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: januvia / allopurinol attending: chief complaint: osh transfer for acute on chronic systolic heart failure and ventricular tachycardia major surgical or invasive procedure: cardiac catheterization lab for epicardial lead placement which was unsuccesful cardiac surgery for upgrade of vvi-icd to biventricular-pacer- icd with addition of epicardial left ventricular pacing lead and transvenous atrial lead, cardioversion cardioversion on history of present illness: 70 f history of ischemic cardiomyopathy (-v icd placed 2 weeks ago, ef 30%) presented to osh on for acute on chronic systolic heart failure and ventricular tachycardia. pt had recent hosptialization ( hospital--> ) for pulmonary edema vs pneumonia requiring intubation, lasix and ceftriaxone. she was extubated after brief period. pt presented back to hospital on with nausea/emesis/ epigastric pain. v tach: on prsentation to osh she found to be in v tach at rate of 160-170s. she was alert during this time, sbp 80s. amiodarone was given but no conversion. she was then cardioverted and shocked back to nsr. (despite icd being in place, it did not go off.) last night she was in a fib then converted to sinus. this morning, she was found to be in v tach again, sp shock then given amiodarone gtt starting this am. she remained in nsr since then. acute systolic heart failure: pt found to be in pulmonary edema and was given lasix 60mg po. echo at osh showed on : ef 30% (2 weeks ago)--> lvef %. apical akinesis and thinning, anterior and inferior akinesis and thinning. during hospitalization, she was hypotensive (sbp 80-90s) with leukocytosis (wbc 23) and was given vancomycin and zosyn for broad empiric coverage. she was transfered to for management of chf and vtach. in the ambulance to she was initialy satting well on 2 l. however, she suddenly became sob and required a non-rebreather. no clear precipitant as ems reports bp and hr overall stable during transfer. no episodes of vt. her arms and legs were cold with bp in the 80s. on arrival to the ccu, pt looked ill, was in respiratory distress. she was transitioned to bipap 100%. cxr was performed and showed pulmonary edema. she was given lasix 60mg iv once with minimal uo. she was then given 100mg iv followed by lasix gtt. . review of systems on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of ankle edema, palpitations, syncope or presyncope. . past medical history: past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: prior mi in (no cabg or cath since then) a fib ischemic cardiomyopathy- lbbb, sp icd. baseline ef 20-30% few weeks ago, now 10% 3. other past medical history: hypothyroidism osteoperosis gout social history: non smoker, no drugs. married family history: n/c physical exam: vs: t 98, hr 66 sinus, 97/61, rr 26, 99% non rebreather general: resp distress, cold feet and arms, ill appearing heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 9 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. cold feet and hands pulses: radial 2+ bilaterally pertinent results: labs: on admission: 12:01pm wbc-17.6* rbc-3.85* hgb-12.3 hct-38.6 mcv-100* mch-32.0 mchc-31.9 rdw-15.9* 12:01pm neuts-90.3* lymphs-4.6* monos-3.4 eos-1.4 basos-0.4 12:01pm glucose-182* urea n-27* creat-1.4* sodium-139 potassium-5.2* chloride-104 total co2-22 anion gap-18 12:01pm calcium-7.9* phosphate-5.1* magnesium-2.5 11:56am glucose-182* lactate-3.2* na+-133 k+-5.7* cl--105 11:56am o2 sat-99 12:01pm pt-16.2* ptt-27.4 inr(pt)-1.5* 12:01pm plt count-243 12:01pm ck-mb-2 ctropnt-0.10* 12:01pm alt(sgpt)-97* ast(sgot)-109* ck(cpk)-50 alk phos-80 tot bili-0.6 on discharge: 06:00am blood wbc-10.6 rbc-3.34* hgb-10.6* hct-33.2* mcv-99* mch-31.7 mchc-31.9 rdw-17.1* plt ct-353 06:00am blood pt-30.8* inr(pt)-3.0* 06:00am blood glucose-90 urean-26* creat-1.4* na-137 k-4.0 cl-97 hco3-33* angap-11 imaging/studies: cardiac echocardiogram: left atrium - long axis dimension: *4.4 cm <= 4.0 cm left atrium - four chamber length: *5.9 cm <= 5.2 cm right atrium - four chamber length: 4.8 cm <= 5.0 cm left ventricle - septal wall thickness: 0.7 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.9 cm <= 5.6 cm left