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 attending: chief complaint: shortness of breath major surgical or invasive procedure: - upper endoscopy - right heart catheterization - left heart catheterization history of present illness: mr. is a 36 m with a history of hiv not on haart, non-ischemic dilated cardiomyopathy with ef of %, and chronic transaminitis who presents with worsening dyspnea on exertion. he states that since his last hospitalization (discharged ), he has been taking his medications as prescribed. however, while he has felt occasionally well for days at a time, every 3-4 days he has a "bad" day where he feels very ill, though the nature of symptoms on bad days has varied. on this occasion, he began feeling poorly on saturday, when he had decreased energy and also developed non-productive cough. he is not aware of having had fever at home, and no chills. he noted worsening doe over this time interval as well, though he is now fairly limited at baseline in terms of what he is able to tolerate in the way of activity (has had to scale back his dog-walking business). he was out with his dogs today when one ran away, and he was forced to it. when he caught up with the dog, he was nauseous and vomited x 1. he also felt extemely weak and sob. as he had also noticed that his weight has increased by 3.5 lbs since friday, he called dr. who instructed him to come into the ed for evaluation. . in the ed, initial vitals were t 100.3, hr 129, bp 100/80, rr 18, 100% on ra . he was given mg iv furosemide given his history of heart failure. d-dimer returned positive, so cta was done but negative for pe. abdominal ct and cxr did not reveal acute pathology. he received morphine for pain control (atypical chest pain, abdominal pain). during his time in the ed, he was tachycardic to 100s-130s and tachypneic to 40s. he was evaluated by the cardiology fellow and started on nitro gtt before transfer to the ccu. at the time of transfer, vitals were t 97.4, hr 121, bp 95/78, rr 42, sao2 100% 3l nc. . on arrival to the floor, he remains dyspneic and also nauseous, though says his breathing is slightly better than on presentation. he has continued chest/abdominal pain which was slightly improved by morphine in the ed. . on review of systems, he endorses chest pani (chronic/constant, "tightness" in center chest) and abdominal pain (worst in the epigastrum, associated with belching and a sensation of bloating, feels like "a knot or something hard....like after you get punched") which is brought on by palpation but not present at rest. he also reports pain in his right calf since earlier today. he has had episodes of orthopnea at home, to the point where a few nights ago he was forced to sleep in a chair because it was the only way he could feel comfortable. he reports diarrhea with up to bowel movements per day, yellowish, no blood, of varying volumes. he is awakened from sleep by the diarrhea. he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors though does get occasional nightsweats. he denies exertional buttock or calf pain. cardiac review of systems is notable for absence of ankle edema, palpitations, syncope or presyncope. all of the other review of systems were negative. past medical history: - hiv (diagnosed , cd4: 627, vl: 2,880 copies/ml in ; initially on haart but stopped several years ago when insurance ran out) - non-ischemic dilated cardiomyopathy with ef of % (etiology unknown, but felt secondary to hiv vs. crystal meth abuse) - chronic transaminitis (hcv vs. congestive hepatopathy) - hepatitis c virus positive - depression - hpv social history: social history: lives alone, msm with 1 male partner. as dog walker. tobacco: denies ever using tobacco. etoh:denies drinking any etoh recently, no h/o of abuse, drinks socially 1-2x/month. illicit drugs: amphetamine and iv crystal meth user, denies since discharge (). no cocaine or heroin. family history: - mother and many relatives of mother: diabetes - father: cva - no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: on admission: vs: t=97.6 bp=97/70 hr=118 rr=24 o2 sat=100% on 2l general: thin young man tachypneic at rest, worse with speech, appearing uncomfortable. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp to just above clavicle cardiac: pmi displaced, distant s1/s2, +2/6 systolic murmur over the llsb lungs: no chest wall deformities, scoliosis or kyphosis. resp were rapid and shallow. