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: demerol / actos attending: chief complaint: congestive heart failure major surgical or invasive procedure: : ultrasound-guided right thoracentesis : ep study- planned biv pacer upgrade, placement dual chamber icd history of present illness: mr. is a 71 year-old gentleman with known cad (cath showed one vessel disease with 70% distal lcx 90% om at mid vessel), dilated cardiomyopathy ( lvef = 10% at compared to 20-25 % in at ), nsvt status post aicd placement in , and paroxysmal atrial fibrillation on amiodarone and coumadin. according to dr. , when he last saw him the patient was doing well. however, despite his most recent cath which showed "single vessel" disease, dr. thinks he has multivessel disease that waxes and wanes on angiography. the patient has always refused intervention in the past. the patient was in his usual state of health until early when he developed an acute chf exacerbation. he was admitted to and treated there. he represented to hospital (current presenatation) after falling out of his chair while asleep and not being able to get up himself. he denied preceeding lightheadedness, chest pain, palpitations, shortness of breath, bladder or bowel incontinence, although he did endorse that he was confused for nearly the entire next day. at he was felt to be clinically in chf with elevated bnp 2880 and pulmonary edema on chest x ray. he was also found to be in afib with rvr. he was admitted to the icu and treated with lasix gtt, diltiazem gtt, and amiodarone to 200 mg daily. his lasix dosing was titrated to 100mg iv bid and he was diuresing well, but developed arf with creatinine increased from 0.9 on admission to 2.1. his lasix and spironolactone were held starting . lfts also became acutely elevated ast from 24 to 4139, alt from 37 to 1335. his acute renal failure and hepatitis were both attributed to ischemic insult from poor cardiac output. it was also thought that he had acute ischemic colitis but there was no lab or imaging studies to support this from the outside hospital. he also was found to have evidence of a uti and was started on antibiotics. he was transferred to on for consideration of -v icd upgrade. he was admitted to and got kayexalate for hyperkalemia of 5.9. the following morning he had an echo (results pending). he was evaluated by ep who thought he would benefit from biv pacing. he underwent persantine perfusion stress test to look for viability of his left ventricle prior to biv placement. secondary to his elevated liver enzymes his amiodarone was decreased and his statin and coumadin were also held. hepatology was also consulted. he is being transferred to the ccu for initation of diuresis with inotropes. past medical history: past medical history: 1) chf- tte 20-25%, dry weight 198 lbs. 2) cad-most recent cath in showed single vessel lcx disease 3) ventricular fibrillation- s/p vf arrest , aicd placed at that time 4) paroxysmal atrial fibrillation- started on amiodarone , also on bb, anticoagulated with coumadin 4) pt uses inhalers, steroids during admission, pfts showing both mod. restrictive and marked obstructive component 5) dm type 2- lantus + humalog iss, hgb a1c 10.3 in at 6) hypertension 7) barrett's esophagus with high grade dysplasia. post cryotherapy x 3, barrx 8) hypercholesterolemia 9) s/p gi bleed- ugib from a gastric ulcer 10) s/p appendectomy 11) s/p bone tumor excision from shoulder 12) ? portal vein thrombosis pacemaker/icd placed: vr 7232cx social history: pt is retired from the police force and security service at hospital. he lives independently at estates senior center, a retirement community. closest family is his cousin ) who lives down the street from him. he was adopted, never married, and has no children. he smoked for 45 yrs, ppd, quit 8 yrs ago. he denies any alcohol intake or other drug use. family history: the patient was adopted and does not know family history. physical exam: physical examination: general: elderly male. drowsy, eyes closed. oriented to year and month, buit thinks at (per team was oriented to earlier today). mood, affect appropriate. heent: ncat. scleral edema, skin appears jaundice. eomi. neck: supple with jvp elevated to ear cardiac: irregularl rhythm, normal s1, s2. no m/r/g. lungs: resp were labored with accessory muscle use. mild wheezes, poor posterior lung exam due to uncooperation. abdomen: soft, ntnd. extremities: pitting edema in legs, thighs, flank skin: warm. no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ pertinent results: cbc wbc-12.3*# rbc-4.93 hgb-12.5* hct-40.9 mcv-83 mch-25.4* mchc-30.7* rdw-15.6* plt ct-307 12:27pm blood wbc-14.9* rbc-4.93 hgb-12.2* hct-40.9 mcv-83 mch-24.8* mchc-29.9* rdw-15.8* plt ct-183 04:30am blood wbc-14.1* rbc-4.71 hgb-12.5* hct-38.6* mcv-82 mch-26.4* mchc-32.3 rdw-15.9* plt ct-216 03:28am blood wbc-11.5* rbc-4.91 hgb-12.0* hct-39.6* mcv-81* mch-24.5* mchc-30.3* rdw-15.7* plt ct-233 differential 09:26pm blood neuts-84.7* lymphs-10.0* monos-4.9 eos-0.1 baso-0.3 coags 09:26pm blood pt-33.0* ptt-30.1 inr(pt)-3.3* 12:27pm blood pt-38.3* ptt-33.2 inr(pt)-4.0* 04:30am blood pt-38.6* ptt-36.2* inr(pt)-4.0* chem 7 