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: hydrochlorothiazide attending: chief complaint: weakness major surgical or invasive procedure: intubation and extubation cardiac catheterization intra-arterial balloon pump placement rij placement and removal pa catheter placement and removal lij placement and removal history of present illness: 83f with chronic systolic chf (ef 40%), transferred from hospital for further management of rapid atrial fibrillation and acute on chronic systolic chf. she states that she had been feeling weak for several weeks prior to her admission there at , with several adjustments to her medications by her pcp. was initially stopped on hydrochlorthiazide about a month prior to hospitalization due to rash, and then started on bumex. this was later increased to 1mg on . it was stopped on due to thinking that this was contributing to her weakness, but she felt no better with discontinuation and was admitted to . . during this time, she also felt progressively worsening shortness of breath that was exacerbated by movement. she also experienced increasing orthopnea as well as increased swelling of her hands and feet over the same period. she had been started on the bumex due to some of this swelling occuring prior to her feeling weak, but this has worsened markedly. . on admission to , admission ekg showed sinus rhythm without ischemic changes. serial cardiac biomarkers were negative. admission bnp 6929. cxr showed increased interstitial markings but no infiltrate, and small l>r pleural effusions. tte shwoed normal lv size, septal wall hypertrophy, lvef 60-65%, 3+ mr, and mildly elevated pa pressures. she was also found to have a uti, and was treate for citrobacter koseri uti with levofloxacin. she does note that 1 week prior to her admission she had an episode of chills, although no frank fevers. on admission she had a significant elevation in her wbc count to 14k with 15% bands. her hospital course complicated by with rvr (as high as 160 bpm) on hd#2 which was treated with diltiazem iv which initially converted back to sinus rhythm. had a rash to hctz and was diuresed with ethacrynic acid/ she was also swabbed for h1n1 which came back negative. she continued to revert back to with rvr and was transferred to . . review of symptoms: denies chest pain, palpitations, melena, brbpr. no pleurisy. she did go on a bus ride prior to her feeling poorly of ~1hr duration. had some nausea prior to admission but none since. reports dysgusia and lack of appetite. unclear about any weight gain or loss. past medical history: 1. cardiac risk factors:: diabetes no, dyslipidemia no, hypertension no 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: chronic systolic chf (ef 40% by tte at osh) 3+ mitral regurgitation hypothyroidism endometrial ca s/p tah/bso glaucoma social history: husband died in . has 2 children, continues to volunteer at up until this recent illness. had previously been independent in her iadls, including grocery shopping. -tobacco history: none -etoh: 1 drink qmonth at most -illicit drugs: none family history: son has history of svt on digitalis. otherwise non-contributory. physical exam: vs: t=97.1 bp=96/57 hr=134 rr=24 o2 sat=97% on 2l general: elderly woman in nad. 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 of 12 cm to angle of mandible cardiac: irregularly irregular, no m/r/g lungs: diffuse fine crackles bilaterally up to of way up thorax. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. pitting sacral edema extremities: 3+ pitting pedal edema. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: 2+ radial and dp bilaterally pertinent results: admission labs: 11:00pm blood wbc-23.4* rbc-3.77* hgb-11.0* hct-33.2* mcv-88 mch-29.2 mchc-33.1 rdw-13.3 plt ct-291 11:00pm blood neuts-71* bands-2 lymphs-16* monos-6 eos-2 baso-0 atyps-1* metas-1* myelos-1* 11:00pm blood hypochr-1+ anisocy-occasional poiklo-normal macrocy-normal microcy-occasional polychr-normal 11:00pm blood pt-13.3 ptt-25.2 inr(pt)-1.1 11:00pm blood glucose-119* urean-27* creat-1.2* na-129* k-4.6 cl-95* hco3-26 angap-13 07:40am blood alt-27 ast-31 ld(ldh)-232 alkphos-193* totbili-0.7 07:40am blood ggt-241* 11:00pm blood calcium-8.3* phos-3.3 mg-1.6 07:40am blood caltibc-199* ferritn-289* trf-153* 07:40am blood tsh-3.3 07:40am blood rheufac-14 ------------------- micro biology . positive lip scrapings --> hsv 1 b-glucan levels or negatives blood cultures - 14 sets from to --> negative urine cultures - 4 sets from to --> negative c diff to --> negative sputum , , --> negative respiratory viral panel --> negative acute toxoplasma, anaplasma, ebv, cmv, babesia --> negative aspergillus, tularemia, ehrlichia --> negative ------------------- discharge labs: ------------------- studies: . ruq us 1. cholelithiasis, but no evidence of cholecystitis or bile duct dilation. 