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: percocet / serax attending: chief complaint: transfer from surgery (ischemic left thumb, chf, afib with rvr) major surgical or invasive procedure: cardioversion thoracentesis left subclavian angioplasty right subclavian hemodialysis line history of present illness: 75f cad s/p cabg, pvd, esrd, lue ischemia from known subclavian stenosis initially admitted to surgery service with ischemic thumb. plan at that time was for heparin gtt and angio to eval l subclavian stenosis. her hospital course has been complicated by afib with rvr (160's) and hypotension (sbp 80's) during hd. she was seen by cardiology, cardioverted x 2 ( and ) for hemodynamic instability, and started on amio. the patient became hypoxic after receiving anasthesia requiring brief icu stay for stabilization. recently she has developed worsening pulmonary edema and trigerred on for hypoxia which has since resolved. she is going for hd again today as bp is now good. from surgical standpoint, she had a mra today and plan is for angio once medically stable and then decision on need for surgical intervention. continues to be anticoagulated with heparin and on vanco/cipro for ischemic thumb. transferred to medicine for further management of chf, afib, and other multiple chronic medical issues. . currently denies sob, dizziness, diarrhea, constpation, blood in stools, abdominal pain. no recent infections, fevers, or chills. at home, able to climb 1 flight stairs without sob, 1 pillow orthopnea. has had 1 prior episode of afib before this admission at rehab after cabg 4 months prior. past medical history: -cad s/p cabg () -dm ii -sarcoidosis with pulmonary involvement -copd (fev1 93% in ; previously on home o2 but not now) -hypothyroidism -esrd on hd (qmwf; due to renal artery stenosis) -renal artery stenosis s/p bilateral stents () -chf (ef>55%) -atrial fibrillation, paroxysmal -pvd s/p left fem - / s/p right fem - / s/p angioplasty and stent -hypercholesterolemia -htn -breast ca s/p left mastectomy -h/o mesenteric ischemia s/p bypass -gastritis -s/p cholecystectomy -chronic anemia (baseline hct 28-30) social history: she lives with her husband. previously independent in her adls. quit tobacco in , no ethanol use. family history: non-contributory physical exam: t 98.1 hr 88 bp 140/76 rr 22 sao2 93% on 4l general: chronically ill appearing, mildly increased wob, speaking in full sentences heent: perrl, eomi, anicteric, op clear, mm very dry neck: supple, trachea midline, no thyromegaly or masses, no lad cardiac: rrr, s1s2 normal, heart sounds muted, no m/r/g, jvp 10cm pulmonary: -basilar crackles, no wheeze chest: well-healed sternotomy scar with 2cm left parasternal nodule abdomen: +bs, soft, nontender, nondistended, no hsm extremities: le and lue warm, rue cool with 1cm eschar at tip of left thumb, left calf bandaged c/d/i, 1+ dp pulses, no peripheral edema neuro: a&ox3, speech clear and logical, cnii-xii intact, moves all extremities pertinent results: hematology: 08:19pm wbc-13.5* rbc-4.43 hgb-13.7 hct-43.7 mcv-99* mch-30.8 mchc-31.2 rdw-18.5* 08:19pm neuts-75.5* lymphs-14.0* monos-7.2 eos-1.7 basos-1.6 08:19pm hypochrom-2+ anisocyt-2+ macrocyt-3+ 08:19pm plt count-414 08:19pm pt-18.8* ptt-33.1 inr(pt)-1.8* . chemistry: 09:20pm glucose-100 urea n-30* creat-4.1*# sodium-133 potassium-7.3* chloride-98 total co2-22 anion gap-20 09:20pm calcium-8.9 phosphate-3.0 magnesium-2.9* . pleural fluid: wbc 81, rbc 63, polys 3%, lymphocytes 64%, monos 23%, eosinophils 3%, mesothelial cells 2%, macrophages 4%, other 1% (reactive mesothelial cell) total protein 3.3, glucose 146, ldh 101, albumin 1.7 gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. fluid culture (final ): no growth. anaerobic culture (preliminary): no growth. negative for malignant cells. . micro: 4:43 pm mrsa screen site: naris (nare) source: nasal swab. positive for methicillin resistant staph aureus. clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. . ecg (): sinus rhythm. baseline artifact makes interpretation difficult. bipihasic t waves in leads v4-v5 are non-specific. compared to the previous tracing of artifact is more pronounced and the t wave change in lead v5 could be positional. . left hand, three views (): there is no evidence of fracture, malalignment, joint space abnormality, or significant soft tissue abnormality. surrounding osseous and soft tissue structures are unremarkable. impression: no evidence for fracture, malalignment, or soft tissue abnormality. . cxr(): moderate bilateral pleural effusion, right greater than left, continues to increase. heart is normal size and the mediastinal