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: flexeril / percocet attending: chief complaint: atrial flutter, shortness of breath major surgical or invasive procedure: 1. tee 2. cardiac catheterization 3. intubation history of present illness: mr. is a 63 year old gentleman with a pmh significant for htn and iddm admitted for aflutter s/p cardioversion complicated by flash pulmonary edema. the patient reports that over the past 2 weeks he has had some chest pressure, "high up" that had been attributed to the nsaids and tramadol he had been taking for his hip pain (oa). the worst pain he felt was days ago, pressure and burning sensation with associated sob in the evening. he went to see his doctor the next day and got omeprazole for gerd, muscle relaxers for his hip pain, and felt better. then last night, he had chest pressure and sob after walking up a flight of stairs. he denies associated nausea, vomiting, palpitations. he said the sob and pressure sensation is worse with deep breaths. he denies any prolonged travel, previous history of pe's, dvt's. pt states that chest pressure is slightly worsened by leaning back. he called his pcp today as he noted a fsbs of 425 for 12 hours (a1c checked last week 7.1). he also endorses associated malaise and uri symptoms including nasal congestion, night sweats, but denies fever, chills, sore throat, myalgias or sick contacts. his pcp's office then instructed the patient to go to the emergency department for further evaluation. . in the ed, initial vs 98.0 83 127/78 18 98%ra. he received 6 mg adenosine, with rhythmn strip demonstrating underlying flutter waves. he then received 20 mg iv diltiazem push with resulting hypotension for which he received calcium gluconate and ivf with good response. at that time, repeat ecg demonstrated persistent ste in the inferior leads, and underwent dccv with resulting conversion to sinus rhythm. post cardioversion, he developed hypoxemia felt to be due to flash pulmonary edema and he was placed on nippv with cpap and a nitro gtt. had intermittent emesis, got zofran. a bedside tte at that time was of poor quality but did not demonstrate any focal wall motion abnormalities. he was then admitted to the ccu for further management. prior to transfer, switched to nrb. treated with 10 units insulin x2 in ed. ua prior to transfer negative. prior to transfer, vs 94 124/65 25 99% nrb. . currently, the patient is having some gas pains, and having chest pressure with some sob. he was feeling well, and then developed nausea and emesis. bp's remained stable, but had intermittent hypoxia into 80's on 100% nrb. switched to cpap. ros: pt had recent black stool this am, but denied bloody stools. he has had right hip since , that has been limiting his activities, and has been getting worse. he has been seen in clinic, and given medications for pain control, though without much relief. otherwise negative for fever, chills, history of cva, dvt's, pe's, myalgias, abdominal pain. past medical history: iddm asthma - wheezing in past, but never been on medications htn osteoarthritis social history: he is a manager of food services at a private school, drinks two alcoholic beverages per week, smokes occasionally pipes, last 30 years ago. family history: significant for diabetes and coronary artery disease in his father. mother was a smoker. father arrhythmia in his 70s. brother with an arrhythmia. physical exam: admission physical: general: sitting up in bed, using some accessory mm of breathing, otherwise nad, oriented x3. mood, affect appropriate. heent: ncat. dry mm. sclera anicteric. eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp unable to appreciate given body habitus cardiac: tachycardic, regular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. using some accessory mm of breathing, wheezes throughout lung fields diffusely, faint crackles at bases abdomen: +bs, obese, soft, ntnd. no hsm or tenderness. extremities: distal extremities cool, dry skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ pt 2+ dp dopplered left: carotid 2+ pt 2+ dp dopplered gu: brown stool, guaiac negative . discharge physical: afebrile, vss gen: alert, oriented, nad heent: supple, jvd at 7cm cv: rrr, no m/r/g resp: ctab post abd: soft, nt, nd, no rebound or guarding extr: 1+ peripheral non-pitting edema neuro: a/o extremeties: pulses: right: dp 1+ pt 1+ left: dp 2+ pt 1+, much colder than right foot skin: intact pertinent results: admission labs: 08:50pm blood wbc-10.2 rbc-3.69* hgb-11.5* hct-32.7* mcv-89 mch-31.3 mchc-35.2* rdw-12.9 plt ct-385 08:50pm blood