09:26pm blood glucose-234* urean-64* creat-2.3*# na-133 k-5.9* cl-93* hco3-30 angap-16 12:27pm blood glucose-188* urean-71* creat-2.3* na-134 k-5.5* cl-94* hco3-32 angap-14 04:30am blood glucose-147* urean-71* creat-2.1* na-133 k-6.5* cl-93* hco3-33* angap-14 05:56am blood k-4.3 02:32pm blood glucose-159* urean-68* creat-1.9* na-133 k-3.5 cl-90* hco3-36* angap-11 03:28am blood glucose-117* urean-59* creat-1.8* na-134 k-3.2* cl-86* hco3-44* angap-7* lfts 09:26pm blood alt-1489* ast-2401* ck(cpk)-48 alkphos-168* totbili-2.1* 12:27pm blood alt-1281* ast-1614* ld(ldh)-682* ck(cpk)-46* alkphos-175* totbili-2.3* 04:30am blood alt-998* ast-946* alkphos-163* totbili-2.4* 03:28am blood alt-724* ast-574* ld(ldh)-312* alkphos-188* totbili-2.1* cardiac biomarkers 09:26pm blood ck-mb-notdone ctropnt-0.05* 12:27pm blood ck-mb-notdone ctropnt-0.03* ett : interpretation: 71 yo man with h/o chf, cad, atrial fibrillation, severe copd and cardiomyopathy with lvef of % was referred for evaluation following admission for ? syncopal episode while in atrial fibrillation with rvr and chf exacerbation. the patient was administered 0.142 mg/kg/min of persantine over 4 minutes. no chest, back, neck or arm discomforts were reported by the patient during the procedure. the ecg is uninterpretable for ischemia in the presence of the lbbb. the rhythm was sinus with rare isolated vpds noted. the blood pressure response to the persantine infusion was appropriate. the heart rate response to the persantine infusion was flat. post-infusion, the patient was administered 125 mg aminophylline iv. impression: no anginal symptoms with an uninterpretable ecg for ischemia in the presence of the lbbb. nuclear report sent separately. sestamibi : interpretation: the image quality is good.left ventricular cavity size is dilated and subjectively appears larger than on study of , but gated images for edv calculation could not be performed due to atrial fibrillation. rest and stress perfusion images reveal no appreciable change in large sized, moderate severity inferior wall perfusion defect. ef calculation could not be performed without gated images. impression: 1. no evidence of reversible myocardial perfusion defect at peak pharmacologic stress. 2. unchanged fixed inferior wall perfusion defect. 3. dilated lv cavity, subjectively worsened since previous exam. echo : the left atrium is mildly dilated. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef= %). there is probable apical thrombus. the right ventricular cavity is dilated with preserved free wall contractility. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trace mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular systolic function is now more severely depressed with new anteroseptal dyskinesis and the apex is now akinetic/dyskinetic. abdominal ultrasound with doppler : impression: 1. no portal vein thrombosis identified. 2. large bilateral pleural effusions and small amount of ascites. 3. stable simple right renal cyst. echo : the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe regional left ventricular systolic dysfunction with the only moving wall being the anterolateral wall. overall left ventricular systolic function is severely depressed (lvef= 15 %). tissue synchronization imaging demonstrates no significant left ventricular dyssynchrony. there is no significant delay in peak systolic contraction between opposing walls. the aortic pre-ejection time is normal at 137 ms (nl <140ms). the delay between left ventricular and right ventricular ejection is 39 ms (nl <40ms). the patient does not meet any modified care-hf criteria for ventricular dyssynchrony, and is unlikely to benefit from resynchronization therapy. the right ventricular cavity is dilated with focal hypokinesis of the apical free wall. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. ct head : subgaleal hematoma at the vertex, without underlying fracture. there is no intracranial hemorrhage. mild parenchymal atrophy is redemonstrated. cxr : in comparison with the study of , allowing for the more upright position, there is probably little overall change. large right and smaller left pleural effusions persist with continued enlargement of the cardiac silhouette and possible mild elevation of pulmonary venous pressure. bibasilar atelectatic changes are seen, and icd device and central catheter remain in place. cxr : in comparison with study of , there has been a thoracentesis with removal of a substantial amount of pleural fluid. there is no evidence of pneumothorax and could reexpansion of the lower right lung. no evidence of reexpansion pulmonary edema. pleural fluid : negative for malignant cells pleural analysis wbc rbc polys lymphs monos meso macro 04:29pm 1150* 9150* 37* 33* 8* 4* 18* pleural chemistry totprot glucose ld(ldh) albumin cholest 04:29pm 3.6 207 219 2.4 59 cxr : in comparison with the study of , there is now an endotracheal tube in place with its tip approximately 4.4 cm above the carina. nasogastric tube extends to the distal stomach. new right-sided aicd has the leads in the region of the right atrium and right ventricle. the overall appearance of the heart and lungs is unchanged without evidence of pulmonary edema brief hospital course: mr. is a 71 year-old gentleman with known coronary artery disease and ischemic cardiomyopathy (ef 10-15%), who presented from with renal and hepatic failure due to cardiogenic shock for biv placement and was transferred to the ccu for initiation of inotropic assisted diuresis. 