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: demerol attending: chief complaint: left flank pain heart beating fast major surgical or invasive procedure: left percutaneous nephrostomy tube, . history of present illness: 59 y/o female with pckd who presented to hospital on with left flank pain, nausea, vomiting, and left ureteral stone seen on ct. patient was sent home with percocet, bactrim, zofran, and told to return to the ed there today to recheck her creatinine. she returned to the ed this morning for the lab draw, and creatinine was elevated to 4.33 from baseline of 2.6. she was given iv pain meds, antiemetics, and antibiotics and then transferred to for further management. she complains of sharp, stabbing left flank pain radiated to her left groin. she was nauseated, which was alleviated by medication given at hospital. she vomited once yesterday. she complains of dysuria, urinary urgency, frequency. she denies fevers, rigors, chest pain, dyspnea. she reports no history of nephrolithiasis. past medical history: polycystic kidney disease cri, baseline creatinine 2.6 hypertension gout hyperlipidemia paroxysmal atrial fibrillation migraine . s/p hysterectomy s/p laparoscope cholecystectomy s/p tubal ligation social history: lives with her male partner. denies use of alcohol or illicits. has smoked half a pack per day "forever." family history: denies family history of cad or afib. father had polycystic kidney disease. physical exam: on transfer to medical service: vs: t 98 hr138 bp124/76 rr20 o2 sat 97% on ra gen: nad, seated upright in bed neuro: aao x 3 neck: no jvd, jvp not elevated cv: tachycardic, irregularly irregular, s1 s2, no murmurs, rubs or gallops pulmonary: crackles at the bases bilaterally of the way up abd: active bowel sounds, soft, non tender, non distended, no hepatosplenomegaly, no rebound or guarding back: no cva tenderness, left nephrostomy tube and drain in place extremities: warm, well perfused, 1+ edema in the lower extremities . pertinent results: 09:00pm blood wbc-13.3* rbc-2.84* hgb-9.0* hct-28.7* mcv-101* mch-31.8 mchc-31.5 rdw-14.1 plt ct-216 09:00pm blood neuts-77.9* lymphs-18.8 monos-2.6 eos-0.3 baso-0.4 09:00pm blood pt-11.0 ptt-26.8 inr(pt)-0.9 09:00pm blood glucose-119* urean-58* creat-4.3* na-136 k-5.0 cl-101 hco3-23 angap-17 09:00pm blood alt-29 ast-37 alkphos-131* totbili-0.4 09:00pm blood lipase-147* 09:00pm blood ck-mb-3 ctropnt-<0.01 04:23am blood calcium-7.9* phos-4.0 mg-1.5* iron-21* 04:23am blood caltibc-226* vitb12-314 folate-greater th ferritn-222* trf-174* 04:23am blood tsh-0.42 09:27pm blood lactate-1.1 . 09:20pm urine color-yellow appear-clear sp -1.009 09:20pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-mod 09:20pm urine rbc-* wbc->50 bacteri-mod yeast-none epi-0 . . ct-abdomen/pelvis : ct of the abdomen without intravenous contrast: in the visualized pelvis, there is bibasal atelectasis. there is no pleural mass, pleural effusion or pneumothorax. the heart is normal in size. there is no pericardial effusion. in the abdomen, evaluation of solid organ system is without contrast. the liver appears similar to prior with multiple hypodensities, likely cysts throughout the liver. there has been a cholecystectomy. the pancreas appears normal. the spleen appears normal. the adrenals are normal. there are innumerable bilateral cysts in the massively enlarged kidneys, characteristic of adult polycystic kidney disease. in the left kidney, there are multiple stones within the kidney parenchyma and cenrtal collecting system that appear similar to the previous scan. although, there is an apparent new collection of stones in the proximal ureter (series 301a, image 29), and this may represent the stone seen on the outside study (series 200b, image 39). the configuration of the right kidney appears similar to prior. abdominal loops of bowel appear normal. there is no abdominal free air, free fluid or pathologic lymphadenopathy. the abdominal aorta is normal in caliber and course and demonstrates atherosclerotic calcifications. ct of the pelvis without intravenous contrast: pelvic loops of bowel appear normal. the bladder and distal ureters appear normal. there is no pelvic free air, free fluid or pathologic lymphadenopathy. musculoskeletal: there is no suspicious osteolytic or osteoblastic lesion. multilevel degenerative changes are seen in the spine. impression: overall, very