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: ciprofloxacin / levofloxacin / fentanyl attending: chief complaint: chest pain/transfer for catherization major surgical or invasive procedure: cardiac catheterization history of present illness: mr. is a 75 yo male with a history of significant vascular disease and cad, including cabg in with lima to lad and svg to om and svg to pda of rca, s/p bms to distal svg to rpda on , lcea in , and laka in as well as multiple pvd procedures who woke up the morning of presentation with some chest pain and heart burn after having a cup of coffee with breakfast. he states his isosorbide usually relieves anginal symptoms, but it had not worked this morning. he tried sublingual nitroglycerine x3 as well with no relief. his pain was burning/sharp in nature, centrally located, without radiation to the upper extremities. he denied nausea, vomiting, or diaphoresis with the event. given his symptoms, his wife took him to for further evaluation. of note, the patient had a similary presentation in early where acs workup was negative for an mi. at , his chest pain was described as "indgiestion". vs at time of presentation were nibp 107/56, pulse 84, respratory 22, )2sat 90 % on ra. t97.4. ekg at that time showed rbbb with new st segment elevations in avr, v1/v2 with std in v4-v6 as well as avl,i. ol q waves were noted in iii, avf. troponin i at that time were elevated at 0.109 with ckmb of 7.4. heparin gtt was started. patient was planned to have a catherization for possible stemi, however the lab at was down and patient requested transfer to for further care. at , patient transferred directly to the lab. received morphine prior to transfer with resolution of chest pain. there, a right radial approach was attempted, however total occlusion of the right subclavian artery was encountered. the radial approach was abandoned and femoral approach was attempted via the rfa. angiography revealed a patent lmca with 40% distal, 70% lad, patent lima at touchdown, occluded lcx and rca, with patnet svg-rca/svg-lcx and lima-lad. left subclavian was also noted to be occluded when imaged. both carotids were noted to be severely diseased with origin of the right sc after spearate origin of the two carotids. also noted were 90% occluded left and right external iliacs at cfa level. hemodynamics revealed brachial nibp to be about 80 mmhg lower than central blood pressures, with ao bp of about 150mmhg. no stents were placed at that time, and the patient continued to be chest pain free. he was transferred to the ccu for further monitroing and eventual initiation of heparin gtt. in the ccu, the patient is in nad. right groin noted to have continual oozing from recent catherization site. review of systems on review of systems, denies cp, sob, nausea, vomiting. has had diarrhea for last 4 days and took loperamide the day prior to presentation given diarrehal symptoms. no blood in bowel movements. no dysuria or hematuria but endorses frequent urinary hesitancy. denies joint pains, cough, hemoptysis, black stools or red stools. has chronic angina. no pnd/orthopnea currently, although has had hf exacerbations several times in the last several months. past medical history: - nstemi - dchf with ef 55% - hypertension - hyperlipidemia - dm2 w/ neuropathy - pvd - presumed small-bowel avms with recurrent gib and anemia (recent bleed in on dual antiplatelet therapy) - h/o erosive esophagitis and avms of the colon - gerd - bph - anxiety - depression - vitamin d deficiency - hypomagnesemia - s/p appendectomy - s/p bladder cystoscopy for non cancerous bladder growths - s/p l bka - cabg: @ ( lima to lad and svg to om and svg to pda of rca, s/p bms to distal svg to rpda on ) - pci: prior to cabg, no stents placed - s/p l carotid endarterectomy - s/p laser eye surgery b/l () social history: he is married and lives with his 2nd wife of 23 years. they have 8 children between them, 7 in the area. they have 17 grandchildren all in the area. - tobacco history: former, 30+ pack years, quit 10+ years ago - etoh: denies - illicit drugs: denies uses a wheelchair at home, transfers independently. family history: mother with dm, 2x amputee, angina, died early 60s two brothers with dm, cad physical exam: admission exam general: obese but nad. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: thick neck but supple. patient laying supine. cardiac: exteremely faint heart sounds. barely auscultated s1/s2. no appreciated adventitious heart sounds. lungs: auscultated anteriorly. no wheezes/rhonchi/rales or coarse breath sounds appreciated. large chest wall. abdomen: distended with midline scar. nbs. slightly tense abdomen without tenderness to palpation. no rebound. no organomegaly appreciated. extremities: s/p lbka. multiple surgical scars on rle c/w prior vascular procedures. bilateral raidal scars consistent with vascular procedure. gu: foley placed. clear urine. skin: scars per above. also with midline sternotomy scar c/w cabg. hyperpigmented macule on penis. pulses: right: non palpaple/non dopplerable dpp, dopplerable ptp, faint femoral pulse with oozing around access site. 1+carotids, 1+ radial left: carotid 1+ radial 1+ femoral 1+ popliteal 2+ discharge exam general: obese but nad. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: thick neck but supple. patient laying supine. cardiac: exteremely faint heart sounds. barely auscultated s1/s2. no appreciated adventitious heart sounds. lungs: auscultated anteriorly. no wheezes/rhonchi/rales or coarse breath sounds appreciated. large chest wall. abdomen: distended with midline scar. nbs. slightly tense abdomen without tenderness to palpation. no rebound. no organomegaly appreciated. extremities: s/p lbka. multiple surgical scars on rle c/w prior vascular procedures. bilateral raidal scars consistent with vascular procedure. gu: foley placed. clear urine. skin: scars per above. also with midline sternotomy scar c/w cabg. hyperpigmented macule on penis. pulses: right: non palpaple/non dopplerable dpp, dopplerable ptp, faint femoral pulse with oozing around access site. 1+carotids, 1+ radial left: carotid 1+ radial 1+ femoral 1+ popliteal 2+ pertinent results: admission labs 10:00pm glucose-104* urea n-37* creat-1.4* sodium-134 potassium-6.5* chloride-98 total co2-27 anion gap-16 10:00pm estgfr-using this 10:00pm ck(cpk)-130 10:00pm ck-mb-8 ctropnt-0.13* 10:00pm calcium-8.4 phosphate-5.3*# magnesium-2.3 10:00pm wbc-6.8 rbc-2.98* hgb-9.5* hct-28.7* mcv-96 mch-32.0 mchc-33.2 rdw-14.4 10:00pm plt count-127* 10:00pm pt-10.6 ptt-27.4 inr(pt)-1.0 03:18pm po2-112* pco2-51* ph-7.39 total co2-32* base xs-5 03:18pm hgb-11.1* calchct-33 o2 sat-97 studies ekg: sinus rate. rbbb morphology with lad fasicular block. old qwaves in inferior leads with small qwaves in v1-v3. st depressions in i, avl, ii, v4-6, with ste's in v1/v2 avr. twi in i, v4-v5. compared to prior on ste's are new as well as std's. cardiac final diagnosis: 1. three vessel coronary artery disease. 2. bilateral subclavian stenoses. 3. bilateral carotid stenoses. 4. bilateral common femoral stenoses. 5. right radial artery pressure ~80 mmhg lower than central aortic pressure. discharge labs 06:05am blood wbc-9.5 rbc-3.40* hgb-11.0* hct-32.8* mcv-96 mch-32.3* mchc-33.6 rdw-16.7* plt ct-165 07:20am blood neuts-77.0* lymphs-12.0* monos-8.2 eos-2.6 baso-0.2 06:05am blood plt ct-165 06:05am blood glucose-127* urean-39* creat-2.0* na-143 k-4.1 cl-111* hco3-23 angap-13 04:32am blood alt-24 ast-26 alkphos-147* amylase-46 totbili-0.3 04:32am blood lipase-34 05:29am blood ck-mb-7 ctropnt-0.24* 06:05am blood calcium-8.8 phos-3.7 mg-2.2 06:11am blood c3-151 c4-46* 03:18pm blood po2-112* pco2-51* ph-7.39 caltco2-32* base xs-5 03:18pm blood hgb-11.1* calchct-33 o2 sat-97 brief hospital course: 75 yo male with a history of significant vascular disease and cad as well as dm, htn, hld, presenting with nstemi vs stemi from osh now status post catherization without further stenting. acute #tia's/sub-acute pca infarct- patient is s/p l cea in . carotid series done on this admission revealed: 1. complete occlusion of the right cca. flow is noted within the right ica, though absence of diastolic flow is concerning for distal stenosis. 2. findings consistent with a 70-79% stenosis of the left ica, with reversed flow within the left vertebral artery into the left subclavian artery, consistent with subclavian steal. on the am of , the patient developed new onset slurring of speech and l sided weakness. this resolved over approximately 1 hour. neurology was urgently called and a stat ct scan was done which revealed new hypodense area in the right pca territory consistent with acute to sub-acute infarct. at this time, the patient was placed on a heparin gtt. this was d/c'ed evening of after patient had melenotic stools and a drop in hct. he experienced a second tia in house on during which he temporarily had a slurring of speech. an mra of the neck was obtained which revealed stenosis of multiple arteries in the neck. after an interdisciplinary meeting btw cardiology, neurology, and vascular surgery, it was decided that the risks outweighed the harms to intervene regarding his arterial disease given his other comorbidities. a family meeting took place on discussing the medical condition and disposition. it was agreed upon with the patient, family, and healthcare personnel that he go to a high skill rehab facility to strengthen the patient enough so he can transfer him self around his home. his status was made "do not hospitalize" while at the rehab facility. dnr and dni orders were also agreed upon. #contrast-induced nephropathy after receiving 300 cc contrast during cardiac , patient had rise in creatinine from 1.4 to 6.5 (peaked ) and then normalized by ??. renal was consulted. they recommended prn lasix boluses for decreased