caliber is stable, the simplest explanation for these findings is cardiac decompensation. . mra left upper extremity (): findings: the origin of the left subclavian artery is widely patent. best evidenced on axial 2d- fiesta images (series 5 image 10) and confirmed with ideal and time-of- flight (tof) imaging is segmental narrowing of the proximal left subclavian artery. the origins of the brachiocephalic artery and left common carotic artery appear unremarkable, and the left subclavian vein appears patent. note is made of atherosclerotic plaque within the aortic arch. the superior vena cava appears widely patent. incidental note is made of prominent mediastinal lymph nodes (series 9 image 17). large bilateral pleural effusions are present. impressions: 1. findings are highly suggestive of left proximal subclavian artery stenosis. further evaluation with a contrast mra could be performed (if dialisis can be scheduled at 3 and 24 hours following the examination) or ct angiography. 2. large bilateral pleural effusions. 3. enlarged mediastinal lymph nodes. . tte (): the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and systolic function are normal (lvef 70%). there is no ventricular septal defect. the right ventricular cavity is dilated. right ventricular systolic function is borderline normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild to moderate (+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is a minimally increased gradient consistent with trivial mitral stenosis. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. moderate to severe tricuspid regurgitation is seen. there is at least moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. compared with the findings of the prior study (images reviewed) of , the mitral and tricuspid regurgitation are increased; there is now qat least moderate pulmonary hypertension; and the right ventricle is now dilated and hypocontractile. . pa and lateral chest x-ray (): compared with the prior exam, there is no significant interval change. enlarged, layering pleural effusions bilaterally are unchanged in size, but are significantly increased since . persistent left lower lobe consolidation is consistent with atelectasis or pneumonia. pulmonary vasculature congestion bilaterally is stable. there is no pneumothorax. the cardiac contour and mediastinal silhouettes are unchanged. right internal jugular central venous catheter terminates at the cavoatrial junction. impression: stable pulmonary edema. . left brachial angiogram (): on ap arteriogram there is a patent arch with a patent proximal subclavian artery and vertebral artery on the left side, the left subclavian just distal to the vertebral artery is occluded with numerous collaterals. we did, after angioplasting the subclavian artery, noticed that there was a dissection in the distal subclavian artery which resolved with prolonged inflation with a 3 x 10 angioplasty balloon. the axillary artery is patent throughout its length, and there is a focal 50-60% stenosis in the mid brachial artery. the radial artery is patent and fills the palmar arch. we do see angioplasty with a 3 x 10 angioplasty balloon, there is some dissection which resolves with prolonged inflation of this angioplasty balloon. however, because of residual stenosis, this region was once again angioplastied with a 4 x 4 angioplasty balloon quite successfully. we opted not to place the stent and secondary to this region of stenosis being in proximity to the clavicle. . duplex doppler abdomen (): findings: the aorta is visualized and is normal in caliber. the sma is visualized and is patent. a normal waveform is seen within the sma. no evidence of any stenosis, although the sma is not visualized throughout its length. impression: limited ultrasound of the aorta and the sma shows patency of the sma with a normal waveform. . le doppler (): patent bilateral femoral popliteal artery bypass grafts with mild elevation of velocities in both common femoral artery regions. in addition based on the diminished metatarsal waveforms there likely is some component of an infrapopliteal/tibial artery occlusive disease. . ue doppler (): significant bilateral distal upper extremity arterial disease more significant on the left than on the right. in addition, there is some component of a subclavian/axillary artery disease on the left side. . chest ct with contrast (): findings: large bilateral pleural effusions, greater on the right side, are new and have high density measuring up to 85 hounsfield units. they are associated with compressive atelectasis of the lower lobes. the airways are patent to the segmental level. there