similar appearance of polycystic kidneys with one group of anterior stones now apparently in the proximal left ureter. . ir-guided percutaneous nephrostomy : (preliminary report) successful placement of 8 french nephrostomy tube into the left kidney. . ecg : atrial fibrillation with rapid ventricular response. delayed r wave progression. modest st-t wave changes. findings are non-specific but clinical correlation is suggested. no previous tracing available for comparison. . ecg : atrial fibrillation with rapid ventricular response. the findings are as outlined on previous tracing of except that ventricular rate is slower. . tte : the left atrium is elongated. the right atrium is moderately dilated. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is mild to moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. mild right ventricular dilation. moderate tricuspid regurgitation. mild to moderate pulmonary hypertension. mild aortic regurgitation. hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 07:20am 8.2 2.67* 8.5* 26.2* 98 31.9 32.5 15.8* 217 08:50am 9.3 2.78* 8.8* 27.9* 101* 31.8 31.6 16.3* 202 07:25am 8.3 2.73* 8.6* 27.5* 101* 31.6 31.4 16.4* 180 04:23am 9.2 2.61* 8.3* 25.6* 98 31.8 32.4 16.4* 125* 09:00pm 7.8 2.40* 7.9* 24.5* 102* 32.9* 32.1 14.0 152 05:27am 8.6 2.45* 8.1* 25.0* 102* 33.2* 32.5 14.1 154 09:00pm 13.3* 2.84* 9.0* 28.7* 101* 31.8 31.5 14.1 216 differential neuts bands lymphs monos eos baso atyps metas 09:00pm 77.9* 18.8 2.6 0.3 0.4 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 07:20am 217 08:50am 202 07:25am 180 04:23am 125* 09:00pm 152 05:27am 154 09:00pm 216 09:00pm 11.0 26.8 0.9 chemistry renal & glucose glucose urean creat na k cl hco3 angap 07:20am 101 23* 2.5* 143 4.7 114* 20* 14 08:50am 103 27* 2.5* 142 4.7 113* 17* 17 07:25am 109* 32* 2.6* 143 5.0 114* 17* 17 04:23am 119* 40* 3.3* 141 4.7 114* 17* 15 09:00pm 270* 46* 3.6* 138 4.3 110* 17* 15 05:27am 117* 61* 4.6* 137 4.8 107 20* 15 09:00pm 119* 58* 4.3* 136 5.0 101 23 17 estimated gfr (mdrd calculation) estgfr 09:00pm using this1 using this patient's age, gender, and serum creatinine value of 4.3, estimated gfr = 11 if non african-american (ml/min/1.73 m2) estimated gfr = 13 if african-american (ml/min/1.73 m2) for comparison, mean gfr for age group 50-59 is 93 (ml/min/1.73 m2) gfr<60 = chronic kidney disease, gfr<15 = kidney failure enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 09:00pm 52 09:00pm 29 37 131* 0.4 other enzymes & bilirubins lipase 09:00pm 147* cpk isoenzymes ck-mb ctropnt 09:00pm 3 <0.011 <0.01 ctropnt > 0.10 ng/ml suggests acute mi chemistry totprot albumin globuln calcium phos mg uricacd iron 07:20am 9.1 3.7 1.5* 08:50am 9.1 3.5 1.6 07:25am 8.6 1.9 04:23am 7.9* 4.0 1.5* 21* 05:27am 8.2* 1.9 hematologic caltibc vitb12 folate ferritn trf 04:23am 226* 314 greater th1 222* 174* greater than 20 ng/ml pituitary tsh 04:23am 0.42 lab use only holdblu 04:23am hold1 hold discard greater than 24 hrs old blood gas whole blood, miscellaneous chemistry lactate 09:27pm 1.11 green-top hematology general urine information type color appear sp 07:30pm straw clear 1.011 06:18am straw cloudy 1.013 source: cvs 09:20pm yellow clear 1.009 dipstick urinalysis blood nitrite protein glucose ketone bilirub urobiln ph leuks 07:30pm tr neg 30 neg neg neg neg 5.5 neg 06:18am mod neg 30 neg neg neg neg 5.5 lg source: cvs 09:20pm lg neg tr neg neg neg neg 5.0 mod microscopic urine examination rbc wbc bacteri yeast epi transe renalep 07:30pm 1 2 few none 0 <1 06:18am 12* >1000* many none 1 source: cvs 09:20pm * >50 mod none 0 07:30pm 06:18am source: cvs 09:20pm chemistry urine chemistry hours creat na k cl 11:43pm random 19 35 6 32 source: cvs 6:18 am urine source: cvs. **final report ** urine culture (final ): klebsiella pneumoniae. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 8 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 2 s ciprofloxacin--------- 2 i gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s brief hospital course: micu course: 59 yof w/ a h/o polycystic kidney disease, baseline cr of 2.6, presented initially with obstructing l uretolithiasis and urinary tract infection on - being transferred to the icu for new atrial fibrillation with rvr and hypotension. . # atrial fibrillation with rvr: the patient has no documented history of atrial fibrillation. she was asymmptomatic during afib with rvr. no thyroid issues in the past, no echo in the past. rvr was thought likely related not only to atrial fibrillation but also to fever / infection and hypovolemia. hypovolemia may be related not only to infection and vasodilation but also to post obstructive diuresis from the percutaneous nephrostomy tube placed today. tsh was within normal range. patient was given ivf boluses until she appeared re-hydrated. patient received 5mg iv lopressor x 2 with no effect on hr but decrease in bp, then was given 5mg iv diltiazem x 3. patient then spontaneously converted to normal sinus rhythm. patient was maintained on po diltiazem 30mg qid. on the morning of , patient had a transient episode of afib and she spontaneously converted back to normal sinus rhythm without any additional intervention. patient was seen by cardiology, who recommended aspirin and tte. given patient's history of pckd, the decision of starting aspirin and/or starting anticoagulation was left to urology service. tte was ordered. the preliminary read of the tte showed elevated right heart pressure and mild to moderate pulmonary hypertension with and ef of 55%. the patient was transferred to medicine on for further managment of her afib before discharge. on the patient was put on 60mg po qid of diltiazem. she remained in normal sinus rhythm all through the night and on the morning of the patient woke up with a migraine headache. she took her morning dose of po dose of diltiazem. she felt nauseous with the migraine and the proceeded to throw up several times. simultaneous she felt her heart beating fast. ekg was done and she was found to be in afib with a ventricular rate in the 140s to 150s and an sbp in the 140s. she did not have chest pain and her o2 saturation remained around 94. she was given 5mg iv of diltiazem which brought her heart rate down into the 90s and back into sinus rhythm. she then received an additional 30mg po and her dose was changed to 90mg po qid. she remained in sinus for the rest of the day on . the patient refused to start 325 mg of aspirin on but began taking aspirin on 325mg po. she was in sinus rhythm and stable for the rest of the day on and overnight to stating that she felt much better. her blood pressure ranged from a sbp of 126-148 overnight from to with a hr in the 80s. the morning of she walked with the nurse around the unit and remained in sinus with a hr in the 80s, o2 saturation at 95%, sbp in the 120s and felt well. she expressed a desire to leave the hospital. # uti: patient has a l perc nephrostomy tube in place for infected stone. the patient has a gnr uti. urine culture grew out gnr, and blood cultures were no growth to date. patient was initially on ampicillin / ceftriaxone, the coverage was changed to ceftriaxone when transferred to . she had occasional low bps, was also tachycardic and in afib/rvr. the patient was transferred to medicine on and was switched from ceftriaxone to cefpodoxime 100 mg twice a day on for a 14 day course. her drain remained in place and she did not have any cva tenderness. she will go home with services to help her with the drain and follow up with dr. in clinic. . # acute on chronic renal failure: baseline cr around 2.6 in the setting of polycystic kidney disease. creatinine was 4.3 on admission. this acute renal failure is likely related to l sided stone as well as pre-renal azotemia. creatinine trended down with volume repletion and on her cr was back to it's baseline at 2.55. . # macrocytic anemia: mcv 101 on admission. vitamin b12 was low normal at 314 pg/ml (normal range 240 - 900). fe studies were consistent with anemia of inflammation (anemia of chronic disease). anemia is also likely related to chronic kidney disease. this anemia is likely a contributing factor to her tachycardia. patient was transfused 1u prbc which increased her hct from 24.5 to 25.6. . # hyperlipidemia: home lovastatin was continued. . # non gap acidosis: this non-anion gap acidosis was likely related to renal failure also could be due to ivf (ns). lr was given later for fluid resuscitation. medications on admission: atenolol 25mg po daily lisinopril 40mg po daily allopurinol 100mg po daily lovastatin 40mg po daily omeprazole unknown dosage percocet prn bactrim, prescribed at ed discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 5. cefpodoxime 100 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 11 days. disp:*23 tablet(s)* refills:*0* 6. allopurinol 100 mg tablet sig: one (1) tablet po once a day. 7. compazine 5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea or migraine: please take for nausea or migraine. disp:*60 tablet(s)* refills:*0* 8. lisinopril 5 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. colace 50 mg capsule sig: capsules po twice a day as needed for constipation. 