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ttp over epigastrum, no rebound/guarding. belly firm but not tense. hepatosplenomegaly. no abdominal bruits. extremities: no c/c/e. ttp of posterior left calf, though no erythema or enlargement. skin: no stasis dermatitis, ulcers, scars, or xanthomas. initially dry, but later markedly diaphoretic on repeat exam pulses: 2+ dp pulses . on discharge: tmax: 37.4 ??????c (99.4 ??????f) tcurrent: 37.2 ??????c (98.9 ??????f) hr: 99 (99 - 131) bpm bp: 100/58(68) {88/44(55) - 110/80(85)} mmhg rr: 25 (16 - 35) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) wgt (current): 71.6 kg (admission): 79 kg height: 70 inch jvp: 8 cm h2o lungs: trace crackles at bases bilaterally, fair air movement cardiac: tachycardic, rr, summation gallop, no murmur heard today abdomen: hepatosplenomegaly, reduced fluid wave compared to previous exams extremities: warm and well perfused, 1+ dp/pt with no edema bilaterally left calf non-tender to palpation with reduced erythema compared to previous exams. no cords felt. groin and right radial site: clean/ dry/ intact pertinent results: basic admission labs: 06:55pm blood wbc-8.1 rbc-5.27 hgb-13.6* hct-41.9 mcv-80* mch-25.9* mchc-32.5 rdw-16.9* plt ct-298 06:55pm blood pt-19.5* ptt-28.1 inr(pt)-1.8* 06:55pm blood glucose-120* urean-29* creat-1.3* na-126* k-4.7 cl-97 hco3-14* angap-20 06:55pm blood alt-623* ast-588* alkphos-103 06:55pm blood calcium-8.3* phos-2.6* mg-2.0 . other significant labs: 05:40pm blood urean-47* creat-1.8* na-118* k-6.7* cl-90* hco3-16* angap-19 06:55pm blood probnp-8715* 07:50pm blood d-dimer-7827* 06:55pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:22pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-pos mthdone-neg 11:22pm urine amphetamines, gc/ms-positive 04:06am blood tsh-2.1 09:20pm blood cortsol-15.7 discharge labs: 05:53am blood wbc-7.6 rbc-5.28 hgb-13.7* hct-42.1 mcv-80* mch-26.0* mchc-32.6 rdw-16.7* plt ct-302 05:53am blood pt-13.5* ptt-29.5 inr(pt)-1.1 09:01am blood na-134 k-4.5 cl-97 05:53am blood glucose-95 urean-16 creat-1.1 na-130* k-6.0* cl-93* hco3-29 angap-14 09:01am blood alt-138* ast-70* ld(ldh)-330* alkphos-99 totbili-1.7* 09:01am blood albumin-3.5 05:53am blood calcium-9.1 phos-3.4 mg-2.3 . microbiology: blood cultures: x2, , and x2 all no growth urine cultures: and both no growth . imaging: ecg (): sinus tachycardia. non-specific st-t wave . . cxr (): marked cardiomegaly, similar compared to the prior study, without pulmonary edema. . ct chest/abd/pelvis (): 1. no central pulmonary embolism. evaluation of the subsegmental pulmonary arterial branches particularly within the lung bases is limited due to poor bolus timing secondary to underlying cardiac dysfunction. 2. marked cardiomegaly with dilated main pulmonary artery measuring 3.8 cm, findings suggestive of underlying pulmonary hypertension. 3. moderate intra-abdominal ascites, similar compared to prior. 4. stable hyperdense lesion in interpolar region of the left kidney, possible hemorrhagic cyst, but not completely characterized on this single phase examination. further evaluation with renal ultrasound is recommended non-emergently. 5. gallbladder wall thickening likely secondary to cardiac dysfunction and third spacing. correlation with clinical signs and symptoms and liver function tests is recommended. 6. heterogeneous enhancement of the liver compatible with passive congestion from cardiac dysfunction. . lle u/s (): deep vein thrombosis seen in the left tibial veins extending into the popliteal, lesser saphenous and the inferior portion of the left femoral vein. . renal u/s (): impression: 1. exophytic partially thin-walled mass in the interpolar region of the left kidney appears stable in size over eight years. some through transmission may be present and consequently this may represent a cyst; however, this cannot be fully characterized with ultrasound. this structure could be followed for stability with ultrasound or mri. 2. trace of ascites. 3. incidentally noted, the liver is diffusely echogenic consistent with fatty infiltration. other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. . upper gi endoscopy (): congestion and abnormal vascularity in the whole stomach compatible with portal gastropathy. possible small grade i varix in the gastroesophageal junction . cardiac cath (): comments: 1. seletive coronary angiography of this right dominant system demonstrated no angiographically apparent coronary disease. 2. resting hemodynamic measurements revealed elevated left and right sided filling pressures with rvedp 14mmhg and wedge pressure of 14mmhg. there was mild pulmonary arterial systolic hypertension with pasp of 37 mm hg. the cardiac index prior to milrinone initiation was low at 1.8ml/min/m2. 3. with a bolus of milrinone (50 mcg/kg) followed by a drip at a rate of 0.375 mcg/kg the cardiac index improved from 1.8 to 2.3 and the wedge pressure improved from 20mm hg to 15 mmhg. final diagnosis: 1. coronary arteries are normal. 2. severe systolic ventricular dysfunction. 