2. soft tissue structure in the portal hilum, possibly an enlarged lymph node, of uncertain etiology and significance. this finding could be further evaluated by ct as clinically indicated. 3. right pleural effusion. . leni low ext possible deep vein thrombosis in one of the two posterior tibial veins of the right calf. this vein demonstrates normal compression, but no vascular flow could be identified. this may represent old clot. no acute dvt is seen on today's exam. no deep vein thrombosis seen in the remainder of the veins of both legs. recommend repeat us in several days to re-evaluate the right leg. . ct abd/pelvis 1. extensive lymphadenopathy seen in the bilateral axillary regions, within the mediastinum, bihilar regions, and the retroperitoneum, and bilaterally within the inguinal regions, which is highly suggestive of a lymphoproliferative disorder such as lymphoma. the spleen and liver are not enlarged. 2. bilateral moderate-sized pleural effusions. 3. multiple bilateral tiny pulmonary nodules. in the setting of a diffuse proliferative disorder this could represent malignant disease, but this appearance is uncommon in lymphoma. these nodules should be followed up with a repeat ct thorax in three months. 4. gallstone within the gallbladder, without overt evidence of acute cholecystitis. if however there is concern for the presence of acute cholecytitis based on clinical factors, a repeat ultrasound could be considered, given suboptimal visualization of the gallbladder noted on the prior study. 5. left-sided inguinal hernia which contains fluid and fat only. . tte impression: mild leaflet thickening with likely torn chordae and eccentric jet of at least moderate mitral regurgitation. normal left ventricular cavity size with preserved global and regional systolic function. mild aortic regurgitation. dilated ascending aorta. . carotid there is no evidence of significant stenosis within the carotid arteries bilaterally. . cxr bilateral pleural effusions are small on the right side and small to moderately large on the left side. the lungs are slightly hyperinflated, which could be due to copd, no consolidation. heart size is top normal. impression: bilateral pleural effusions otherwise no acute findings. . cxr moderate bilateral pleural effusion may be slightly smaller today than on . left lower lobe is collapsed, atelectasis is less severe at the right base. upper lungs grossly clear. mild cardiomegaly stable. no pneumothorax. left pic line is angled sharply in the mediastinum probably cannulating the azygos vein. brief hospital course: 83 y.o woman with history of chronic systolic chf with 2 week history of generalized weakness and shortness of breath, recently admitted to for weakness, transferred here to for management of new with rvr. she was found to have a flail mitral valve. she was transferred to ccu for hypotension, and was in septic shock despite no positive cultures. ct demonstrated diffuse lymphadenopathy with pulmonary nodules. she required intubation for respiratory failure (pulmonary edema) and spent 10 days on the ventilator. thereafter, she received intensive diuresis complicated by contraction alkalosis. ms. chose not to proceed with a mitral valve repair at this time. she will be discharged to continue diuresis and rehabilitation . # respiratory failure: patient was intubated from to for respiratory failure. the most likely etiology is pulmonary edema in the setting of severe mr and heart failure. sputum culture negative for infections. following extubation, she required non-invasive ventillation and very agressive diuresis with lasix gtt. her respiratory status slowly but steadily improved. on the day of discharge, she was satting well alternating room air and 3l oxygen via nasal cannula. lasix gtt was discontinued on , and she was discharged with po lasix, metolazone and spironolactone for continued diuresis, and to correct alkalosis and hypernatremia. . # anasarca / volume overload / septic shock: patient has a history of chronic systolic heart failure and patient??????s initial presenting symptoms were consistent with failure (sob, orthopnea, edema). repeat tte showed mild leaflet thickening with likely torn chordae and eccentric jet of at least moderate mitral