ventricle - systolic dimension: 4.0 cm left ventricle - fractional shortening: *0.18 >= 0.29 left ventricle - ejection fraction: 15% to 20% >= 55% left ventricle - stroke volume: 33 ml/beat left ventricle - cardiac output: 2.71 l/min left ventricle - cardiac index: *1.50 >= 2.0 l/min/m2 left ventricle - lateral peak e': 0.10 m/s > 0.08 m/s left ventricle - septal peak e': 0.40 m/s > 0.08 m/s left ventricle - ratio e/e': 5 < 15 aorta - sinus level: 2.6 cm <= 3.6 cm aorta - ascending: 3.0 cm <= 3.4 cm aorta - arch: 2.4 cm <= 3.0 cm aortic valve - peak velocity: 1.1 m/sec <= 2.0 m/sec aortic valve - lvot vti: 13 aortic valve - lvot diam: 1.8 cm mitral valve - e wave: 1.2 m/sec mitral valve - e wave deceleration time: *124 ms 140-250 ms tr gradient (+ ra = pasp): 23 to 25 mm hg <= 25 mm hg pulmonic valve - peak velocity: 0.7 m/sec <= 1.5 m/sec findings left atrium: mild la enlargement. right atrium/interatrial septum: a catheter or pacing wire is seen in the ra and extending into the rv. left ventricle: normal lv wall thickness and cavity size. severe regional lv systolic dysfunction. estimated cardiac index is depressed (<2.0l/min/m2). no lv mass/thrombus. no resting lvot gradient. right ventricle: mildly dilated rv cavity. mild global rv free wall hypokinesis. aorta: normal diameter of aorta at the sinus, ascending and arch levels. aortic valve: no as. no ar. mitral valve: mild (1+) mr. lv inflow pattern c/w restrictive filling abnormality, with elevated la pressure. tricuspid valve: normal pa systolic pressure. pericardium: no pericardial effusion. general comments: suboptimal image quality - poor echo windows. suboptimal image quality as the patient was difficult to position. suboptimal image quality - body habitus. conclusions the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is severe regional left ventricular systolic dysfunction with anterior, septal and apical akinesis. there is moderate hypokinesis of the remaining segments (lvef = 15-20%). the estimated cardiac index is depressed (<2.0l/min/m2). no masses or thrombi are seen in the left ventricle. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. there is no aortic valve stenosis. no aortic regurgitation is seen. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: severe regional and global left ventricular systolic dysfunction, most c/w ischemic cardiomyopathy. mild mitral regurgitation. elevated intracardiac filling pressures and low cardiac index other diagnostics: chest xray as compared to the previous radiograph, there is no relevant change. borderline size of the cardiac silhouette with left pleural effusion and subsequent atelectasis. extent of the effusion is constant. minimal atelectasis at the right lung base but no evidence of interval appearance of focal parenchymal opacity suggesting pneumonia. unchanged position and course of the pacemaker leads. cardiac perfusion persantine 1. fixed, severe, very large perfusion defect involving the lad territory. 2. increased left ventricular cavity size. severe systolic dysfunction with akinesis of the apex, entire distal ventricle and the entire mid ventricle rest thalium impression: 1. severe resting perfusion defect of the apex, entire distal ventricle and entire mid ventricle, indicating low probability of recovery of function of these segments after revascularization. the remaining basal segments have normal tracer uptake, indicating viability of these segments. ct abdomen with contrast impression: 1. unchanged appearance of subcapsular splenic hematoma. 2. bilateral pleural effusions, small amount on the right and moderate amount on the left. 3. small non-obstructing stone measuring 5 mm in the lower pole of the left kidney. ekg: atrial fibrillation with mean rate of 82 beats per minute. demand ventricular pacing in a left bundle-branch block pattern. compared to the previous tracing of the rhythm is now atrial fibrillation which is being tracked by the pacemaker. brief hospital course: 70 f with history of ischemic cardiomypathy (ef previously 30%) sp transfered from osh for v tach and acute on chronic systolic heart failure. active issues by problem: # acute on chronic systolic heart failure: the patient's