neuts-81.4* lymphs-11.7* monos-5.9 eos-0.6 baso-0.4 08:50pm blood glucose-411* urean-42* creat-1.7* na-128* k-5.4* cl-92* hco3-24 angap-17 08:50pm blood calcium-9.2 phos-3.8 mg-1.9 02:58am blood lactate-4.4* . discharge labs: 06:30am blood wbc-9.4 rbc-3.66* hgb-11.0* hct-32.7* mcv-89 mch-30.0 mchc-33.6 rdw-14.2 plt ct-525* 06:30am blood glucose-115* urean-9 creat-0.9 na-139 k-3.7 cl-101 hco3-25 angap-17 . pertinent labs: cardiac enzymes: 08:50pm blood ck-mb-10 mb indx-4.1 08:50pm blood ctropnt-<0.01 02:02am blood ck-mb-7 ctropnt-<0.01 05:56am blood ck-mb-6 ctropnt-<0.01 . lft's: 08:50pm blood alt-59* ast-35 ld(ldh)-206 ck(cpk)-242 alkphos-179* totbili-0.4 03:59am blood alt-1157* ast-1070* ld(ldh)-1232* alkphos-162* totbili-1.1 05:56am blood lipase-13 01:32am blood ggt-150* . virology: 03:59am blood hbsag-negative igm hbc-negative 08:15am blood hiv ab-negative 02:31pm blood pep-no specifi 03:59am blood hcv ab-negative 08:15am blood herpes simplex virus 1 and 2 antibody igm-pnd 08:15am blood virus b antibodies-pnd . inflammatory workup: 02:31pm blood caltibc-182* ferritn-858* trf-140* 02:31pm blood cortsol-30.2* 05:56am blood crp-163.1* 01:32am blood rheufac-22* 01:53am blood -negative 11:00pm blood esr-108* . studies: tte : conclusions left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is a moderate sized pericardial effusion. study is technically inadequate to evaluate for tamponade physiology. . tte : conclusions due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is a small to moderate sized pericardial effusion. there are no rv diastolic invagination seen, and no other echocardiographic signs of tamponade, although the patient is quite tachycardic, making definite exclusion of tamponade by echo challenging. results were discussed in person with the team caring for the patient and the decision was to assess for pericardial tamponade with invasive hemodynamics. . tte : conclusions the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). doppler parameters are most consistent with normal left ventricular diastolic function. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , the pericardial effusion is slightly smaller. . cardiac cath : prelim report findings estimated blood loss: <100 cc hemodynamics (see above): elevation and equalization of filling pressures. preserved x and exaggerated y descent. square rot sign on rv pressure tracing and concordance noted on lv/rv simultaneous tracing. tee performed in the cardiac catheterization laboratory to further define mitral valve and determine if the pericardial effusion could be tapped with echocardiographic guidance to determine whether this effusion was contributing to the overall shock state. an apical window was visualized showing approximately 0.5 -1 cm of fluid. an attempt with 4 passes using a micropuncture (20 gauge) needle with continuous pressure monitoring, echocardigraphic (tee and tte) and fluoroscopic guidance was made but administration of agitated saline could not confirm placement of the needle in the pericardial space. as the patient's condition remained stable during the case, it was determined that further drainage would not be possible from a percutaneous route further attempts at pericardiocentesis were aborted. assessment & recommendations 1. mixed cardiogenic and vasodilatory shock 2. myocardial function consistent with restrictive physiology 3. chest xray 4. aborted guided pericardiocentesis. . cxr : impression: 1. interval prominence of interstitial markings and top normal heart silhouette could suggest vascular congestion. correlate with clinical symptoms. 2. focal opacity at the left mid lung could be atelectasis and less likely a focus of superinfection. . cxr : an endotracheal tube is in situ, the tip of which lies at least 6 cm from the carina, this can be advanced 2-3 cm to achieve more secure seating if required. multiple ekg leads projected over the chest. there has been an increase in the consolidation evident at the left lower lobe and in the lingula without significant associated loss of volume. this raises concern for possible pneumonia. a left pleural effusion is minimal if any. . cxr #2: impression: chest examination confirms a sizable left lower lobe infiltrate already present on preceding examination nine hours earlier. possibility of sizeable aspiration pneumonia can be considered. there appears to be some progression, although a sizable density existed already on the preceding study. . cxr : impression: 1. stable pulmonary edema and left lower lobe retrocardiac opacity, potentially representing atelectasis. however, pneumonia cannot entirely be excluded. 