3. improvement in ventricular function with milrinone initiation. 4. mild pulmonary arterial hypertension . echo report (on milrinone drip): the left atrium is moderately dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is severely dilated. there is severe global left ventricular hypokinesis (lvef = 15%). the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: markedly dilated left ventricle with severe systolic dysfunction, c/w noncoronary cardiomyopathy. dilated and mildly hypokinetic right ventricle. mild mitral regurgitation. mild pulmonary hypertension. compared with the prior study (images reviewed) of , severity of mitral regurgitation has decreased. lv cavity is slightly larger. the other findings are similar. brief hospital course: pt is a 36yo male with hep c, hiv not on haart, dilated cardiomyopathy of unclear etiology with an ef of %, and transaminitis who presented with worsening shortness of breath likely due acute on chronic heart failure. . active issues . # dilated cardiomyopathy: etiology of pt's cardiomyopathy is unclear. possibly related to his hiv status or chronic amphetamine use. dr. was consulted and he felt a right heart catheterization would be helpful to better evaluate the severity and etiology of patient's heart failure. right heart catheterization showed no angiographically apparent coronary disease, but elevated left and right sided filling pressure with rvedp 14 mmhg and wedge pressure of 14 mmhg, as well as mild pulmonary systolic hypertension with pasp of 37 mmhg. a milrinone drip was started then patient loaded on oral digoxin. significant improvement in left ventricular function was noticed with improvement of cardiac index from 1.8 to 2.3 ml/min/m2 and wedge pressure from 20 to 15 mmhg. . # acute exacerbation of chronic heart failure: given his history of dilated cardiomyopathy (ef 10%), weight gain, and elevated bnp, patient's acute dyspnea was thought to be secondary to a chf exacerbation. possible triggers include illicit drug use given patient's positive urine tox (though patient denies) or medication non-compliance/undermedication. pe also possible given patient's complaint of pleuritic chest pain and his asymmetric calf swelling later found to be a dvt. patient was aggressively diuresed, initially on a lasix gtt then later on oral torsemide. pt was initially started on a nitro gtt as well to improve pulmonary vascular congestion which was quickly weaned off. the efficacy of diuresis was significantly improvement since the initiation of milrinone drip, with the net fluid balance of negative 9.5 liter in 3 days. his beta-blocker was held in the setting of his acute exacerbation and an ace was held in the setting of his elevated creatinine. pt was felt to be stably diuresing on oral torsemide at the time of his leave. outpatient issues - patient was instructed to take torsemide 20 mg daily - patient will need close monitoring of electrolytes, especially cr given the newly started diuresis regimen - on discharge, patient has a dry weight of 71.6 kg . he was instructed to measure his weight daily. - upon discharge, patient taking oral digoxin, torsemide, lisinopril . # left lower extremity dvt: on presentation patient was complaining of left calf pain. ultrasound showed a large dvt extending into the thigh. patient was started on heparin gtt for anticoagulation. hepatology performed an egd in this patient to determine whether pt had any contraindications to anticoagulation and found only a small grade i varix and signs of portal gastropathy. they recommended that coumadin therapy be initiated in this patient with an inr goal of 2.5-3 given patient's baseline liver dysfunction and elevated inr. lovenox bridge was provided while awaiting patient's inr to reach therapeutical range. outpatient issues: - started lovenox 80 mg injection twice daily for blood clots - started warfarin 4 mg po qd - patient was instructed to start routine inr check through at . . # pleuritic chest pain: pt intermittently complains of right-sided chest pain located near the apex and sometimes traveling to the back of his shoulder. pain unlikely to be cardiac in origin given patient's repeatedly negative ekgs. though ct pe on admission was negative for pe, the study was somewhat limited given patient's poor ef and the incorrect timing of the contrast. however, further studies have thus far been deferred as patient is currently being appropriately anticoagulated for his confirmed dvt. further discussion will need to occur about whether patient would benefit from an ivc filter. . # hepatopathy/transaminitis: pt has had elevated liver enzymes for the past several admissions, possibly related to his recently discovered hep c viral load