is mild interseptal thickening associated with mild diffuse ground-glass opacity in the upper lobes. in the upper lobes, there are no focal lung nodules or masses. there are coronary calcifications in the lad, circumflex, and right coronary artery. there is no pericardial effusion. surgical clips in the anterior mediastinum are new, as is the abnormal soft tissue density in the anterior mediastinum. this could be post-surgical changes. dual-lumen catheter from the right side has its tip in the cavoatrial junction. multiple prevascular lymph nodes are unchanged in size. some of the enlarged paratracheal lymph nodes have increased in size. for instance, a right lower paratracheal lymph node that measures 17 mm, was 15 mm (2:21). lymph nodes in the ap window measure 10 mm and are stable, as is the subcarinal and bilateral lymphadenopathy. patient is post median sternotomy. there are no bone findings of malignancy. sternal wires are intact. there is evidence of left mastectomy, cholecystectomy, and stents in both renal arteries. the kidneys are atrophic. there is diffuse atheromatosis of the splenic artery. some clips are seen adjacent to the sma. please correlate with prior interventions. there is mild extrahepatic biliary duct dilatation which is incompletely imaged. the pancreas is atrophic. the visualized portions of the spleen, liver, and adrenal glands are unremarkable. there are subcentimeter, paraceliac, and peripancreatic lymph nodes which do not meet ct criteria for pathology. impression: new large high density bilateral pleural effusions, greater on the right side. this could be hemorrhagic. small septal thickening associated with mild ground-glass opacity in the upper lobes is likely due to interstitial pulmonary edema but given the association of high-density pleural effusion, lymphangitic carcinomatosis cannot be totally excluded. coronary calcifications. bulky mediastinal and hilar lymphadenopathy which is stable. dilated extrahepatic biliary duct and cbd. please correlate with prior interventions. . prior studies - . mra neck (): 1. the proximal right internal carotid artery stenosis seen in has worsened and the maximal degree of stenosis is probably on the order of 75% diameter stenosis currently. 2. there is stable mild left internal carotid artery stenosis proximally. 3. there is an approximately 60% diameter stenosis at the origin of the right subclavian artery, post-stenotic dilatation. the right vertebral artery origin is widely patent. . carotid u/s (): 70-79% right ica stenosis. 40-59% left ica stenosis. . stress echo (): ef>55% the patient exercised for 9 minutes according to treadmill protocol reaching a peak heart rate of 74 bpm and a peak blood pressure of 172/50 mmhg. the test was stopped because of fatigue. this level of exercise represents a fair exercise tolerance for age. in response to stress, the ecg showed no st-t wave changes (see exercise report for details). there was a blunted heart rate response to stress . the blood pressure response to exercise was normal. resting images were acquired at a heart rate of 57 bpm and a blood pressure of 126/54 mmhg. these demonstrated normal regional and global left ventricular systolic function. doppler demonstrated trace aortic regurgitation and mild mitral regurgitation with no significant resting lvot gradient. impression: fair functional exercise capacity. no ecg or 2d echocardiographic evidence of inducible ischemia to achieved workload. suboptimal study. target hr not achieved. . tte (): ef>65% the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. no vegetation seen (cannot exclude). brief hospital course: 75f with mmp including chf, copd, esrd presents with ischemic left thumb. course complicated by chf, afib with rvr. . # chf: diastolic dysfunction. ef preserved (70%) with rv dilatation. volume overloaded on transfer from surgery service, but successfully volume managed at hemodialysis by the renal team. appears euvolemic prior to discharge, with o2sat mid-90's on room air. she will continue hd qmwf for volume management. bb was started but then held along with acei given widened pulse pressure (calcluated map ~ 60) and concern for extremity perfusion in setting of recent occlusion. after acute issues have resolved, would recommended restarting bb and acei as tolerated. continued 2gm na+ diet, fluid restriction 1.5l, daily weights. followup with cardiology and pcp. . # afib: paroxysmal, on coumadin at home. coumadin was held at admission given planned procedure for ischemic left thumb (see below) and she has been covered with heparin gtt. she developed 2 episodes of hemodyncamically unstable afib