ef was 30% few weeks prior to admission, then on admission found to be 10%. the acute worsening of systolic function was likely triggered by ventricular tahycardia and heart failure. troponins were not elevated at osh making another acute ischemic event less likely, however given no history of cath but + history of inferior-posterior mi, it was unclear whether the exacerbation was due to an ischemic event. -history of infero-posterior mi. the patient was initially hypotensive and dyspneic on arrival to ccu. she improved with bipap and was able to be weaned down to face mask after diuresis. nitroprusside and lasix gtts were initiated. the patient diuresed nicely, was weaned off nasal canula oxygen and and was transitioned to torsemide. we also initiated coreg and captopril to optimize hemodynamics. patient agreed to workup of her heart disease and etiology of the chf exacerbation, see below in coronary artery disease. # arrhythmias: the patient suffered 2 episodes of ventricular tachcyardia episodes on day of admission likely from scar from inferior region. she also has chronic atrial fibrillation and takes coumadin at home. the coumadin was held (as was heparin gtt) upon admission due to suspicion of a splenic hematoma on osh ct scan (see below). her icd was adjusted to fire at 160 bpm instead of 200 (icd did not fire at osh because the threshold was set to the latter). after stabilization of her splenic hematoma a heparin gtt was initiated with ptt goal of 50-70. patient was started on amiodarone while in house loading dose 200 tid for 7 g total, pt was continued 200tid (last day ), then on decreased dose to 200 daily for maintenance. #biv placement: the patient went for biv lead placement for more efficient squeeze. patient has a low ef and lbbb and we thought she would benefit from a biv palcement. cardiology tried to place biv in the cath lab on but they were unsuccesful. on surgery took her to for upgrade of vvi-icd to biventricular-pacer- icd with addition of epicardial left ventricular pacing lead and transvenous atrial lead and she was also cardioverted at this time. as a complicaton there was a minor left ventricular perforation at the time of the left ventricular lead implant which was oversewn. patient was cared for by cardiac surgery for about 24 hours than transferred to the floors to have continuous care by the ccu team. though patient was cardioverted on she soon after went back into afib. heparin was restarted after surgery with goal ptt 50-70. she was also on keflex for total of 5 days after her biv placement. on she was cardioverted and she went back into sinus rythm. she was discharged on coumadin and will follow up with cardiology in the outpatient setting to discuss how long she should be on coumadin and if she still is in sinus rythm. #splenic infarct: ct at osh showed suspected splenic infarct vs. hematoma. repeat ct w/ contrast here confirmed the suspicion and showed increasing size of lesion. acs consulted and recommended to hold heparin/warfarin for afib and no surgical indication as not a good surgical candidate. after rescrutinization of the ct scans, surgery thought patient might benefit from embolization therapy. interventional radiology was consulted and decided no intervention was needed at this time because the patient's hcts were stable and not downtrending. we trended her hematocrits every 6 hours and got another repeat ct scan which showed stable blood counts and no interval change in hematoma. etiology of spleic infarct and hemhorragic conerversion werent clear however it is likely patient through a clot from her a-fib which caused splenic infarct then led to hemhorragic conversion. ct surgery recommended we restart anticoagulation because of her afib and we put her back on heparin drip with goal ptt 50-60. # coronary artery disease: pt has history of ischemic cardiomyopathy due to history of mi in past. she has refused cardiac catheterization in the past. given the documented mi in the past, it was postulated that ongoing coronary artery disease was the possible culprit for the chf exacerbation/vtach. she underwent a viability study on which showed severe resting perfusion defect of the