10. lovastatin 40 mg tablet sig: one (1) tablet po once a day. 11. diltiazem hcl 360 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: 1. pyelonephritis and obstructing left ureteral stone status post left percutaneous nephrostomy tube. 2. paroxysmal atrial fibrillation with rapid ventricular response 3. migraine . secondary diagnoses: - hypertension - polycystic kidney disease discharge condition: stable discharge instructions: you were initially hospitalized here for treatment of an infected kidney stone in your left kidney and a kidney infection. a percutaneous nephrostomy was done and you were placed on antibiotics. your stay was complicated by the fact that your heart went into a rhythm called atrial fibrillation which made you feel your heart beating fast. you were placed on a medication called diltiazem which you should continue to take when you leave the hospital. this rhythm can be triggered by many things including infection and stress and you should seek medical attention if you feel your heart beating fast when you leave the hospital. you should follow up with your primary care doctor and discuss arranging follow up for you with a cardiologist to manage your cardiac medications. -you may shower but do not bathe, swim or otherwise immerse your nephrostomy incision for 4 weeks. -please change your dressings around the nephrostomy as often as needed to keep your skin as dry as possible. -do not lift anything heavier than a phone book for 2 weeks. -tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. replace tylenol with narcotic pain medication. max daily tylenol dose is 4gm, note that narcotic pain medication also contains tylenol (acetaminophen) -do not drive or drink alcohol while taking narcotics -colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -resume all of your home medications, except for atenolol, which was stopped because this is not safe in the setting of kidney disease -you were started on a new medication, diltiazem, for control of the rate of your atrial fibrillation -your lisinopril dose was decreased to 5mg daily because you were placed on diltiazem which can also lower your blood pressure -you should follow up with your doctors about the reduced dose of lisinopril and they can decide whether to increase it or not -you should also take a full dose aspirin 325mg every day for stroke prevention since you have atrial fibrillation. we highly recommend that your follow up with your pcp the day of discharge and arrange for continued management of your cardiac condition and medications with a cardiolgist. -please take antibiotics as prescribed until finished -if you have fevers > 101.5 f, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. -call dr. office () upon discharge to schedule a follow-up appointment to discuss removal the obstructing stone and the percutaneous nephrostomy tube. followup instructions: contact dr. office () upon discharge to arrange follow up appointment for removal of percutaneous nephrostomy tube and obstructing kidney stone. you have an appointment with your pcp . on at 2:30 pm (please call dr. office and reschedule if this time does not work for you). you should discuss finding a cardiologist with dr. to follow up on your paroxysmal atrial fibrillation and taking 325mg aspirin daily with regards to your kidney function. procedure: percutaneous nephrostomy without fragmentation diagnoses: acidosis anemia in chronic kidney disease tobacco use disorder friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site acute kidney failure, unspecified atrial fibrillation other chronic pulmonary heart diseases hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia hypovolemia hydronephrosis calculus of ureter migraine, unspecified, without mention of intractable migraine without mention of status migrainosus renal failure, unspecified acute pyelonephritis without lesion of renal medullary necrosis polycystic kidney, autosomal dominant uric acid nephrolithiasis 

Answer: The patient is high likely exposed to