1. acute on chronic systolic heart failure: the patient was found to be in acute decompensated systolic chf at . he was transferred to for biv icd upgrade. he was admitted to the floor where diuresis was attempted, but was unsuccessful with lasix iv bolus. he had evidence of multi-organ failure with elevated transaminases and creatinine. an echocardiogram was performed that revealed ef 10-15%. he underwent setstamibi perfusion test which showed a dilated lv cavity, and unchanged fixed inferior defect but viable left lateral ventricle wall. there was discussion as to have patient undergo myocardial viability study in order to see if catheterization and restoration of perfusion could improve patient's ejection fraction. however, pt's outpatient cardiologist, dr. felt that his cardiomyopathy was unlikely ischemic and catheterization would likely not be helpful in his case. the cardiac electrophysiology service was consulted who believed the patient would be a good candidate for biv placement. however, pt would require treatment of his overt heart failure first. because of his poor diuresis on the floor, he was admitted to the icu for initiation of milrinone for ionotropic support. he was started on milrinone and lasix drips with metolazone 5 mg q day and had good urine output to this. he was aggressively diuresed from his admission weight of 103 kg to below 83kg, with a dry weight 2 years ago around 90 kg. his total body edema improved dramatically, however pt still retained fluid in the form of pulmonary edema and pleural effusions. due to concerns for enlarging right sided pleural effusion seen on cxr, pt underwent ultrasound-guided thoracentesis which revealed 1.5 l pleural fluid, which was negative for malignant cells. pt tolerated procedure well and his creatinine and overall clinical presentation improved over his hospital course. he was discharged on a reduced dose beta blocker, reduced dose ace inhibitor, as well as torsemide 20mg daily. originally, the patient had been planned for biv-icd upgrade for synchrony. the procedure was delayed due to patient's ongoing diuresis as well as episodes of atrial fibrillation with rvr, requiring better rate control. pt underwent procedure on which was technically complicated and ultimately could not be done due to difficulty from complicated anatomy (coronary sinus was too wide to anchor the lead). the procedure was also complicated by hypotension and ventricular fibrillation, requiring shocks. his pacemaker was replaced as a dual chamber icd and was functioning appropriately. 2. transaminitis: patient presented from with elevated lfts that were most consistent with shock liver as the etiology. the hepatology service was consulted who agreed this was most likely acute ischemic liver. a right upper quadrant ultrasound was performed which did not show portal or hepatic thrombosis. his statin was held and his amiodarone was reduced from 200 to 100 mg . hepatitis serologies showed immunity against hepatitis b surface antigen, otherwise negative. his lfts and inr were monitored closely and improved overtime. when liver function resolved, amiodarone was changed back to 200mg daily. 3. acute kidney injury: the patient presented with an elevated creatinine to 2.3 from 0.8. there was no obstruction per osh ultrasound. it was thought that his renal failure was secondary to intravascular depletion from poor systolic function. his medications were renally dosed. he was started on milrinone and lasix drip and had good response to this with improved creatinine. creatinine was carefully monitored during his hospital course and improved to his baseline at time of discharge. 4. uti: the patient had a known uti with culture positive for klebsiella pneumonia sensitive to levofloxacin from osh. he was continued on ciprofloxacin which was thought to adequately cover the organism. 5. cad: the patient's most recent cath showed single vessel disease. a perfusion stress test showed unchanged fixed inferior wall perfusion defect. he was continued on his aspirin, metoprolol. his lfts improved. he was restarted on lipitor 40mg. 6. atrial fibrillation: originally pt was in nsr. he was continued on amiodarone, digoxin, and metoprolol. he was maintained on heparin gtt while in-house, and was restarted on coumadin prior to discharge. coumadin had been being held in the setting of potential biv placement. pt did experience a few episodes of atrial fibrillation with rapid ventricular response, which may have been precipitated by chf/ volume status. these episodes were asymptomatic w/ hrs in the 110s to 120s. pt was maintained on his outpatient regimen as above, as his cardiac output was very rate-dependent given his poor ejection fraction. heparin gtt should be continued until inr therapeutic. 7. diabetes: home dose lantus decreased and sliding scale insulin continued in house. 