with rvr requiring cardioversions. she was evaluated by cardiology and loaded with amiodarone. she was monitored on telemetry and remained in sinus rhythm throughout the rest of hospitalization after transfer from the surgery service. amiodarone was decreased from 400 to 200 which she should continue for 1 week, then decrease to 200 qd per cardiology recommendations. ecgs were followed for qt prolongation given amio which were lengthened at 480-500 but stable. after angioplasty (see below) she was restarted on coumadin (goal inr ) but remains subtherapeutic and will need to be continued on heparin gtt until inr goal reached (then heparin should be discontinued). . # cad: s/p cabg. no acute issues and remained chest pain free. she was continued on asa and statin. bb and acei were initially given then held due to concern for low map. consider restarting as outpatient when acute issues resolve. . # esrd: reportedly due to renal artery stenosis s/p bilat renal artery stents. outpatient () hd schedule qmwf. volume removal initially limited by hypotension and rapid afib but repeatedly successful after amiodarone loading. followed closely by the renal consult team. continued on nephrocaps. plan to resume qmwf hemodialysis schedule after discharge. . # pvd, ischemic thumb: the patient presented with gangrenous left thumb with known known l subclav stenosis and was initially admitted to the surgery service for planned intervention. she is also s/p bilat fem- bypass in the past, a patient of dr. . mra of the left upper extremity confirmed left proximal subclavian artery stenosis. on , the patient underwent successful angioplasty of the left subclavian which was complicated by self-limited distal dissection per the op report. perfusion to the left hand improved after the procedure and her discomfort resolved. per , no intervention on the thumb at this time but will continue with close observation. she was given empiric vancomycin and ciprofloxacin for the ischemic thumb per recs and completed 15 day course. in addition, the patient was briefly on plavix peri-angioplasty given possible stent but d/c'd after the procedure as no stent was deployed. underwent non-invasive studies per . also complained for right parasthesias and weakness, evaluated by and believed likely not due to hypoperfusion but rather neuropathy. followup with dr. . . # bilateral pleural effusions: large (r>l) and increased from prior, noted on upper extremity mra and cxr, and confirmed on chest ct. also with enlarged mediastinal lymph nodes that are stable compared to prior studies; no new mass observed. radiology believed likely complex fluid such as hemorrhagic or complex cellular debris based on houndsfield units, but at thoracentesis 1.5l clear serous fluid was drained consistent with transudate by light's criteria (tp ratio 0.5, ldh ratio 0.51, ldheff 101), therefore most likley chf. other causes such as post-obstructive (does have h/o breast ca, smoking), malignant less likely. there was 1 'other' cell on diff which turned out to be a reactive mesothelial cell. pleural fluid culture was negative. she will followup with pulmonary (see below). . # dm2: hgba1c 7.0%. increased home lantus dose given elevated fingersticks in order to maintain tight blood sugar control given chronic wound, digit ischemia. . # copd: fev1 93% in ; previously on home o2. also with prior pulmonary sarcoidosis (seen by dr. in ) that has been quiescent. ct chest results as above. continued inhalers, nebulizers prn. given addition of amiodarone on baseline chronic lung disease, she is scheduled for outpatient pfts and followup with dr. from pulmonary. . # htn: was initially hypotensive in setting of afib with rvr, but improved with rate control and hd. ccb discontinued. bb, acei started but then help low map and concern for extremity perfusion. consider restarting as outpatient. . # hypothyroidism: last tsh in . this admission tsh elevated at 24, but free t4 normal; likely sick euthyroid. would recheck once acute issues resolve. continued levothyroxine per home regimen. . # hypercholesterolemia: continued statin. . # gastritis: continued ppi. . # anemia: chronic esrd with baseline ~30. currently hct stable with no evidence active bleeding. receiving epo at hd per renal recs. . # ?bacteremia: blood culture on admission with 1/4 bottles with proteus mirabilis sensitive to cipro. unclear significance, may have been contaminant. multiple repeat cultures were negative. s/p 15 day course vanco/cipro for ischemic thumb. remained afebrile. medications on admission: meds (at home): coumadin 2mg po qd nexium 40mg po qd lipitor 10mg po qd aspirin 81mg po qd