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: ace inhibitors / albuterol attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation/extubation history of present illness: 62 yo female with history of morbid obesity, diastolic congestive heart failure, type ii diabetes mellitus, htn, h/o afib and pe on coumadin (recently transition to lovenox from warfarain for a scheduled opt colonoscopy), pulmonary htn and hld who bibems with htn urgency with findings consistent with flash pulmonary edema. . per pt's daughter, pt was undergoing bowel prep for her colonoscopy the night prior and was not wearing her bipap at home when she went to bed. pt awoke around 3am, not wearing home bipap, acutely sob and hypertensive to 220/140 per ems report, got 12 sl nitro on transfer. there was no reported chest pain per daughter the night prior, unclear if there is associated cp during the acute episode. for her scheduled opt , she was transitioned to lovenox from warfarin recently. she was on warfarin for her history of afib and pe. she is also on amiodarone for her afib. . ed course: patient's initial vitals were 103 224/104 28 97% on bipap, off bipap 76%. she was fighting the bipap and had vomitting episodes prior to recieving zofran, no observed aspiration event per report. nitro gtt was started. ekg: st@100 lbbb c/w prior ekgs. pcxr: bilat lower lobe whiteout. given concern for ventilation and airway protection, she was intubation w/ etomidate 40 succ 160. pcxr: ett and ogt in place. her vitals prior to transfer: 64 91/56 17 99% on cmv (peep 10, fio2 100%, rr 15 tv550; ph 7.29 pco2 55 po2 83 hco3 28) off propafol now on fentanyl and versed. she also recieved lasix 150 iv x1 for treatment of her pulmonary edema. contact: daughter. . on review of systems, s/he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: +diabetes (dm), +dyslipidemia, +hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: cath ' (no intervention) -pacing/icd: none 3. other past medical history: costochondritis coronary artery disease pulmonary hypertension h/o pe diastolic congestive heart failure (ef >55% 03/09) osa (cpap 7cm h2o at home with o2) bradycardia dm ii hypertension dyslipidemia afib on coumadin (recently started on lovenox for a colonoscopy) possible renal infarct presumably due to cardiac source of embolus s/p hysterectomy ~20 yrs ago for fibroids social history: no tobacco, etoh, substance abuse. lives in with her daughter. 5 children, 15 grandchildren. previously a preschool teacher, but working to get disability d/t her mmp. family history: mother: brain tumor, osteoporosis father: lung ca (smoker) 8 sisters, 2 brothers; one sister with " problem, smoker", htn; another sister with "tumor removed from brain, breast, stomach" physical exam: on admission: vs: t=98.7 bp=121/70 hr=60 rr=15 o2 sat=98% on cmv general: intubated, sedated, moving all 4 extremities freely. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple, unable to assess jvp. 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: intubated, b/l breath sounds noted. abdomen: soft, ntnd. no hsm or tenderness. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ on discharge: _________ pertinent results: labs: wbc: 05:00am blood wbc-14.7*# rbc-4.48 hgb-13.0 hct-40.8 mcv-91# mch-29.1 mchc-31.9 rdw-15.3 plt ct-437# 05:28am blood wbc-8.4 rbc-3.51* hgb-10.3* hct-31.5* mcv-90 mch-29.4 mchc-32.8 rdw-15.4 plt ct-295 06:00am blood wbc-6.9 rbc-3.45* hgb-10.5* hct-31.1* mcv-90 mch-30.5 mchc-33.8 rdw-15.5 plt ct-291 06:00am blood wbc-6.6 rbc-3.72* hgb-11.2* hct-33.8* mcv-91 mch-30.1 mchc-33.1 rdw-15.7* plt ct-309 basic coagulation (pt, ptt, plt, inr): 05:00am blood pt-14.1* ptt-21.1* inr(pt)-1.2* 05:28am blood pt-14.8* ptt-27.5 inr(pt)-1.3* 06:00am blood pt-14.5* ptt-26.9 inr(pt)-1.3* 06:00am blood pt-15.2* ptt-27.0 inr(pt)-1.3* chemistry: 05:00am blood glucose-240* urean-13 creat-1.5* na-142 k-2.8* cl-99 hco3-22 angap-24* 02:44pm blood glucose-141* urean-16 creat-1.6* na-143 k-4.4 cl-107 hco3-23 angap-17 05:28am blood glucose-154* urean-17 creat-1.6* na-141 k-3.9 cl-104 hco3-30 angap-11 03:08pm blood glucose-246* urean-18 creat-1.6* na-140 k-4.3 cl-103 hco3-29 angap-12 06:00am blood glucose-167* urean-22* creat-1.5* na-140 k-3.8 cl-101 hco3-30 angap-13 06:00am blood glucose-142* urean-19 creat-1.4* na-145 k-4.1 cl-105 hco3-31 angap-13 cardiac enzymes: 05:00am blood ck-mb-4 probnp-806* 