coumadin at disposition without a bridge as the incremental daily risk from embolic phenomena in atrial fibrillation is quite low and she was spending the vast majority of her time in sinus rhythm. 4) e. coli uti - the patient was found to have an e. coli uti during her hospitalization. she was treated with three days of ceftriaxone iv based on susceptibility data. later cultures revealed cure of this organism but did grow yeast. as the patient had an indwelling catheter at this point and wasn't symptomatic the foley was removed and no further treatment was rendered for this presumed colonization. 5) anemia of ckd - patient has a baseline anemia w/ hct of approximately 30. hct monitored daily and trended down during period of extreme volume overload and worse uremia in early . as patient was continuing to complain of subjective shortness of breath and given generally precarious status she was transfused three units prbc's during this period. hct responded appropriately to these transfusions and no signs of clinically apparent bleeding. minimal symptomatic improvement was noted with these transfusions. the patient did begin to trend down once again as discharge approached but this was slow and presumed due to poor nutrition. no further transfusions given. 6) htn ?????? on admission the patient was on metoprolol and lisinopril. lisinopril was stopped as the patient's renal function began to decline and couldn't be restarted given continued hope for renal recovery. metoprolol had to be stopped during period immediately preceding and immediately following initiation of dialysis when the patient was having multiple hypotensive episodes. metoprolol was restarted prior to discharge as blood pressures began to improve and hydralazine was also started for afterload reducttion presuming that lisinopril would not be started in the near future. 7) hypotension: in the days immediately preceding and immediately following initiation of dialysis the patient had considerable problems with hypotension with as low as the 80's. these were presumed secondary to a combination of hypovolemia and inadequate cardiac output in the setting of total body fluid overload and aggressive diuresis and/or fluid removal with hd. in the days preceeding hd initiation dopamine and dobutamine were used to maintain map's >60. neo-synephrine was needed for one night in order to maintain pressures in the face of a need to wean dopamine secondary to tachycardia. after dialysis was initiated the patient was hypotensive following her first treatments. initially attempts were made to manage this with pressors, but ultimately it was shown to respond to fluid boluses. this stifled attempts to make patient more fluid negative but did allow continued dialysis and improvement of metabolic abnormalities. after the first few days of dialysis blood pressures began to improve allowing more consistent fluid removal without further hypotension. 8) anuric acute kidney injury on chronic kidney disease: the patient has ckd with baseline creatinine of approximately three. with aggressive diuresis this eventually increased to >4 and patient stopped making urine. this anuric was presumed secondary to dehydration and poor pump function causing prerenal insult in setting of ckd. diuresis was stopped prior to anuria and the patient was started on dopamine in hopes of increasing renal perfusion. she was not able to tolerate dopamine due to tachycardia but was able to tolerate dobutamine and was observed on this therapy for any signs of renal recovery. unfortunately, this did not occur and bun and cr continued to rise as patient's volume status continued to become more progressively positive. with increasing uremia and volume overload the patient became increasingly symptomatic with nausea, fluctuating mental status, mild asterixis, generalized weakness, and anorexia. bun peaked at 84 and cr peaked at 5.1. ultimately, the patient's children (her health care proxies) elected to proceed with a temporary course of hemodialysis. a temporary ij line was placed and patient received hemodialysis, which was initially complicated by hypotension. this limited the amount of fluid removal which was possible. bun and cr fell quite quickly but the patient continued to be quite symptomatic and despondent with fluctuating mental status and intermittent expressions of a desire to just be left alone to die and/or stop care. eventually, after treatments the patient's blood pressure began to better tolerate hd and thus more aggressive fluid removal was possible. at this the patient began to improve symptomatically and was more interactive and had fewer complaints of shortness of breath. unfortunately, patient self discontinued her first ij line, which led to the placement of a second after the patient was asked and expressed a desire to continue dialysis. prior to discharge a more permanent, tunneled hd catheter was