2. amorphous slightly linear right mid lung opacity likely representing atelectasis versus a small focus of alveolar edema; a small focus of pneumonia is not entirely excluded however. . hip xray : impression: interval development of joint space narrowing of the left hip since joint injection on . concern for septic arthritis versus rapidly progressive osteoarthritis. discussed with house officer at the time of interpretation. patient will be scheduled for diagnostic ultrasound with possible aspiration if fluid is present. . ruq u/s : impression: 1. diffusely echogenic liver, which is compatible with fatty infiltration. more severe forms of liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. small non-shadowing stone seen within the gallbladder, without son evidence of cholecystitis. . hip u/s : impression: degenerative changes and synovitis about the left hip. no evidence of effusion or fluid collection. . . micro: . sputum cx : 12:40 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): sparse growth commensal respiratory flora. . blood cx , x2: no growth. blood cx , x2: no growth. . urine cx : no growth urine cx : no growth urine cx : no growth . 5:15 am stool **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). . stool culture : 4:25 pm stool consistency: not applicable source: stool. **final report ** fecal culture (final ): no enteric gram negative rods found. no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. . viral studies: 8:15 am blood (cmv ab) **final report ** cmv igg antibody (final ): negative for cmv igg antibody by eia. <4 au/ml. reference range: negative < 4 au/ml, positive >= 6 au/ml. cmv igm antibody (final ): negative for cmv igm antibody by eia. interpretation: no antibody detected. greatly elevated serum protein with igg levels > mg/dl may cause interference with cmv igm results. . lyme serologies: pending . 08:15 virus b antibodies results pending . 08:15 herpes simplex virus 1 and 2 antibody igm results pending brief hospital course: hospital course: mr. is a 63 year old gentleman with a pmh significant for htn and iddm admitted for aflutter s/p cardioversion complicated by flash pulmonary edema. his hospital course was complicated by hypotension likely sepsis, and constrictive pericarditis. pt's course also complicated by shock liver and acute renal failure in setting of hypotension. . active issues: # atrial flutter: etiologies for aflutter included acs, vs. pe vs. pericarditis or effusion or pericarditis vs. lung disease or infection. pt with diffuse ste though timing and clinical picture not c/w mi. pericarditis thought to be most likely given diffuse ste and viral symptoms prior to admission. pericarditis could be explaining some syx given positional change and diffuse ste. cardiac enzymes were cycled and negative. he was initially started on heparin gtt, which was stopped after acs was ruled-out. pt had continued to be hypotensive, and there was concern for tamponade, despite initial tte negative for tamponade physiology. pulsus was checked overnight, and was negative. the morning of admission, pt became more hypotensive requiring pressors, and pulsus was detected on examination. he went for repeat tte, which demonstrated pericardial effusion but no tamponade physiology. a left and right heart cath demonstrated restrictive physiology but no evidence of tamponade. pericardiocentesis was attempted, but was unable to drain. he had a repeat tte, which again showed a very small pericardial effusion and no evidence of tamponade. further infectious workup is discussed below. he had a recurrent episode of atrial flutter and brief atrial fibrillation after diuresis with lasix. he was started on metoprolol for beta blockade. he was started on amiodarone gtt briefly, and transitioned to oral amiodarone with a taper. he spontaneously converted to sinus. he was discharged to continue amiodarone for a triggered event, and metoprolol. he was started on coumadin with a heparin bridge. he was instructed to have pt/inr checked for close monitoring. . # restrictive cardiac physiology: as above, right heart cath demonstrated restrictive physiology. spep, upep, and hemochromatosis labs were sent. ferritin was elevated, but not severely to suggest hemochromatosis. spep and upep were negative. rf was 22, negative. pt had elevated esr and crp. viral serologies were sent and negative for cmv. herpes virus, virus, and lyme serologies were still pending at the time of discharge. pt will follow-up with cardiology for further