apex, entire distal ventricle and entire mid ventricle, indicating low probability of recovery of function of these segments after revascularization. the remaining basal segments have normal tracer uptake, indicating viability of these segments. on we got cardiac perfusion persantine showing fixed, severe, very large perfusion defect involving the lad territory and increased left ventricular cavity size. severe systolic dysfunction with akinesis of the apex, entire distal ventricle and the entire mid ventricle. patient was not a candidate for revascularization in cath lab because the scans indicated that this damage was old. #c diff: pt presented with an elevated wbc 19 with predominant polys. a c.diff assay came back positive, and the patient was treated with metronidazole in house. last day of flagyl was . after the biv patient was on c-surgery floor and they restarted her home colchicine for gout. she subesquently had diarrhea differtnial was from starting the colchicine vs cdif. she was restarted again on flagyl an told to continue for another 14 days. # acute renal failure: cr 1.4 initialy at osh then improved to 1.1 , now 1.4 and has been stable for a few days. unknown true baseline. differential: pre-renal in setting of chf and low intravascular volume, ain in setting of penicillin antibiotics at osh, atn (preceeded by pre-renal), foley in so less likely obstruction and post-renal. renal vein thrombus and renal artery clot also possible in pt with known a fib and ?splenic infarcts in the past. given her exposure to contrast on the first ct abdomen in house, contrast nephropathy was the likely culprit for her though pre-renal chf was also likely a cause. she was treated with supportive therapy including titration of bp meds and strict monitoring of her i/os. her cr was at 1.4 at time of admission. it is possible this is her new baseline. # diabetes type 2: patient was on insulin sliding scale. tansitional issues. #chf: will follow up with cardiologist #diarrhea: being treated for recurrent cdif with flagyl. if patient develops cdiff again she should get po vanco #arrythmias: patient has history of afib and was cardioverted while in house and went into sinus but she is at high risk for converting back to afib and this should be followed up by cardiologist in outpatient setting. she was sent home on coumadin and discussion should be made at folllow up about how long she should be on it. #splenic hematoma: it appeared stable while she was here however this should be followed up in outpatient setting by her pcp #biv placement: patient will follow up with dr who performed the surgery for biv lead placement medications on admission: preadmission medications listed are correct and complete. information was obtained from patientfamily/caregiver. 1. alendronate sodium 70 mg po qsun 2. anucort-hc *nf* (hydrocortisone acetate) 25 mg rectal as needed rectal pain 3. carvedilol 6.25 mg po bid 4. colchicine 0.6 mg po bid 5. fluocinonide 0.05% ointment 1 appl tp 6. furosemide 60 mg po daily 7. glipizide 5 mg po bid 8. isosorbide mononitrate (extended release) 30 mg po daily 9. jantoven *nf* (warfarin) 5 mg oral daily 10. levothyroxine sodium 100 mcg po daily 11. lisinopril 5 mg po daily 12. simvastatin 20 mg po daily 13. vagifem *nf* (estradiol) 25 mcg vaginal 2 times per week 14. lantus *nf* (insulin glargine) 70 units subcutaneous daily 15. spironolactone 25 mg po daily 16. polyethylene glycol 17 g po daily 17. estroven regular strength *nf* (mv,ca,min-fa-herbal no.159) one tab oral daily 18. aspirin 81 mg po daily 19. multivitamins 1 tab po daily 20. vitamin d 400 unit po daily 21. docusate sodium 100 mg po bid discharge medications: 1. alendronate sodium 70 mg po 1x/week () 2. aspirin ec 81 mg po daily 3. carvedilol 25 mg po bid hold for sbp < 100, hr < 60 rx *carvedilol 25 mg one tablet(s) by mouth twice a day disp #*60 tablet refills:*2 4. lisinopril 2.5 mg po daily rx *lisinopril 2.5 mg one tablet(s) by mouth daily disp #*30 tablet refills:*2 5. anucort-hc *nf* (hydrocortisone acetate) 25 mg rectal as needed rectal pain 6. simvastatin 20 mg po daily 7. spironolactone 25 mg po daily 8. levothyroxine sodium 100 mcg po daily 9. amiodarone 