or congestive hepatopathy from his cardiac dysfunction. there are clear signs of portal hypertension on egd and other imaging has shown some ascites and a diffusely echogenic appearance of the liver that cannot rule out cirrhosis. patient will likely require an outpatient liver biopsy to better characterize the extent of his liver disease if his lfts do not completely recover with decreased volume load outpatient issues - patient has an appointment with dr. on for hepatology follow-up. - patient need recheck of lft prior to the hepatology appointment . # kidney cyst: noted on ct imaging. found to be stable for the past eight years on follow-up ultrasound, so likely requires no further work-up. . # hyponatremia: patient's sodium has been low early in admission, likely a hypervolemic hyponatremia given patient's cardiac and liver disease. in addition to his ongoing diuresis, patient was started on 1000cc fluid restriction though there is some question as to his compliance with this. upon admission to the ccu with close monitoring of i/o and relaxation of fluid restriction to 1500 ml/day, na recovered to 134 on discharge. . # - respirations: pt was noted to have a - respiratory pattern while sleeping and occasionally while awake as well. pt might benefit from bipap or cpap though he has tolerated this poorly in the past. pulmonology was consulted and pt will be set up with a sleep study as an outpatient. outpatient issues - sleep studies have been discussed with patient. patient is aware that this could be set up through his primary care doctor. . # abdominal pain: etiology unclear; possibly there is a component of gerd given epigastric tenderness, belching. possibly relates to transaminitis/hepatic congestion or his portal gastropathy. could also be due to pressure secondary to ascites. . # acute kidney injury: patient's creatinine has been elevated throughout this admission. appears to be pre-renal based on his urine lytes so likely due to poor forward flow. his creatinine was much improved since the initiation of milrinone drip. upon his leave of hospital, his serum creatinine returned to 1.1. . chronic issues . # hiv: off of haart, though last cd4/vl showed reasonable control. patient need follow-up with id as an outpatient to better follow his disease progression. . # substance abuse: patient denies recent methamphtamine use but his urine tox screen is confirmed positive for amphetamines by gc/ms. social work, patient is hesitant to seek treatment for his addiction and becomes defensive when asked about his drug use. . transitional issues . # patient left ama due to difficulty with his business/ dogs living at his house and not having anyone to help feed/ clean the dogs. we attempted to have social work help with the issue with the dogs, but patient refused. # please contact / social work team early if patient re-admitted. # patient expressed to social work a frustration with what he views as poor communication on the part of the medical staff. special attempts should be made to make sure patient is always informed and updated about his plan, including minute details about test results and medication changes. # patient has cardiology followup with dr. on for furhter evaluation of his congestive heart failure. patient on 2.5mg lisinopril, could not tolerate 5mg previously, although up titration could be considered. # patient will also follow up with and diuresis clinic for weight and possible lasix iv (patient weighed 71.6 kg at discharge). # patient has infectious followup with dr. on for further evaluation of his hiv and hepatitis c and possibly starting antiretroviral therapy as we believe that his cardiomyopathy is more likely infectious in etiology than due to his ivda. # patient has hepatology followup with dr. on for further evaluation of his transaminitis and hepatitis c. # patient has a scheduled followup with his primary care doctor dr. at at on and for to weight the patient and check electrolites/ renal function/ liver function since patient started digoxin, torsemide, lisinopril and we would like lfts prior to his liver appointment. his sleep studies shall be arranged through dr. . patient should have aggressive electrolyte monitoring. medications on admission: - metoprolol succinate 25 mg po daily - furosemide 10 mg po daily - spironolactone 12.5 mg po daily - ambien prn - tylenol pm prn discharge medications: 1. warfarin 2 mg tablet sig: two (2) tablet po once a day. disp:*60 tablet(s)* refills:*0* 2. spironolactone 25 mg tablet sig: 0.5 tablet po daily (daily). 3. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 5. enoxaparin 80 mg/0.8 ml syringe sig: one (1) subcutaneous q12h (every 12 hours). disp:*14 syringe* refills:*2* 6. torsemide 20 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 7. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: - systolic heart failure (ejection fraction 15%) - deep vein thrombosis - portal gastropathy - congestive hepatopathy - acute renal failure - hyponatremia secondary: - amphetamine abuse discharge condition: stable although high likelyhood of re-admission as patient leaving ama and not fully diuresed. patient still with summation gallop upon discharge, as well as mild crackles at bases. blood chemistries/ liver function tests improving but not at baseline. discharge instructions: dear mr. , you were admitted with shortness of breath that was most likely due to your heart failure and extra fluid in your system. you were treated with medications to help remove fluid with significant improvement in your symptoms. while you were here, you were also found to have blood clots in your left leg and were started on blood thinning medications. you had an egd study to evaluate your abdominal pain and for dilated veins in the esophagus, and you were found to have irritation of the stomach likely related to liver dysfunction from your heart failure (veins in the esophagus were near-normal). you were noted to have periods of apnea (stopped breathing) while you were sleeping, and you were seen by the pulmonary team who recommend an outpatient sleep study. your shortness of breath and chronic chest and abdominal pain is likely all related to your heart failure and the buildup of fluid in your system. therefore, it is very important that you take your medications as prescribed, keep all of your doctors , and monitor your fluid intake. you should weigh yourself at home every morning and call dr. office if your weight increases by more than 3 lbs (weigh yourself as soon as you get home for a baseline on your home scale). you should monitor your fluid intake (beverages and liquid foods) and try to limit yourself to 1500 ml (1.5l) of fluid daily. finally, it is very important that you stop using crystal meth or other amphetamines, as these may be the cause of your heart failure and can worsen your condition. you did not want further information about support for quitting during this admission, but if you change your mind please speak to dr. or one of your other physicians as there are many resources available to assist you with staying clean. as you know, it was our recommendation that you remain in the hospital for further medical care. you have elected to be discharged against medical advice. please call dr. or dr. if you experience a recurrence of symptoms right away, as this may help to keep you out of the hospital. we have made the following changes to your medication regimen: - begin taking lovenox 80 mg injection twice daily for blood clots - begin taking warfarin 4 mg by mouth daily for blood clots - begin taking lisinopril 2.5 mg by mouth daily for your heart failure - begin taking digoxin 0.125 mg by mouth daily for your heart failure - begin taking torsemide 40 mg by mouth daily for your heart failure (this is a diuretic to help decrease fluid) - begin taking omeprazole 20 mg by mouth daily for your stomach pain - stop taking furosemide (this will be replaced by torsemide) followup instructions: 1. primary care department: when: wednesday at 10:20 am with: , md building: sc clinical ctr campus: east best parking: garage *you need to call your insurance to list dr. as your pcp before this appointment. *you will need to have your electrolytes checked at this appointment. 2. cardiology department: cardiac services when: thursday at 10:00 am with: , md building: campus: east best parking: garage 3. clinic when: thursday at 11:00 am with: , np building: 4. through at . you have already been contact regarding follow up blood tests on monday. please arrange to have your inr checked then. 5. infectious disease department: when: wednesday at 12:00 pm with: , md, phd building: sc clinical ctr campus: east best parking: garage 6. liver provider: , (liver center) date: time: 08:00a location: lm bldg (), procedure: combined right and left heart cardiac catheterization other endoscopy of small intestine combined right and left heart angiocardiography diagnoses: other primary cardiomyopathies acidosis congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma acute kidney failure, unspecified hyposmolality and/or hyponatremia portal hypertension other chronic pulmonary heart diseases other specified disorders of stomach and duodenum acute on chronic systolic heart failure asymptomatic human immunodeficiency virus [hiv] infection status painful respiration acute venous embolism and thrombosis of deep vessels of distal lower extremity 

Answer: The patient is high likely exposed to