05:00am blood ctropnt-0.01 02:44pm blood ck-mb-5 ctropnt-0.08* 10:04pm blood ck-mb-4 ctropnt-0.05* elements: 02:44pm blood calcium-8.4 phos-3.6 mg-1.5* 05:28am blood calcium-8.3* phos-2.6* mg-1.8 03:08pm blood calcium-8.9 phos-3.1 mg-2.0 06:00am blood calcium-8.8 phos-2.6* mg-1.9 06:00am blood calcium-9.1 phos-3.2 mg-1.8 tfts: 02:44pm blood tsh-10* 05:28am blood free t4-1.3 02:44pm blood t4-9.0 microbiology: mrsa screen negative vre screen negative urine: 10:32am urine osmolal-368 10:32am urine hours-random urean-277 creat-83 na-76 k-47 cl-98 10:32am urine eos-negative 06:45am urine blood-neg nitrite-neg protein-300 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg 06:45am urine color-yellow appear-clear sp -1.010 imaging: - portable tte (complete) done at 1:00:00 pm final echocardiographic measurements results measurements normal range left atrium - long axis dimension: *4.4 cm <= 4.0 cm left atrium - four chamber length: *7.1 cm <= 5.2 cm right atrium - four chamber length: *7.6 cm <= 5.0 cm left ventricle - septal wall thickness: *1.3 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: *1.2 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *5.7 cm <= 5.6 cm left ventricle - systolic dimension: 4.0 cm left ventricle - fractional shortening: 0.30 >= 0.29 left ventricle - ejection fraction: 50% >= 55% left ventricle - lateral peak e': *0.05 m/s > 0.08 m/s left ventricle - septal peak e': *0.04 m/s > 0.08 m/s left ventricle - ratio e/e': *27 < 15 aorta - sinus level: 3.3 cm <= 3.6 cm aorta - ascending: *3.5 cm <= 3.4 cm aortic valve - peak velocity: 1.4 m/sec <= 2.0 m/sec aortic valve - lvot diam: 2.0 cm mitral valve - e wave: 1.2 m/sec mitral valve - a wave: 0.5 m/sec mitral valve - e/a ratio: 2.40 mitral valve - e wave deceleration time: 211 ms 140-250 ms tr gradient (+ ra = pasp): *36 mm hg <= 25 mm hg findings this study was compared to the prior study of . left atrium: moderate la enlargement. right atrium/interatrial septum: markedly dilated ra. left ventricle: mild symmetric lvh. top normal/borderline dilated lv cavity size. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. low normal lvef. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. trivial mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: trivial/physiologic pericardial effusion. conclusions the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is top normal/borderline dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded, although in the short-axis views there is a suggestion of focal inferoseptal hypokinesis. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: hypertrophied and mildly dilated left ventricle with borderline systolic function, most consistent with hypertensive heart. no clinically-significant valvular disease seen. mild pulmonary hypertension. - ecg study date of 4:50:26 am marked baseline artifact. p waves are poorly visible but there appears to be a p wave with prolonged a-v conduction in lead v1 which is not visible in any other lead. complete left bundle-branch block with secondary st-t wave changes. compared to the previous tracing of , though the heart rate has increased, there are no other diagnostic interval changes. - chest (portable ap) study date of 4:55 am impression: severe pulmonary edema with some pleural effusion and bibasilar atelectasis. - chest (portable ap) study date of 7:25 am findings: as compared to the previous radiograph, there is no relevant change. moderate cardiomegaly, moderate pulmonary edema. no pleural effusions. no newly occurred focal parenchymal opacities. - ecg study date of 4:26:00 am sinus rhythm. left bundle-branch block. borderline q-t interval prolongation. non-specific st segment changes in the high lateral leads. compared to the previous tracing of the ventricular response rate has increased. brief hospital course: 62 yo female with history of morbid obesity, diastolic congestive heart failure with an ef of 55%, type ii diabetes mellitus, htn, h/o afib and pe on coumadin (recently transition to lovenox from warfarin for a scheduled opt colonoscopy), pulmonary htn and hld who bibems with htn urgency with findings consistent with flash pulmonary edema, was intubated in ed for airway protection. . # htn urgency: on arrival, the patient's bp was noted to be 220/140 per ems, with a cxr with bilateral lower lobe whiteout. the concern was for flash pulmonary edema in