8. copd - patient treated and discharged to rehab on albuterol and ipratropium nebulizers as needed. outpatient maintenance medications (spiriva and advair) should be restarted prior to discharge home from rehab. medications on admission: current medications from transfer: toprol xl 50mg po qday lantus 45u sc qhs humalog sliding scale zocor 80mg po qhs amiodarone 200mg po bid asa 81mg vit b12 1000 mcg qday coumadin (held upon transfer for inr 3.19) midodrine 5mg po bid lasix 100mg po (given once on ) levofloxacin 250mg iv q 48hrs aldactone (currently held) . home medications (per cards note ): amiodarone 200 mg daily lipitor 40 mg daily digoxin 0.125 mg daily advair inhaler twice a day lasix 80 mg daily lantus insulin 90 units daily humalog per sliding scale lisinopril 10 mg daily metoprolol succinate 200mg daily pantoprazole 40 mg twice a day potassium 40 meq daily spironolactone 25 mg daily spiriva twice a day coumadin mg daily aspirin 81 mg daily vitamin b12 1000 mg daily . discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 4. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 5. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 7. torsemide 20 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 9. cephalexin 500 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 3 days. 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm. 13. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 14. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 15. insulin glargine 100 unit/ml solution sig: ten (10) units subcutaneous at bedtime. 16. humalog 100 unit/ml solution sig: 1-10 units subcutaneous four times a day: per sliding scale. 17. heparin, porcine (pf) 100 unit/ml solution sig: 1000 (1000) units intravenous continuous infusion: target ptt: 60 - 100 seconds. for ptt <40: 4100 units bolus then increase infusion rate by 400 units/hr. for ptt 40 - 59: units bolus then increase infusion rate by 200 units/hr for ptt 60 - 100*: no change. for ptt 101 - 120: reduce infusion rate by 200 units/hr. for ptt >120: hold 60 mins then reduce infusion rate by 400 units/hr and contact md. . 18. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every 4-6 hours as needed for shortness of breath or wheezing. 19. ipratropium bromide 0.02 % solution sig: one (1) inhalation every 4-6 hours as needed for shortness of breath or wheezing. discharge disposition: extended care facility: discharge diagnosis: primary: acute systolic chf secondary: paroxysmal atrial fibrillation copd hypertension diabetes discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you came to after you fell out of your chair and were unable to get back up. you were found to be in heart failure. you were given medications to help, but were found to have worsening organ damage from your poor heart function. you were transferred to for a biv icd to help improve the function of your heart. during your hospitalization you were admitted to the ccu for fluid removal with special medications. you tolerated this well and underwent a procedure where doctors attempted to change your pacemaker do a different type. unfortunately, this was unsuccessful and you have a new pacemaker on your right side now (previously on your left) that is very similar to your previous pacemaker. your medication regimen was changed to optimize your heart function. you are being sent to rehab to get your strength back prior to going home. weigh yourself every morning, md if weight goes up more than 3 lbs. medication changes: discontinue lasix discontinue spironolactone decrease lantus to 10 units at night decrease lisinopril to 2.5 mg daily decrease metoprolol succinate to 100 mg daily decrease pantoprazole to 40 mg daily start torsemide 20 mg daily start cephalexin 500 mg every 6 hours for 3 days start heparin 100 units/ml continuous infusion while inr subtherapeutic start colace 100 mg twice a day start senna 1 tab twice a day start bisacodyl daily as needed for constipation continue all other medications as previously prescribed followup instructions: cardiology: dr. and : date/time: monday at 11:30 am. clinical center, , , . an appointment has been made to follow-up with the physicians who put in your new pacemaker. please go to this appointment on at 3pm as listed below. please keep the following appointments: provider: , podiatry date/time: 1:25 provider: clinic phone: date/time: 2:30 procedure: venous catheterization, not elsewhere classified thoracentesis implantation or replacement of automatic cardioverter/defibrillator, total system [aicd] revision or relocation of cardiac device pocket diagnoses: other primary cardiomyopathies hyperpotassemia coronary atherosclerosis of native coronary artery pure hypercholesterolemia unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver acute kidney failure, unspecified hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified atrial fibrillation paroxysmal ventricular tachycardia cardiogenic shock long-term (current) use of anticoagulants ventricular fibrillation acute on chronic systolic heart failure other specified disorders of circulatory system 

Answer: The patient is high likely exposed to