regurgitation. ef was normal (>60%), but it could be over-estimated due to severe mr. was hypotensive, and required ivf boluses, vasopressors, as well as an intra-aortic balloon pump which was removed 2 days later. patient developed anasarca secondary to fluid resuscitation during intubation. the fluid is from hypoalbuminemia, chf, and leaky capillaries either from septic physiology or idiopathic ( syndrome). patient required aggressive diuresis with iv lasix boluses and lasix gtt. she diuresed roughly 1 litre daily from onward, and her anasarca significantly improved. she was started spironolactone on , and metolazone on . lasix gtt was discontinued and patient was started on po lasix on . she was discharged with po lasix, metolazone and spironolactone for continued diuresis, and to correct alkalosis and hypernatremia. . # fever of unknown origin/leukocytosis of unknown origin/diffuse lymphadenopathy: patient's admission wbc was 23.4, which peaked at 50, and slowly drifted down on broad spectrum (vanc, and doxy) antibiotics. a ct scan demonstrated diffuse lymphadenopathy & pulmonary nodules. id and hem/onc were consulted. there was no agreement on the cause. general surgery defferred lymph node biopsy until stabilization of condition. etiology was likely infection but except for a positive b-glucan and positive hsv from lip swab, she had a negative workup including: 1) negative urine culture, sputum (bacterial and viral) cultures, stool (incl cdiff) blood cultures, flu negative (at osh), and rf normal. 2) negative cmv/ebv, anaplasma, lyme rickettsial, toxo, tularemia studies. all serologies sent except for an hiv test as patient is unable to consent. ppd placed on is negative as of (though anasarca makes interpretation difficult.) her wbc slowly dropped to a plateau of .5 and was afebrile for > 10 days by the time of discharge. the plan is to re-ct her thorax in 2 months to follow status of lymphadenopathy. . # shock, septic and cardiogenic: be secondary to presumed infection, less likely cardiogenic despite acute mr with rvr, because she had low svr, high cardiac output and was warm to touch. high mixed venous saturations was also suggestive of predominantly septic physiology. it could also be a leaky capillary syndrome. patient required 2 pressors and then spent roughly one week on low rates of levophed. her map had been 55-75 from onwards. her arterial and central line were pulled on . . # new atrial fibrillation: pt went in and out of af frequently. infection and worsened mr (although la is not significantly dilated) are the most likely etiologies. tsh was normal. rate-control was attempted with diltiazem and metoprolol without success. electrical cardioversion was attmpted but patient continued to stay in with rvr and hypotension. she was then started on amiodarone at 1 mg/min followed by po amiodarone 200mg , in an attempt to medically cardiovert her to sinus rhythm. eventually she was started on digoxin with conversion to sinus rhythm. however, she still goes into intermittently. she was discharged on digoxin 0.125mg daily. patient was on heparin gtt with goal ptt 60-80, and is now being bridged to coumadin (on 5mg coumadin daily). . # dysnatremia: patient sas hyponatremic on admission. pt was intravascularly dry on admission, so initially hyponatremia was thought to be hypovolemia. she became hypernatremic in the context of free water restriction, and aggressive diuresis. hypernatremia improved after the tube feeds were changed to low na nutren 2.0 and free water flushes were increased to 250cc per 6 hours. . # acute renal failure: patient's admission creatinine 1.2, which peaked to 1.9 in the setting of septic shock. patient was evaluated by renal, and hd was planned. however, with aggressive fluid resuscitation and pressors, patient's uop and creatinine improved significantly. thereafter, she had transient elevations in bun without a rise in creatinine despite aggressive diuresis. . # uti: patient arrived at having been treated with levofloxacin at outside hospital for uti; she was transitioned to cipro. she continued to spike fevers (see above). her antibiotic coverage was broadened to vancomycin and piperacillin-tazobactam, which were transitioned to vancomycin and meropenem. her fever & leukocytosis course resolved as above, and subsequent urine cultures were negative. . # elevated alk phos and ggt: patient had no abdominal pain on admission. ruq us showed no significant abnormalities, no biliary obstruction. ct showed no significant hepatobiliary abnormalities. elevated