the setting of hypertension. the cause of the patient's hypertension was unclear, although it might be have been attributable to the large volume fluid shift in the setting of her bowel prep for colonoscopy, scheduled to take place the day of her admission. the patient was brought up to the ccu on a nitro gtt, which was eventually weaned off. she was also intubated in the ed given the concerns for ventilation and airway protection. she was given iv furosemide in the ed, and upon transfer to the icu was given 150 mg iv lasix x 2, with a small response in urine output less concerning for volume overload and more consistent with flash pulmonary edema. she was extubated the same afternoon with good oxygenation on 4 l, which apparently is her home dose of o2 as well. while an inpatient, we started the patient on a wean off her clonidine, and discontinued the patient's nifedipine, isosorbide mononitrate, and metoprolol. by her discharge, we had increased her furosemide to 100 mg from 80 mg , and had started the patient on labetalol 200 mg tid, in addition to amlodipine 10 mg qhs. on this regimen, the patient's blood pressures were slightly better control, with systolics in the 120s to occasionally the 180s. as an outpatient, the patient will require further titration of her blood pressure medication, but will also require a work-up for causes of secondary hypertension; we suggest starting with a renal mri to assess for fibromuscular dysplasia versus renal artery stenosis, with a plan to explore other potential causes such as adrenal adenoma in the future if inital work-up is negative. # dchf: likely worsened in the setting of hypertensive urgency, which tipped the patient over into flash pulmonary edema. repeat echo showed overall left ventricular systolic function is low normal (lvef 50-55%). the patient was continued on lasix for diuresis, a beta-blocker, and . the patient's beta-blocker was transitions to labetalol for better bp control # cad: cath showed no cad. the patient had a romi with troponin peaking at 0.08, and downtrending to 0.01. ekg did not have any concerning st elevations or depressions, although in the setting of lbbb this was difficult to determine. the patient did have an episode of chest pain 2 nights prior to her discharge: ekg at that time did not show any concerning st depression or elevation, and the patient's pain was reproducible to palpation, and resolved with 2 mg iv morphine. the patient was discontinued on aspirin 325 daily as well as atorvastatin 40 mg daily, in addition to her bb, and . . # rhythm: patient remained in atrial fibrillation during her hospitalization. she was continued on her home dose of amio and a beta-blocker, ulitmately transitioned to labetalol. she was started on lovenox given that her inr was not therapeutic, as she had been getting lovenox as an outpatient in preparation for her colonscopy. she was dc'ed on lovenox bridge to her high dose coumadin, followed by clinic. # pulm htn/history of pe: the patient is on a home dose of warfarin 40 mg daily, consistent with warfarin resistance. she was discharged on lovenox, with a plan to discontinue lovenox once her inr became therapeutic. she is followed by a clinic, who was notified her discharge. # : thought to be secondary to poor forward flow and altered hemodynamics. this improved slightly during her admission from 1.6 to 1.4, although not yet back her baseline around 1.2. she will need outpatient follow-up of her creatinine on her current diuretic regimen; her urine studies did not reveal any evidence of ain # hypothyroidism: most consistent with sick euthyroid with tsh of 10 and free t4 of 1.3, did not change home dose of continue levothyroxine at 25mcg daily. # loose tooth: the patient's left superior incisor fell out of her mouth in the emergency department when the ed had scissored open jaw in order to evaluate airway for intubation. she will require outpatient dental evaluation to see if a replacement can be made and if there has been any underlying trauma to her jaw bone. # hcm: repeat colonoscopy; last colonoscopy was 3 years ago and revealed adenomas; patient was unable to complete her colonscopy secondary to the above events. ## transitions of care - changed patient's home dose of metoprolol to labetalol, follow bps carefully - dental visit to evaluate tooth trauma during intubation - as outpatient, perform mra of