200 mg po daily rx *amiodarone 200 mg one tablet(s) by mouth daily disp #*30 tablet refills:*2 10. cholestyramine 4 gm po bid duration: 1 weeks rx *cholestyramine (with sugar) 4 gram one packet by mouth twice a day disp #*14 packet refills:*0 11. digoxin 0.125 mg po every other day rx *digoxin 125 mcg one tablet(s) by mouth every other day disp #*15 tablet refills:*2 12. torsemide 40 mg po daily rx *torsemide 20 mg two tablet(s) by mouth daily disp #*60 tablet refills:*2 13. vagifem *nf* (estradiol) 25 mcg vaginal 2 times per week 14. vitamin d 400 unit po daily 15. multivitamins 1 tab po daily 16. glipizide 5 mg po bid 17. lantus *nf* (insulin glargine) 30 units subcutaneous daily please go back up on your dose if your blood sugar is high 18. fluocinonide 0.05% ointment 1 appl tp 19. jantoven *nf* (warfarin) 1 mg oral daily rx *warfarin 1 mg one tablet(s) by mouth daily disp #*30 tablet refills:*2 20. metronidazole (flagyl) 500 mg po q8h duration: 12 days rx *metronidazole 500 mg one tablet(s) by mouth three times a day disp #*36 tablet refills:*0 21. outpatient lab work please check inr and chem-7 on with results to dr. at phone: fax: icd 9: 427.31 22. estroven regular strength *nf* (mv,ca,min-fa-herbal no.159) 0 tab oral daily discharge disposition: home with service facility: vna of southern co. discharge diagnosis: acute on chronic systolic chf atrial fibrillation diabetes mellitus hypertension coronary artery disease dyslipidemia c difficile colitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure caring for you while you were hospitalized at the . you were admitted with congestive heart failure and a dangerous heart rhythm called ventricular tachycardia. you were started on amiodarone to treat this rhythm and it is now gone. we attempted to place another pacer lead in your heart through the veins but needed to place it surgically instead. you tolerated this procedure well and it seems that your heart is pumping better. we have adjusted your medicines to keep the fluid off that we have removed during your stay. your weight at discharge is 145 pounds and you need to keep your weight here to prevent fluid overload. please weigh yourself every day and call dr. if your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. you should also follow a low sodium diet as we discussed. you are on warfarin (coumadin) to prevent a stroke resulting from the atrial fibrillation. please continue to take this medicine. dr. will monitor the blood levels and tell you how much to take. . followup instructions: . department: cardiac surgery when: thursday at 1:30 pm with: , md building: lm bldg () campus: west best parking: garage . name: , a address: , , phone: appointment: friday 2:00pm name: , address: , , phone: *the office is working on a follow up appointment for your hospitalization with your cardiologist. it is recommended you be seen within 2 weeks of discharge. the office will contact you at home with an appointment. if you have not heard within 2 business days please call the office at the above number. . name: dr location: -cardiology address: north acc 4th fl, , ma phone: appt: at 1pm procedure: diagnostic ultrasound of heart other electric countershock of heart arterial catheterization other and unspecified repair of ventricular septal defect implantation of cardiac resynchronization defibrillator, total system [crt-d] central venous catheter placement with guidance diagnoses: acidosis hyperpotassemia congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified acquired hypothyroidism gout, unspecified atrial fibrillation accidental puncture or laceration during a procedure, not elsewhere classified paroxysmal ventricular tachycardia other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia osteoporosis, unspecified intestinal infection due to clostridium difficile old myocardial infarction surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation embolism and thrombosis of other specified artery acute on chronic systolic heart failure other diseases of spleen fitting and adjustment of automatic implantable cardiac defibrillator chronic passive congestion of liver 

Answer: The patient is high likely exposed to