urine output. the patient never required dialysis and his hyperkalemia and hyperphosphatemia were managed medically. #cad/stemi: coronary angiography showed no significant changes from his recent catherization in 4/. no culprit lesion could be identified. cardiac enzymes were cycled and troponin rose from .13 to .24. the patient was continued on his home dose of plavix and asa in the setting of his recent bms placement. his home dose of isosorbide nitrate (90mg qam) was changed to 60mg qhs to due to multiple hypotensive episodes encountered during the hospital stay. rosuvastatin was changed to atorvastatin 80 and his metoprolol succ 100mg qd was changed to metropolol tartrate 50 mg . #pvd/subclavian stenosis: no intervention done during this hospital stay. as was mentioned above, the patient has severe pvd affecting the subclavian, vertebral, and carotid system. as he is not an appropriate candidate for surgery the recommendation made to the patient was medical management. #upper gi bleed the patient has a history of gi bleeds and avm's with known gastric avm's. after being placed on a heparin gtt for a tia on , the patient had melenotic stools and a 5 pt drop in hct (30 to 25) the evening of . the heparin gtt was d/c'ed and due to patient's hx of angina and vascular disease, he was transfused slowly with 1uprbc with an appropriate response. after heparin gtt d/c'ed, no more melena detected and q6hr cbc's were stable. however, upon transfer back to the ccu on the patient had 1 more episode of melena. hcts remained stable and no invasive intervention was performed. the patient's aspirin and clopidogrel were d/ced and dypiradimole/aspirin (aggronox) was started in consult with neurology- the thought was to anticoagulate the patient to treat his tias and pvd affectively while reducing his chance for continuing gi bleed. chronic #htn: discrepancy between peripheral reads and central reads by about 100 mmhg. on cardiac catheterization, it was noted that central bp was about 150 mmhg. target bp should be about 70-80s/40s (equivalent to 170s/140s centrally). for this reason, urine output and mental status were used as a surrogate for patient's tru bp. lisinopril was d/c'ed contrast-induced nephropathy. metoprolol was changed to 50 mg as above. #t2dm. insulin-dependent, with complications of nephropathy and retinopathy. ssi was continued in house #bph: home finasteride and tamsulosin were continued in house. # anxiety and depression: patient has long history of anxiety and depression. citalopram 40 mg was continued in house and later increased to 60 mg daily. alprazolam dose was decreased from 0.5mg to .25mg tid to allow for more reliable neuro exam as patient appeared to be having recurrent tia's. transitional issues:important - the patient is being discharged to a high level rehab facility with the intent as described above. he has multiple active medical conditions that you should know about. his status is "do not hospitalize"- these will apply to chief complaints for chest pain, and any neurologic events. 1. ongoing tias. the patient may experience slurred speech or eye deviation or weakness daily. these are not new. he is being optimized medically with aggronox for transient neurologic ischemia. he has been evaluated by neurology, cardiology, and vascular surgery for this and the recommendation was made to not intervene. please be aware that this is his baseline. 2. chest pain- the patient has severe coronary artery disease that is chronic and will not benefit from intervention. he should be medically managed if chest pain should occur. please go up on his isosorbide mononitrate as blood pressure tolerates. sublingual nitroglycerin is also an option. 3. gi bleeds- patient has chronic small bowel avms. in the event that he has a massive gi bleed, he be considered for hospitalization because blood transfusions may help him symptomatically. however, he should only be hospitalized if he has major bleeding and if he symptomatic. diabetes- please follow up on blood sugars and adjust diabetes medications as necessary. regimen has been changed multiple times since admission. medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from webomr transfer handwritten rx list. 1. levemir 18 units breakfast 2. alprazolam 0.5 mg po tid:prn anxiety / nausea 3. finasteride 5 mg po daily 4. esomeprazole magnesium *nf* 40 mg oral once daily 5. gabapentin 300 mg po q 12h 6. rosuvastatin calcium 10 mg po daily 7. aspirin 325 mg po daily 8. clopidogrel 75 mg po daily 9. metoprolol succinate xl 100 mg po daily 10. tamsulosin 0.4 mg po hs 11. furosemide 40 mg po daily 12. citalopram 40 mg po daily 13. sucralfate 1 gm po bid 14. cyanocobalamin 50 mcg po daily 15. vitamin d unit po daily 16. ferrous sulfate 325 mg po daily 17. magnesium oxide 400 mg po once duration: 1 doses 18. repaglinide 2 mg po bidwm 19. multivitamins 1 tab po daily 20. ascorbic acid 500 mg po bid 21. fish