management. . # hypoxemia, respiratory distress: differential included flash pulmonary edema, vs. aspiration vs. infection vs. pe. initially likely secondary to flash pulmonary edema given aflutter and fluid overload with wheezing on examination. aspiration was thought to also be contributing given emesis in the setting of cardioversion. he was treated with diuresis and improved slightly. however, he continued to be hypoxic despite nrb. cpap was attempted, though, pt had emesis, and was unable to tolerate. he required mechanical ventilation. repeat cxr demonstrated consolidation suggestive of possible aspiration. he was treated with broad spectrum abx given hypotension and concern for sepsis (see below). regarding workup for restrictive pericarditis, spep, upep, and hemochromatosis labs were sent. ferritin was elevated, but not severely to suggest hemochromatosis. spep and upep were negative. this physiology was thought to be in part incidental in setting of infection and flash pulmonary edema. he was treated with lasix gtt with good diuresis. he was successfully extubated. . # hypotension: likely to sepsis, differential included cardiogenic shock. pt's bp's dropped on the evening of admission. he was initially hypertensive requiring nitro gtt, but became hypotensive requiring pressors. originally there was concern for cardiogenic shock and concern for tamponade. however, pulsus was negative initially, and tte that morning demonstrated pericardial effusion, but without evidence of tamponade. he developed a fever on day 2, and cardiac cath demonstrated low svr, consistent with destributive shock and septic picture. he was placed on broad spectrum abx and cultures were sent (see below). his bp's improved, and he was able to be weaned off pressors. . # sepsis: as above, pt developed hypotension, with picture of sepsis given fever, and low svr's on cath. he was started on broad spectrum abx. cultures were sent and negative. sputum culture grew respiratory flora. given history of hip pain, there was concern for septic joint. a right hip u/s demonstrated no fluid to tap. orthopedics was consulted and recommended mri; however, pt was unable to tolerate the procedure. this was not pursued further during this admission given that it was unlikely to change management. he was treated for an 8 day course of antibiotics for aspiration pneumonia. he improved, and he remained afebrile and hemodynamically stable. . # acute renal failure: baseline creatinine 0.9-1, up to 1.7 on admission. differential included pre-renal vs. atn vs. ain given recent ppi use vs. rhabdo. atn pre-renal etiology and later to atn to continued hypotension as the most likely etiology. rhabdo was ruled-out given normal ck. his creatinine trended upward after hypotension. urine sediment was bland, and cr improved. but resolved, with pre-renal etiology most likely given urine lytes. his acei was initially held and then restarted after resolution of . cr was normal at time of discharge. . # transaminitis: pt developed severely elevated ast/alt in the setting of hypotension, requiring pressors, likely shock liver. ruq u/s demonstrated fatty liver, but no evidence of portal vein thrombosis, and normal tbili not c/w obstructive physiology. lft's were followed and downtrended. . # anemia: baseline hct >40, with drop of 32.7 on admission. no s/s bleeding, guaiac negative. iron studies were sent and c/w acd given very elevated ferritin and low tibc. pt had inflammatory picture with elevated crp and esr. his hct stabilized without any s/s of bleeding. . # hyponatremia: likely hypovolemic initially, and also secondary to hyperglycemia (corrected na normal for blood glucose). lytes were trended, and na improved after better glycemic control and fluid resuscitation. . # htn: pt was initially hypertensive on admission, and required nitro gtt on admission overnight. pt then became hypotensive as above, and all anti-hypertensive were held. he was started on metoprolol for beta blockade given atrial flutter as above, and his acei was restarted. . # diarrhea: pt had large bm's. c diff was negative, and stool studies were negative. most likely recent abx use. he improved on loperamide. . # iddm: pt presented with hyperglycemia, likely due to underlying illness. he was placed on an insulin sliding scale, but briefly required an insulin drip for better control. his blood sugars continued to be poorly controlled, and was consulted, with subsequent improvement in bg control. he was discharged on levemir, metformin and glipizide. . # superficial thrombophlebitis: pt had infiltrated iv, and upper