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: heparin agents attending: chief complaint: sub-sternal chest pain major surgical or invasive procedure: s/p cath and stent placement to lcx and lad s/p tracheostomy history of present illness: 70y/o m w/ dm2, hypercholesterolemia, obesity, and tobacco use. woken up at 4am by substernal non radiating chest pain, went to bathroom and came back, chest pain worsened , severely diaphoretic, wife noticed patient was very pale. no sob, no lh/dizzyness, called ems they arrived at ~6am. transported to hospital, en route received ntg x3, asa, oxygen, pain decreased to . at gsm ekg initially showed ste in leads ii,iii,avf with std in v1-v4. pt repeat ekgs then showed ste in ii,iii,avf as well as v5-v6 with coupling. patient received heparin bolus and gtt, integrellin gtt, morphin sulfate 2mg x 3, lopressor 5mg x 2, and transferred to for pci. cath revealed: right dominant; 3vd+lm; rca-to distal; lmca-small with mild dampining; lad-80% proximal/mid; lcx-90% thrombotic proximal lesion. hd: ra 13; rv 58/16; pap 58/30; pcwp 31; co 4.0; ci 2.2; svr 1665; pasat 72% cypher stent was placed in the lcx. pt had iabp placed due to high filling pressures, bridge to possible cabg, and because of lm disease. pt ci was around 1.6 so pt was increased with no improvement so low dose dopamine was started. past medical history: dm2, hypercholesterolemia, h/o dvt (2 clots in left leg) treated medically 2 years ago, h/o ruptured disk s/p surgery -30yrs ago, colonic polyps (non malignant per patient), urinary incontinence, obesity. social history: h/o tobacco use, no etoh, no ivdu, family history: cad, dm, cancer; father died 75 from mi, brother 62 from mi, sister 60's from mi. physical exam: vs: afebrile, bp 125/72, hr 64, rr13 pertinent results: brief hospital course: 70 yo m with dm2 who p/w stemi with pci's to lcx and lad, c/b pericardial effusion/pericarditis, arf, liver failure, pna, chf, hit, afib. brief course by system. 1. cardiovascular -a. coronaries/cad: severe 3vd + lm by cath report with initial pci placed in lcx. pt was continued on asa, plavix, metoprolol, lipitor, and an . ct consulted and pt received a stress test to assess if cad significant enough for cabg but the mibi showed an irreversible defect and so it was felt that a cabg would not be beneficial. following this, however, pt developed sscp again that was unable to be controlled with a nitro gtt and multiple other medications. ecg showed slight st depressions in v2-v5 and pt was taken emergently back to cath where it was seen that the lcx was still patent. at this time 3 stents were placed in the lad, however after the procedure the pt was still c/o cp. bp was slightly low after the cath and an echo showed a pericardial effusion without tamponade - managed as below. pt was continually managed on asa, plavix, metoprolol, and atorvastatin. captopril was held while pt had arf. several times during admission, low dose captopril was added to the medical regimen, however pt suffered from short episodes of hypotension where on one occasion required brief pressor support. after discharge, patient should be restarted on ace inhibitor once pt stable and volume status maximized. * -b. pump/chf: echo showed ef 30-40%. pt had iabp initially placed after cath then removed since it was determined that it was not helping pt. pt eventually weaned of dopamine and improved. he was felt to be in chf and was diuresed gently until the pericardial effusion was discovered - likely dressler's syndrome. no evidence of tamponade. pt was given some fluids and watched carefully. he remained hemodynamically stable and the effusion was followed with serial echo's and was seen to be resolving. at no point did the pt have hemodynamic compromise or pulsus. pt's o2 sats were low, however, and he was felt to be wet based on lung exam and peripheral edema. cr bumped to 4.6 following the second cath (likely atn) and uop dropped. he was given hemodialysis and o2 sats and lung exam gradually improved. once kidney fxn improved with time he was diuresed with lasix. he received dye loads with imaging of his le's and cr bumped again so diuresis was slowed but eventually he was successfully diuresed with lasix. overall pt volume overloaded but stable. needs continued gentle diuresis with lasix. pt has responded to lasix quite well while hospitalized and should continue to be diuresed gentle adjusting the lasix dose as necessary. * -c. rhythm/a fib: when pt was initially admitted he was in nsr. on he went into afib and was started on a heparin gtt. cardioversion