oil (omega 3) 1000 mg po bid 22. ocuvite *nf* (vit a,c & e-lutein-minerals;<br>vit c-vit e-lutein-min-om-3) 1,000-60-2 unit-unit-mg oral once daily 23. nitroglycerin sl 0.3 mg sl prn chest pain 24. hydralazine 50 mg po q8h 25. docusate sodium 100 mg po bid 26. senna 1 tab po bid:prn constipation 27. polyethylene glycol 17 g po daily 28. prochlorperazine 10 mg po q6h:prn nausea 29. isosorbide mononitrate (extended release) 30 mg po daily discharge medications: 1. alprazolam 0.25 mg po tid:prn anxiety / nausea 2. ascorbic acid 500 mg po bid 3. citalopram 60 mg po daily 4. cyanocobalamin 50 mcg po daily 5. docusate sodium 100 mg po bid 6. ferrous sulfate 325 mg po daily 7. finasteride 5 mg po daily 8. fish oil (omega 3) 1000 mg po bid 9. gabapentin 300 mg po bid 10. levemir 18 units breakfast 11. isosorbide mononitrate (extended release) 120 mg po qhs 12. multivitamins 1 tab po daily 13. nitroglycerin sl 0.3 mg sl prn chest pain 14. senna 1 tab po bid:prn constipation 15. sucralfate 1 gm po bid 16. tamsulosin 0.4 mg po hs 17. vitamin d unit po daily 18. metoprolol tartrate 50 mg po bid hold for heart rate <60 or extreme lethargy 19. esomeprazole magnesium *nf* 40 mg oral once daily 20. prochlorperazine 10 mg po q6h:prn nausea 21. sulfameth/trimethoprim ds 1 tab po bid 22. simethicone 40-80 mg po qid:prn bloating 23. dipyridamole-aspirin 1 cap po bid 24. atorvastatin 80 mg po daily 25. acetaminophen 650 mg po q6h:prn pain do not exceed 4gm /day 26. metformin (glucophage) 500 mg po bid discharge disposition: extended care facility: - discharge diagnosis: primary- unstable angina transient ischemic attacks gi bleed secondary- contrast-induced nephropathy peripheral vascular disease type ii diabetes discharge condition: level of consciousness: mentating ok (conversant, answering questions) but with active neurological impairment activity status: out of bed with assistance to chair or wheelchair. mental status: confused - sometimes. discharge instructions: you were admitted to the hospital for chest pain and were taken to the cardiac catheterization lab. the doctors in the lab found no new blockages in your arteries. the vessels from your open heart surgery looked healthy. however, they did find you have other arteries around your body with significant disease, including your subclavian arteries. dr recommends you have a procedure to explore and possibly treat this disease. unfortunately, the contrast used during your cardiac catheterization caused you to have kidney damage during your hospital stay. this improved over several days with fluids and iv water pills. you were found to have severe peripheral vascular disease in the arteries of your neck, which has been resulting in "transient ischemic attacks", or tias. this has been complicated by your gi bleeding. the vascular surgeons, neurologists, and cardiologists all agreed that any surgical intervention would only cause more harm than good to your medical condition. we had a family meeting and decided to discharge you from the hospital to a high level rehab facility to increase your strength before going home. we discussed possibly getting hospice care involved once you are home. please see your medication list to review changes made to your medications. it was a pleasure taking care of you, mr . followup instructions: department: cardiac services when: thursday at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage md, procedure: coronary arteriography using two catheters left heart cardiac catheterization diagnoses: hyperpotassemia coronary atherosclerosis of native coronary artery esophageal reflux urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified acute myocardial infarction of other anterior wall, initial episode of care aortocoronary bypass status occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes personal history of tobacco use depressive disorder, not elsewhere classified hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) percutaneous transluminal coronary angioplasty status other and unspecified hyperlipidemia anxiety state, unspecified other and unspecified angina pectoris long-term (current) use of insulin right bundle branch block old myocardial infarction family history of ischemic heart disease do not resuscitate status urinary complications, not elsewhere classified atherosclerosis of native arteries of the extremities, unspecified chronic diastolic heart failure diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled background diabetic retinopathy above knee amputation status angiodysplasia of stomach and duodenum with hemorrhage other drugs and medicinal substances causing adverse effects in therapeutic use family history of diabetes mellitus chronic total occlusion of artery of the extremities occlusion and stenosis of carotid artery with cerebral infarction subclavian steal syndrome phantom limb (syndrome) 

Answer: The patient is high likely exposed to