placed. prior to her cabg the patient had expressed a strong preference to not remain on permanent hd but did express willingness to do it temporarily. there will be continued conversations between the patient, her family, and nephrology about the exact parameters of temporary dialysis and duration of this therapy. until a decision to stop is made that patient will continue to be dialyzed as an outpatient at her macu. 9) delirium: the patient had waxing and mental status around the period when dialysis was initiated. she generally remained a&o*3 but was quite unwilling or unable to participate in discussions about her care and would vacillate between expressing anger at having care continued versus a desire to keep going. she also appeared quite somnolent. the patient was also intermittently quite agitated and would scream for her children at times. was disoriented to time and situation on one day in particular when she thought she was in ??????a doctors ?????? and ??????being hypnotized.?????? the patient also self-discontinued her first ij as described above. patient was managed on haloperidol at the worst of this period, which worked well. etiology of delirium was never fully understood as it began during worst of uremia but continued as the uremia resolved with dialysis. infection was considered but she was having daily chest radiographs at this time and urine culture revealed only yeast (described above). ekg and daily chest radiographs showed no acute change. possibly metabolic encephalopathy vs icu psychosis vs chronic sleep disturbance vs pseudodementia were entertained in the differential. these symptoms eventually began to resolve with a longer period of dialysis and clearer decisions about course and goals of care. at time of discharge patient mentating at close to if not at baseline. 10) depression: the patient became quite depressed and despondent as her hospital course continued. at the peak of her renal failure and uremia she was intermittently asking her children to put her out of her misery and "put me to sleep like an animal." patient also persistently complained that she couldn't breathe and of subjective dyspnea despite stable and reasonable o2 saturations. the patient has a history of depression and it was thought at least part of her despondency and symptoms were due to depression and a degree of somatization. psych was consulted and initially recommended haloperidol for agitation. patient's mood began to improve and she became more interactive as her situation improved. the patient was also transitioned to an increased citalopram dose, which she tolerated well. 11) anorexia: the patient's appetite became very poor during this hospitalization. this initially started during the period of worsening fluid overload and uremia when she had considerable nausea. this was presumed multifactorial possibly due to gut edema and nausea. after initiation of dialysis the patient's nausea improved but she continued to have very poor p.o. intake. given somewhat unclear goals of care at this point and unclear decisions regarding desired interventions parenteral or tube feedings were repeatedly discussed but were not initiated. eventually, patient's appetite began to improve though po intake was poor. supplements were offered and diet was advanced with some improvement in po intake prior to discharge. a trial of megesterol was initiated but eventually discontinued as the patient objected to the taste of the medication and po intake was improving without it. 12) ethics/goals of care: at the height of the patient's renal failure there were multiple discussions with the patient's family as well as nephrology, cardiothoracic surgery, and cardiology teams about the best course to pursue. prior to surgery the patient had met with nephrology and agreed to "temporary" dialysis with unclear parameters about how long this could last. she had also expressed a strong desire to not be on permanent dialysis. as patient's mental status was fluctuating and expressed conflicting wishes at different times of day and to different children it was quite difficult to ascertain her wishes at that time. given previous willingness to pursue temporary dialysis and nephrology's prediction of 50% chance of renal recovery to the point of not needing further dialysis, the choice was made to proceed with hd. initially, the patient was intermittently quite despondent and expressed interest in ending her life or not having any more therapy and/or dialysis, but this was alternating with periods of expressing a desire for further treatment. after the patient was dialyzed and more consistently mentally clear she expressed a desire to proceed with dialysis for some period of time. 13) hyperlipidemia ?????? the patient was continued on her outpatent atorvastatin. the patient was initially on sc heparin for dvt prophylaxis and this was maintained when she was not on systemic anticoagulation for a fib. she was maintained on her home ppi. she initially was full code but later in her hospitalization in consultation with her family her status was changed to dnr/dni. she will be discharged to a macu for further optimization of her medical care and to continue to receive hemodialysis. medications on admission: 1. allopurinol 100 mg daily 2. heparin (porcine) 5,000 units sc tid 3. epoetin alfa 4,000 unit sc qmowefr (monday -wednesday-friday). 