was attempted on but was unsuccessful and so pt was started on amiodarone. initially his hr was difficult to control (120's-130's) and was refractory to max doses of metoprolol. he was started on digoxin for one day, however, then he started c/o nausea and it was felt that digoxin would not likely be a good drug for him. at this point he had the recurrent cp and was taken back to cath. after cath and the development of the pericardial effusion, his hr remained in the 70-80's even without metoprolol. he was maintained on the amiodarone only. heparin was stopped when hit was discovered, and then amio was stopped when liver enzymes became extremely elevated. pt remained in afib and rates were well controlled with metoprolol that was again titrated up to 100 po tid. however, during hospital stay suffered from hypotension at times requiring cessation of beta blockade. pt was restarted on short acting carvediol and tolerated dose of 3.125 mg po qd. on discharge, patient a fib seems too be well rate controlled on his current coreg dose. he will need to be cardioverted as an outpatient after 4 weeks therapeutic inr. in regards to anti-coagulation, pt's coumadin briefly held secondary to gi bleed and restarted one week prior to discharge. inr supratherapeutic on 5mg po qhd and will be sent home on 3mg po qhs. inr will require multiple checks in the upcoming weeks. * -d. peripheral vasculature: pt was found to be hit-ab+ and was started on argatroban right away. he was ruled out for pe's with an mri and hepatic vein thrombosis with abdominal ultrasound. he did develop ischemic necrosis of his r foot which was felt to be due to hit as well as possible cholesterol emboli. he underwent angioplasty of r posterior tibial artery with increased perfusion. since patient has diffuse dry gangrene vascular surgery recommends that he return for follow up in weeks to determine if amputation will be necessary. at time of discharge vascular surgery would consider bypass grafting for which he needs to follow up after discharge from rehab. this is no indication for amputation at this point. patient should also follow up with heme. * 2. pulm: pt was felt to be hypoxic during this hospitalization mostly due to pulmonary edema. abg's remained stable and o2 was titrated to keep o2sats above 93%. o2sats improved and oxygen requirements decreased as pt was diuresed. he was felt to have a possible pneumonia in the middle of his hopitalization that was treated with ceftriaxone x 10 days. pt was ventilated for a prolonged period requiring tracheostomy. at time of dischage patient over ventilator support for 5 days requiring on oxygen by face mask. * 3. renal: pt came in with a cr of 1.3. his kidney function remained relatively good until the 2nd cardiac catheterization, afterwhich the pt was felt to suffer from dye-induced atn. cr bumped to 4.6 and uop dropped. he was given hemodialysis for several days in order to keep his fluid status stable. his kidneys then recovered and uop rose. cr trended down. after this pt was treated with mucomyst before and after all of his dye related proceudures but cr bumped up slightly again after catheterization of r foot occurred. at discharge pt cr stable at 1.6, slightly elevated from his baseline. * 4. gi: pt had hematemesis episode . egd showed gastritis only and pt was started on protonix 40 . he later had a 2 day episode of nausea and vomiting which was guiac negative in the middle of the hospitalization of which etiology was not determined. symptoms resolved with pr compazine. later he also had guiac positive stools, but hct remained stable. recommend pt obtain further workup for gib as outpt with colonoscopy. pt also had an episode of tongue swelling after his foot angioplasty which was felt to be an allergy to the dye. he was given benadryl, solumedrol, and famotidine and symptoms resolved. pt to be discharged on prilosec daily. * 5. heme: coagulopathy/thrombocytopenia: hit + causing microangiopathic ischemic feet, on argatroban . this was titrated carefully to avoid supratherapeutic levels (ptt target 60-75). after all surgical procedures were completed, pt was transitioned to coumadin, which he will need to be on for approximately 3-6 months due to hit. * 6. endocrine: dm2 was stable and pt was followed by . * 7. neuro: during the fourth week of his hospitalization the pt began to have episodes of confusion most consistent with sundowning. he was calmed and reoriented easily. started zyprexa 2.5 mg po qhs. on the day patient was to be discharged to rehab with the aforementioned hospital