lisinopril 5mg po qsututhsa norvasc 2.5mg po qmwf synthroid 175mcg po qd lantus 10 units sc qd serevnet inh spiriva inh qd flovent inh ambien 10mg po qd tums nephrocap qd pred forte 1% gtt qd . meds (on transfer): vancomycin 1gm iv (dosed at hd per level, goal 15-20) ciprofloxacin 500mg po qd heparin gtt aspirin 81mg po qd metoprolol 12.5mg po tid amiodarone 400mg po bid atorvastatin 10mg po qd albuterol nebs q4h prn fluticasone inh 2puffs salmeterol inh 1puff tiotropium 1 cap inh qd levothyroxine 175mcg po qd tums nephrocaps 1 cap po qd docusate 100mg po bid biscodyl prn nystatin 5mg po qid prn protonix 40mg po qd prednisolone 1% 1 drop od qd sarna lotion hydrocodone-acetaminophen 1-2 tabs q4-6h prn lantus 10 units qhs iss discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q3-4h (every 3 to 4 hours) as needed. 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 8. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). 9. lidocaine hcl 2 % solution sig: ten (10) ml mucous membrane tid (3 times a day) as needed. 10. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 11. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic daily (daily). 14. salmeterol 50 mcg/dose disk with device sig: one (1) disk with device inhalation q12h (every 12 hours). 15. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical daily (daily) as needed: apply to affected areas. 16. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 17. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 18. heparin (porcine) in d5w 100 unit/ml parenteral solution sig: one (1) sliding scale intravenous asdir (as directed): monitor ptt with goal 60-80; discontinue when inr>2.0. 19. warfarin 3 mg tablet sig: one (1) tablet po hs (at bedtime): monitor inr (goal ); discontinue heparin gtt when inr > 2.0. 20. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 weeks. 21. amiodarone 200 mg tablet sig: one (1) tablet po once a day: start on after finishing 200 dose. 22. insulin glargine 100 unit/ml solution sig: twelve (12) units subcutaneous at bedtime. 23. insulin regular human 300 unit/3 ml insulin pen sig: one (1) sliding scale subcutaneous four times a day. discharge disposition: extended care facility: - discharge diagnosis: primary: ischemic left thumb congestive heart failure, diastolic paroxysmal atrial fibrillation with rapid ventricular response pleural effusions . secondary: coronary artery disease status post bypass diabetes mellitus, type ii pulmonary sarcoidosis chronic obstructive pulmonary disease hypothyroidism end stage renal disease on hemodialysis peripheral disease hypercholesterolemia hypertension history of breast cancer status post left mastectomy history of mesenteric ischemia status post arterial bypass gastritis status post cholecystectomy anemia discharge condition: good discharge instructions: please take all medications as prescribed. . you will continue to have hemodialysis every monday, wednesday, and friday. . new medications: amiodarone changed medications: coumadin, lantus discontinued medications: lisinopril, norvasc . call your doctor or return to the ed immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. followup instructions: you are scheduled for the following appointments. please contact the provider with any questions or if you need to reschedule. . cardiology: dr. (). phone: . date/time: 12:30pm . pcp: . date/time: 11:15am. . pulmonary function lab (, , ) phone: date/time: 10:30 provider: , pt, ccs date/time: 11:45 pulmonary: dr. (, , ) phone: date/time: 1:00. please call to confirm that you will make this appointment. . vas,biocare lmob (nhb) date/time: 10:00a surgery: , surgery (nhb) date/time: 10:30a. procedure: hemodialysis other electric countershock of heart other electric countershock of heart angioplasty of other non-coronary vessel(s) venous catheterization for renal dialysis thoracentesis arteriography of other intrathoracic vessels arteriography of other specified sites procedure on single vessel diagnoses: anemia in chronic kidney disease end stage renal disease coronary atherosclerosis of native coronary artery pure hypercholesterolemia unspecified pleural effusion congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified atrial fibrillation peripheral vascular disease, unspecified sarcoidosis accidental puncture or laceration during a procedure, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease hypotension, unspecified methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation stricture of artery diastolic heart failure, unspecified gangrene arterial embolism and thrombosis of upper extremity 

Answer: The patient is high likely exposed to