alk phos (mild) with ggt elevation and bump in bilirubin in the absence of other liver enzyme elevations is the classic pattern of congestive hepatopathy. as her fluid status improved, so too did her liver enzyme elevation. . # insomnia: patient has been having trouble sleeping at night. several medications have been tried, including ativan, trazodone 25mg and 50mg, and mirtazapine. it appears that mirtazapine at 7.5mg plus ativan iv 1mg prn have been helping with her insomnia. . # normocytic, normochromic anemia with normal rdw: fe studies c/w acd s/p 2u prbc??????s. retic 1.5, indicating poor bone marrow response. b12 and folate were normal. . # glaucoma: home eye drops were continued. . # hypothyroidism: tsh 3.3: home levothyroxine dose was continued. . # history of hypertension: home lisinopril was held given hypotension. . # code: patient became dnr/dni during this admission. . # dvt prophylaxis: patient was on heparin gtt with goal ptt 60-80, and is being bridged to coumadin (on 5mg coumadin daily). . # access: patient will be discharged with a picc line. . # nutrition: patient will be discharged with a dobhoff for tube feed. . # contact: daughter (hcp) home: and cell: please continue heparin drip until patient has been therapeutic on warfarin (inr ) for 48 hours, then can d/c heparin drip. patient's warfarin dose should be adjusted for goal inr of . daily weights please check daily weights and increase furosemide dosing if patient's weight increases more than 3lbs/ day. patient is still slightly fluid overloaded from ccu stay and should continue to lose some weight. once weights stabilize metolazone may be removed from regimen. outpatient radiology patient needs repeat ct torso in months to re-assess diffuse lymphadenopathy. outpatient lab work patient will need at least 3*/wk electrolytes to monitor na, k, cl, hco3, bun, cr, ca, mg, and p and repletion prn. 1. heparin gtt (goal ptt ) until inr 2. cardiopulmonary monitoring, on lasix, metolazone and spironolactone for diuresis, contraction alkalosis and hypernatremia. 3. monitor daily cbc and electrolytes 4. continue tf as main source of nutrition, still npo except meds as of last speech and swallow evaluation due to aspiration risk 5. speech and swallow re-evaluation in 3 days to see if patient can tolerate po food without aspiration medications on admission: medications on transfer: diltiazem gtt @ 5 mg/hr ethacrynic acid 25 mg iv x 1 () lovenox 70 mg daily levothyroxine 88 mcg daily lumigan 0.03% 1 drop each eye at bedtime tylenol prn dorzolamide 2% 1 drop each eye daily ecasa 81 mg daily levaquin 750 mg qod . medications at home: bumex 1 mg (had been d/c'd ) lisinopril 10 mg daily levoxyl 88 mcg daily boniva 150 mg monthly trusopt 1 drop tid lumigan 1 drop at bedtime discharge medications: 1. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. acetaminophen 160 mg/5 ml solution sig: ml po q6h (every 6 hours) as needed for pain, fever. 6. mirtazapine 15 mg tablet sig: 0.5 tablet po hs (at bedtime). 7. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed) as needed for dry eyes. 8. ipratropium bromide 0.02 % solution sig: nebs inhalation q6h (every 6 hours) as needed for wheezing. 9. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 10. lorazepam 1 mg iv hs:prn insomnia 11. digoxin 125 mcg tablet sig: one (1) tablet po once a day. 12. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 13. heparin (porcine) in d5w 10,000 unit/100 ml parenteral solution sig: titrate to ptt 60-80 unit intravenous continuous: check ptt q6h, goal ptt 50-80, continue heparin gtt until inr . -------- heparin iv sliding scale: start new infusion now. give patient an initial bolus. diagnosis: atrial fibrillation patient weight: 68.04 kg initial bolus: 5400 units ivp initial infusion rate: 1200 units/hr target ptt: 60 - 100 seconds ptt <40: 2700 units bolus then increase infusion rate by 250 units/hr ptt 40 - 59: 1400 units bolus then increase infusion rate by 150 units/hr ptt 60 - 80*: ptt 81 - 120: reduce infusion rate by 150 units/hr ptt >120: hold 60 mins then reduce infusion rate by 250 units/hr . 14. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 15. metolazone 5 mg tablet sig: one (1) tablet po daily (daily): hold if sbp<85. 16. spironolactone 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold if sbp<85. 17. dorzolamide 2 % drops sig: one (1) drop ophthalmic tid (3 times a day). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 19. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed for constipation. 20. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: neb inhalation q6h (every 6 hours) as needed for wheeze. 21. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 22. anticoagulation please continue heparin drip until patient has been therapeutic on warfarin (inr ) for 48 hours, then can d/c heparin drip. patient's warfarin dose should be adjusted for goal inr of . 23. daily weights please check daily weights and increase furosemide dosing if patient's weight increases more than 3lbs/ day. patient is still slightly fluid overloaded from ccu stay and should continue to lose some weight. once weights stabilize metolazone may be removed from regimen. 24. outpatient radiology patient needs repeat ct torso in months to re-assess diffuse lymphadenopathy. 25. outpatient lab work patient will need at least 3*/wk electrolytes to monitor na, k, cl, hco3, bun, cr, ca, mg, and p and repletion prn. discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses: - respiratory failure requiring intubation - hypotension, septic shock - atrial fibrillation with rapid ventricular response - anasarca - posterior chordae tendonae tear of the mitral valve - subacute deep vein thrombosis - diffuse lymphadenopathy secondary diagnoses: - anemia - glaucoma - hypothyroidism discharge condition: afebrile, hemodynamically stable. dobhoff in place for tube feed. requires 2-3l/min oxygen via nasal cannula. mental status:clear and coherent level of consciousness:alert and interactive activity status:out of bed with assistance to chair or wheelchair discharge instructions: it was a pleasure to be involved in your care, mrs. . you were admitted to because of weakness and arrhythmia called "atrial fibrillation". you were found to have severe leakage through one of your heart valves, called "mitral regurgitation", which was likely an acute change and could have contributed to fluid accumulation in your lungs, making your breathing difficult. we have been using iv medications to get rid of the fluid in your lungs, and your respiratory status has significantly improved. as you get better, you can re-consider having the surgery to repair your mitral valve. you have an appointment with the cardiac surgeon, dr. on , to have further discussions on the surgery. your white count was significantly elevated, and your clinical picture was highly suspicious for infection, but all the cultures that we obtained were negative. we had hematology-oncology servie see you during your hospital stay, and they do not think you have lymphoma. you will need to have a repeat ct scan in 2 months to see if the lymphadenopathy (lymph node swelling) resolves. you had a long hospital course in the cardiac intensive care unit, and you were intubated for 10 days. as a result, you are very weak, and you require tube feeds to gain your strength back. you will be discharged to a rehab, where you will get more intensive physical therapy. please weigh yourself every morning, md if weight goes up more than 3 lbs. your medications have been changed. the medication list is attached. followup instructions: we have made an appointment for you to see cardiologist, dr. , at on at 1:00pm. please call if you have any questions. we also made an appointment for you to see a cardiac surgeon, dr. , at for followup on at 2:00pm. please call if you have any questions. please follow-up with your primary care physician, . , l. within the next 2-4 weeks. please call to make an appointment. you will need a repeat ct scan of your abdomen & pelvis in the next 2 months. you can talk to your pcp regarding getting the repeat ct scan. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more left heart cardiac catheterization insertion of endotracheal tube enteral infusion of concentrated nutritional substances other electric countershock of heart arterial catheterization implant of pulsation balloon diagnoses: anemia of other chronic disease mitral valve disorders acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia hyposmolality and/or hyponatremia severe sepsis unspecified acquired hypothyroidism atrial fibrillation unspecified glaucoma personal history of malignant neoplasm of other parts of uterus acute respiratory failure septic shock other diseases of lung, not elsewhere classified hyperosmolality and/or hypernatremia acute on chronic systolic heart failure enlargement of lymph nodes insomnia, unspecified mixed acid-base balance disorder edema chronic venous embolism and thrombosis of deep vessels of proximal lower extremity 

Answer: The patient is high likely exposed to