course, he began having brbpr with bp to 88/54. patient was stabilized and given 2 units of rbc and 4 units of ffp to reverse high inr. tagged red cell study was performed which showed delayed bleeding on sigmoid area. during this time period hcts were- 33.1 (prior to bleed)--30.5--30.8 (after transfusion crit want to 33.7)and inr became 1.4. patient was transferred back to unit. inr on was 1.7 so patient was given 2 more units if ffp and he had more bleeding from the rectum with and hct fell to 27.8. patient was then given 2 more units of rbcs and hct was then 40. patient was preped for colonoscopy. on the morning of patient became acutely hypoxic and agitated, and the question of pe arose. patient also was given diltiazem for afib with rvr. abg at that time as 7.31/75/70 and chest x-ray indicated worsening failure so patient was given lasix. on exam it seemed patient was not moving much air, so he was given nebs and bipap. simultaneously patient began bleeding form rectum. patient was placed on 100% non-rebreather and blood gas was then 7.28/81/116. thereforem decision to intubate and obtain ct to rule out pe. post intubtaion, patient systolic bp dropped to 50. sats in the 80's. r ij cortis was placed and ns bolus was given. 1 unit ffp given and levophed given. bp increased to 200/100. patient heart rate increased to 140's and he was given lopressor. there was no evidence of pe on ct. in addition, nurse that patient was inadvertently given heparin -- slight amount in flush. heme was then consulted. once stable, patient had repeat tagged red cell scan and was prepped for colonoscopy. colonoscopy revealed a rectal ulcer. a narrative of the hospital course following this sentinel event: the bleeding slowly resolved on argatroban but he remained intubated with difficulty weaning from the ventilator. as his fluid overloaded state with pulmonary edema was thought to be contributing to this, multiple attempts were made to diurese extra fluid using dopamine/vasopressin as needed for hypotension, natrecor, lasix, with only moderate success. a pa catheter was inserted for tighter control of volume status on . eventually diuresis was achieved with 1-2 liters out per day. potassium had to be repleted extremely aggressively during this period, and he was able to achieve negative fluid balance of minus 1-2 liters per day. the ace and beta blocker were held due to low blood pressures. he also had multiple runs of syptomatic nsvt starting . for these he was continued on metoprolol and loaded on amiodarone. additionally, it was felt that this lack of diuresis and poor pressures were due to the a. fib. a tee revealed no thrombus on , so he was loaded with amiodarone and he was cardioverted multiple times, cardioverted -> back in afib -> reattempt cardioversion -> back in afib in minutes - reattempt cardioversion - back in 2 days. as these were unsuccessful, the amiodarone was decreased to qd dosing for vt prevention. anticoagulation with argatroban changing over to coumadin is planned. a third reason it was believed that it was difficult to extubate him during the original intubation is that he had a persistent metabolic alkalosis. this was believed to be a result of respiratory compensation leading to apnea. after failing diamox he was given arginine 60 g iv for two days which corrected the bicarbonate and his apnea. he also developed hypernatremia during hospitalization and was maintained on free water boluses to keep his sodium less than 145. he was extubated successfully following a 3 day period of sinus rhythm, then 3 days later had to be reintubated for respiratory distress and hypotension later discovered to be a recurrent mssa pneumonia. the swan was reinserted which showed a picture consistent with sepsis superimposed on chf. he was treated with vasopressin. oxacillin and then trached due to the difficulties of weaning from the ventilator. he was weaned with pressure support and trach collar as tolerated. while on the argatroban, he began to again have brbpr/melena on . gi was reconsulted and an egd showed gastritis without active bleed. since he had a known rectal ulcer, this was thought to be the cause and supportive care was maintained and the argatroban was held. he was transfused to keep above 30. vascular surgery signed off during the hospitalization and he may choose to have lower leg amputations as an outpatient. his blood sugars were controlled with insulin drip transitioned to iss. pt started on empiric zosyn upon suffering from hypotension. pt without obvious source of infection. at time of discharge pt was treated for 10 out 14 days of zosyn. pt to continue zosyn 6.25 q6hr times 5 days upon discharge. medications on admission: glucophage, mvi, asa, lipitor, ?one other dm med discharge medications: 1. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual asdir (as directed). 2. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 3. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). 4. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day) for 300 days. 5. sodium chloride 0.65 % aerosol, spray sig: two (2) spray nasal qid (4 times a day) as needed. 6. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 7. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day) as needed. 8. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po qd (once a day) as needed. 9. atorvastatin calcium 40 mg tablet sig: two (2) tablet po qd (once a day). 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 11. spironolactone 25 mg tablet sig: two (2) tablet po qd (). 12. amiodarone hcl 200 mg tablet sig: two (2) tablet po qd (). 13. sertraline hcl 50 mg tablet sig: one (1) tablet po qd (). 14. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 15. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 16. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day) as needed. 17. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q3-6h () as needed. 18. lorazepam 0.5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for insomnia, anxiety. 19. trazodone hcl 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 20. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 21. warfarin sodium 1 mg tablet sig: three (3) tablet po hs (at bedtime): titrate as needed for goal inr . 22. furosemide 20 mg tablet sig: two (2) tablet po daily (daily): titrate for volume status. 23. piperacillin-tazobactam 2-0.25 g recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 5 days. 24. insulin sliding scale discharge disposition: extended care facility: - discharge diagnosis: status post st wave elevation mi chf heparin induced thrombocytopenia afib gi bleed secondary to gastritis and antral ulcer necrotic toe with dry gangrene diabetes s/p traceostomy discharge condition: stable discharge instructions: please follow up with the appointments listed below, continue to monitor your daily weights and call your doctor immediately if there is a significant weight change. call your doctor/ or go to er if you develop chest pain, sob, fainting. followup instructions: please follow up with your primary care physician, , . , within 1 week after discharge from rehab. please call for follow up with dr. at . pt will need to be started on ace inhibitor after cr is stable and bp stable. please calll and make a follow up appointmnet with (ep) (. patient will need cardioversion after 4 weeks of anticoagulation secondary to a. fib. please make a follow up appointmnet with dr. in vascular surgery to evaluate av fistula and perfusion of feet, question amputation verse bypass. please call and reschedule your follow up appointmnet with hematology for heparing induced thrombocytopenia: provider: , md where: hematology/oncology phone: md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified other endoscopy of small intestine other endoscopy of small intestine injection or infusion of platelet inhibitor left heart cardiac catheterization diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances hemodialysis other electric countershock of heart angioplasty of other non-coronary vessel(s) percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy colonoscopy implant of pulsation balloon pulmonary artery wedge monitoring insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) transfusion of packed cells transfusion of other serum injection or infusion of nesiritide insertion of drug-eluting coronary artery stent(s) insertion of drug-eluting coronary artery stent(s) infusion of vasopressor agent diagnoses: subendocardial infarction, initial episode of care acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified acute and subacute necrosis of liver unspecified septicemia severe sepsis atrial fibrillation acute respiratory failure other shock without mention of trauma peripheral vascular complications, not elsewhere classified methicillin susceptible pneumonia due to staphylococcus aureus anticoagulants causing adverse effects in therapeutic use atherosclerosis of native arteries of the extremities with gangrene aneurysm of artery of lower extremity acute gastritis, with hemorrhage postmyocardial infarction syndrome 

Answer: The patient is high likely exposed to