renal arteries to r/o fmd - as an outpatient, perform colonoscopy admission weight: not performed intubation discharge weight: 132.3 kg medications on admission: aspirin 325 mg daily clonidine 0.2 mg tid coumadin "as directed" 30-40 mg daily diovan (valsartan) 320 mg daily klor-con 40meq lantus 52 units qhs levothyroxine 25 mcg daily nifedipine 60 mg novolog (insulin aspart) solution 100 unit/ml : 1 unit tid per sliding scale toprol xl (metoprolol succinate) 150 mg daily vitamin d (ergocalciferol (vitamin d2) 50,000 unit weekly amiodarone 200mg daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. clonidine 0.1 mg tablet sig: one (1) tablet po bid (2 times a day) for 3 days: then decrease to 0.1 mg daily for 3 days, then d/c. 3. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 4. potassium chloride 10 meq tablet extended release sig: four (4) tablet extended release po twice a day. 5. insulin glargine 100 unit/ml solution sig: fifty two (52) units subcutaneous once a day. 6. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 7. insulin lispro 100 unit/ml solution sig: 0-12 units subcutaneous four times a day: per sliding scale . 8. vitamin d 50,000 unit capsule sig: one (1) capsule po once a week. 9. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 10. labetalol 200 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 11. enoxaparin 120 mg/0.8 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours): take twice daily until at coumadin clinic tells you to stop. disp:*8 syringe* refills:*2* 12. amlodipine 10 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 13. furosemide 40 mg tablet sig: 2.5 tablets po bid (2 times a day). disp:*150 tablet(s)* refills:*2* 14. outpatient lab work please check chem-7, pt/inr on monday wtih results to dr. at and at clinic at 15. warfarin 5 mg tablet sig: eight (8) tablet po once daily at 4 pm. 16. atorvastatin 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: acute on chronic diastolic chf hypertensive emergency diabetes mellitus type 2 dyslipidemia 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: you had an acute exacerbation of your diastolic congestive heart failure, likely from the bowerl prep for the colonoscopy. you were intubated to support your breathing and diuresed with a lasix infustion. your weight at discharge is 291 pounds. we have adjusted your medicine to help you get rid of additional fluid slowly to get to your dry weight of about 270 pounds. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. your blood pressure was very high which also contributed to your congestive heart failure. we have changed your medicine regimen to help better control your blood pressure. please buy a blood pressure cuff and check your blood pressure 2-3 times per day. record results and bring them to all your doctor's appts. . we made the following changes to your medicines: 1. wean off clonidine by taking 0.1 mg for 3 days, then 0.1 mg daily for 3 days, then d/c. 2. discontinue nifedipine, isosorbide mononitrate and metoprolol 3. increase furosemide to 100 mg twice daily 4. start labetolol at 200 mg three times a day for your high blood pressure. 5. continue lovenox injections twice daily at home until tells you to stop. 6. start taking amlodipine 10 mg at night for your high blood pressure 7. please continue to take 40 mg warfarin daily. will call you at home with further instructions. 8. decrease the atorvastatin to 40 mg daily because of an interaction with the amiodarone followup instructions: department: liver center when: thursday at 9:20 am with: building: lm campus: west best parking: garage department: cardiac services when: monday at 3:20 pm with: , md building: sc clinical ctr campus: east best parking: garage name: , m. location: community health center address: , , phone: appt: at 2:15pm md, procedure: insertion of endotracheal tube diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation acute on chronic diastolic heart failure other chronic pulmonary heart diseases peripheral vascular disease, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure morbid obesity long-term (current) use of anticoagulants personal history of venous thrombosis and embolism unspecified hypertensive heart disease with heart failure open wound of tooth (broken) (fractured) (due to trauma), without mention of complication 

Answer: The patient is high likely exposed to