4. pantoprazole 40 mg tablet po daily 5. calcitriol 0.25 mcg po every other day (every other day). 6. citalopram 20 mg po daily (daily). 7. atorvastatin 40 mg po daily 8. docusate sodium 100 mg capsule po bid 9. tramadol 50 mg po q 6 hrs as needed for pain. 10. aspirin e.c. 325 mg po daily (daily). 11. calcium carbonate 500 mg tablet tidac (3 times a day (before meals)). 12. senna 8.6 mg tablet po bid 13. metoprolol succinate 12.5 mg po daily 14. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 15. lisinopril 2.5 mg po daily 16. furosemide 20 mg tablet po once a day discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. acetaminophen 500 mg capsule sig: capsules po q6h (every 6 hours) as needed for pain. 5. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 6. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tidac (3 times a day (before meals)). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 8. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 9. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 10. metoprolol succinate 25 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po daily (daily). 11. hydralazine 25 mg tablet sig: one (1) tablet po q8h (every 8 hours). 12. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 13. citalopram 20 mg tablet sig: 1.5 tablets po daily (daily). 14. ipratropium bromide 0.02 % solution sig: one (1) vial inhalation q6h (every 6 hours) as needed for sob/wheeze. 15. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily, prn () as needed for pain: off for 12 hours per day. 16. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 17. heparin (porcine) 5,000 unit/ml solution sig: 4000- unit dwell injection prn (as needed) as needed for line flush. 18. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed. 19. morphine 10 mg/ml solution sig: 0.1cc intravenous every four (4) hours as needed for shortness of breath or wheezing. 20. allopurinol 100 mg tablet sig: one (1) tablet po every 3 days (every 3 days). 21. multivitamin tablet sig: one (1) tablet po daily (daily). 22. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 23. warfarin 5 mg tablet sig: one (1) tablet po once a day: please titrate dose to goal inr of . 24. outpatient lab work please check inr on . titrate dose to goal inr of . discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary -------- 1) acute on chronic systolic and diastolic heart failure 2) coronary artery disease status post coronary artery bypass graft x 4 on 3) acute kidney injury on chronic kidney disease 4) atrial fibrillation 5) s/p mitral valve annuloplasty secondary ---------- 1) hypertension 2) hyperlipidemia 3) anemia of chronic kidney disease 4) atrial fibrillation 5) depression 6) gout discharge condition: asymptomatic with stable vital signs discharge instructions: you were admitted to the hospital with worsening congestive heart failure leading to the build up of fluid around the lungs and in the legs. please weigh yourself every morning and call your physician should your weight increase by greater than 3 lbs. please adhere to a 2 gram per day sodium diet and a 1 l daily fluid restriction. your dose of lasix (furosemide) was increased to . please continue taking your other medications as prescribed. please call your physician or return to the emergency department immediately if you experience lightheadedness, dizziness, passing out, falls, difficulty swallowing, chest pain, shortness of breath, palpitations, worsening cough, back pain, abdominal pain, vomiting, diarrhea, bloody or dark stools, or leg swelling. . please continue to refrain from smoking. information was given to you on admission regarding smoking cessation and preventing relapses. followup instructions: nephrology: provider: . phone: pt may see nephrologist at macu. . provider: , md phone: date/time: at 1:20pm, clinical center, . . primary care: , md phone: date/time: office will call you with a time. procedure: venous catheterization, not elsewhere classified hemodialysis venous catheterization for renal dialysis thoracentesis diagnoses: anemia in chronic kidney disease urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified 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 depressive disorder, not elsewhere classified chronic kidney disease, unspecified acute respiratory failure acute on chronic combined systolic and diastolic heart failure 

Answer: The patient is high likely exposed to