extremity ultrasound demonstrated thrombosis of superficial veins. . transition: 1. follow-up: pcp . , cardiologist dr. 2. labs/studies pending at time of discharge/require further follow-up or evaluation: viral serologies for herpes, , and lyme 3. code: full 4. medical management: - increased lisinopril from 5mg daily to 10mg daily - started amiodarone with a taper - started metoprolol succinate - started coumadin . . medications on admission: medications: confirmed wtih pharmacy codeine 30 mg one q4-6 prn pain cyclobenzaprine 10 mg qhs prn diazepam 2 mg qhs prn anxiety glipizide xl 10 mg insulin levemir 15 units in am, no sliding scale lisinopril 5 mg daily metformin 1000 mg po bid omeprazole 20 mg daily simvastatin 40mg daily tramadol 50 mg po tid - stopped taking viagra prn - last used several weeks ago ibuprofen 200mg prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. diazepam 2 mg tablet sig: one (1) tablet po three times a day as needed for anxiety. 3. glipizide 10 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po twice a day. 4. levemir 100 unit/ml solution sig: fifteen (15) units subcutaneous once a day. 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 9. outpatient lab work please check lft's, chem 7 and pt/inr on thursday with results to dr. at phone: fax: 10. amiodarone 200 mg tablet sig: one (1) tablet po tid (3 times a day) for 1 weeks: start on . disp:*42 tablet(s)* refills:*0* 11. amiodarone 200 mg tablet sig: one (1) tablet po twice a day for 1 weeks: start on . disp:*14 tablet(s)* refills:*0* 12. amiodarone 200 mg tablet sig: one (1) tablet po once a day: start on . disp:*30 tablet(s)* refills:*2* 13. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. 14. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: diastolic dysfunction anemia of chronic disease atrial flutter superficial thrombosis of basilic and cephalic veins acute renal failure aspiration pneumonia hyponatremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: yuu had an abnormal heart rhythm called atrial flutter which we cardioverted in the emergency room to a regular rhythm. we started your on amiodarone to keep you in a regular rhythm and warfarin to prevent a stroke from the atrial flutter. after the cardioversion, you had fluid overload that required a breathing tube and medicines to take off the fluid. you were treated in the ccu and we also found a chronic anemia, some fluid in the lining of your heart, a pneumonia that was treated with antibiotics and kidney failure that has resolved. we have sent many test for viral infections and most have come back negative. there are a few that are still pending at this time and dr. will check these with you next week. you had diarrhea from the antibiotics that we treated with imodium. . we made the following changes to your medicines: 1. increase the lisinopril to 10 mg daily 2. stop taking cyclobenzaprine and simvastatin 3. start taking metoprolol succinate to lower your heart rate 4. start taking warfarin (coumadin) to prevent blood clots from the atrial flutter rhythm 5. start taking imodium (loperamide) to treat the diarrhea, stop taking this medicine once diarrhea resolves. 6. start taking amiodarone to keep your heart in a normal rhythm. you will take one pill 3 times a day for one week, then twice a day for one week, then daily thereafter. followup instructions: department: orthopedics when: friday at 2:15 pm with: , md building: campus: east best parking: garage department: internal medicine when: tuesday at 1:45 pm with: , md, mph building: (, ma) campus: off campus best parking: free parking on site department: cardiac services when: monday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours combined right and left heart cardiac catheterization coronary arteriography using two catheters angiocardiography of left heart structures diagnostic ultrasound of heart insertion of endotracheal tube other electric countershock of heart pericardiocentesis diagnoses: other primary cardiomyopathies anemia of other chronic disease acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver unspecified septicemia hyposmolality and/or hyponatremia atrial fibrillation asthma, unspecified type, unspecified atrial flutter sepsis pneumonitis due to inhalation of food or vomitus cardiogenic shock long-term (current) use of insulin acute diastolic heart failure acute pericarditis, unspecified nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] acute venous embolism and thrombosis of superficial veins of upper extremity 

Answer: The patient is high likely exposed to