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: history of present illness: this is a 75-year-old woman with a history of congestive heart failure, acute renal failure, diabetes mellitus, hypertension, and peripheral vascular disease who presents with shortness of breath and dyspnea on exertion for three days. the patient was in her usual state of health until approximately three days prior to admission when she reports running out of her lasix pills. over the next few days she became progressively more short of breath. she denies increased pedal edema but noticed significant worsening orthopnea and episodes of paroxysmal nocturnal dyspnea. she denies any episodes of chest pain, diaphoresis, palpitations, nausea, and vomiting over the last several days. she does report decreased urine output. she denies intractable nausea, vomiting, confusion, neurologic symptoms, or pruritus. she complains of pain in her right upper quadrant for the past two days, worse with inspiration. otherwise, she denies any fevers, chills, dysuria, diarrhea, constipation, rash, sore throat, or flu-like symptoms. she was hospital day in at with congestive heart failure and acute renal failure. since then, her creatinine has been elevated; her last being 3.9. an echocardiogram at the outside hospital had a normal ejection fraction of 55%. past medical history: 1. congestive heart failure; recent admission to for congestive heart failure led to evaluation with echocardiogram with an ejection fraction of 55%, dobutamine. 2. acute renal failure, renal ultrasound at negative. last creatinine was 3.9 in . 3. insulin-dependent diabetes mellitus times 30 years. 4. hypertension; poorly controlled recently. 5. hypercholesterolemia. 6. peripheral vascular disease, status post femoral-femoral bypass. 7. history of lyme's disease; treated with ceftriaxone. 8. status post appendectomy. 9. status post cholecystectomy. 10. hypothyroidism. 11. question of temporal arteritis. allergies: penicillin causes hives; aspirin cause stomach burning. medications on admission: lasix 80 mg p.o. b.i.d., atenolol 25 mg p.o. q.d., pravachol 20 mg p.o. q.d., levoxyl 0.375 mg p.o. q.d., cardia-xt 420 mg p.o. q.d., flonase 50 mcg 2 puffs b.i.d., prednisone 5 mg p.o. q.d., insulin nph 32 units q.a.m. and 10 units q.p.m. social history: a 20-pack-year history of smoking; quit 20 years ago. no alcohol use. she is a retired illustrator. family history: she has three children with diabetes mellitus. physical examination on presentation: on admission vital signs revealed a temperature of 98.6, heart rate of 84, respiratory rate of 24, blood pressure of 190/70, oxygen saturation of 94% on room air and 96% on 4 liters. in general, tachypneic, speaking without difficulty. head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. extraocular muscles were intact. the oropharynx was unremarkable. neck was supple. no lymphadenopathy. jugular venous pressure about 10 cm to 12 cm. heart revealed a regular rate and rhythm. no murmurs, gallops or rubs. lungs revealed crackles in lower half of both lung fields. decreased breath sounds at the bases. the abdomen was soft, nondistended, normal active bowel sounds. mild tenderness in the right upper quadrant. no . extremities revealed no clubbing, cyanosis or edema. pedal pulses were 2+. neurologic examination revealed no wrist or ankle drop. strength was in the extremities. no asterixis. no myoclonus. pertinent laboratory data on presentation: on admission white blood cell count was 15.1, hematocrit of 33.6, platelets of 231. differential revealed 77.4% neutrophils, 17.2% lymphocytes, and 4.7% monocytes. sodium of 140, potassium of 4.6, chloride of 100, bicarbonate of 24, blood urea nitrogen of 106, creatinine of 4.8, blood glucose of 82. urinalysis revealed 0 red blood cells, 0 to 2 white blood cells, rare bacteria. radiology/imaging: electrocardiogram revealed a normal sinus rhythm with a heart rate of 68, normal axis, no q waves, 2-mm st depressions in v6 and 1 mm in v5, a nonspecific conduction delay. chest x-ray revealed pulmonary edema, blunted angles. impression: this is a 75-year-old woman with a history of congestive heart failure, acute renal failure (now chronic), insulin-dependent diabetes mellitus, and hypertension who presented with shortness of breath after running out of her lasix three days prior to admission. hospital course: 1. cardiovascular: initially, the patient was thought to be volume overloaded given her chest x-ray. there was no clear evidence of any cardiac event causing her congestive heart failure. a normal ejection fraction on recent echocardiogram suggesting diastolic heart failure possibly secondary to longstanding hypertension and decreased renal function. this situation was thought to be exacerbated by her acute-on-chronic renal failure with a decreased response to diuretics. in the emergency department she only put out 100 cc of urine to 80 mg of intravenous lasix in two hours. the patient's cardiac enzymes were cycled, and she ruled out for a myocardial infarction. her beta blocker was held initially and then restarted after two days. she was initially on a nitroglycerin drip, and she was given lasix 160 mg times one. for coronaries, she was continued on her statin and atenolol. the patient was initially placed on lasix 80 mg intravenous b.i.d. and zaroxolyn. she was also continued on her calcium channel blocker initially for hypertension control. an echocardiogram showed moderate 2+ mitral regurgitation, moderate symmetric left ventricular hypertrophy, an ejection fraction of greater than 60%, mild left atrial enlargement, left ventricle with a restrictive filling pattern, mild pulmonary hypertension, a small pericardial effusion. because the patient's creatinine was continuing to rise, her lasix and zaroxolyn were both decreased, and clonidine was added for blood pressure control. the patient had some episodes of bradycardia which led to an unstable blood pressure at the beginning of her stay. eventually, the patient was switched back to lasix 80 mg b.i.d. (which is her home dose). her blood pressure control remained poor. on , because her creatinine continued to worsen, her lasix was discontinued altogether. her hypertension improved, but her clonidine was titrated further to have better control. on , the patient went for her perm-a-cath and arteriovenous fistula for hemodialysis initiation, and while she was in the operating room was bradycardic to the 20s and received atropine. she also had a pause in her electrocardiogram. postoperatively, her heart rate continued to be in the 30s and 40s, and she was hypothermic, but her blood pressure was preserved. she was transferred to the coronary care unit for one night for observation overnight. her beta blocker was held, as was her calcium channel blocker. the source of the bradycardia was unclear. the pacer pads were in place but were not used. the following day, her heart rate improved and she was transferred back out to the floor. given the fact that hemodialysis was inevitable, and ace inhibitor was added to her regimen for hypertension. on , a low-dose beta blocker was restarted. the patient tolerated this well. a lipid panel was checked and was found to be within normal limits. her statin was then discontinued given her elevated alt and ast. while she was in the coronary care unit, she was also ruled out for a myocardial infarction; although, her troponin was slightly elevated at 0.7 (probably due to renal failure). 2. renal: the patient presented with acute-on-chronic renal insufficiency. this was thought to be progression of her intrinsic renal disease which may be secondary to her diabetes or hypertension, or maybe secondary to prerenal decreased flow. a renal consultation was requested. initially, she was diuresed aggressively as above. a renal ultrasound done at in showed bilateral small kidneys, each measuring approximately 8 cm. creatinine continued to worsen, reaching in the high 4s on . magnetic resonance angiography of her kidneys was done to rule out renal artery stenosis, and this was inconclusive. magnetic resonance angiography showed the left kidney of 8.1 cm, right kidney of 8.6 cm. no hydronephrosis. delayed nephrogram and perfusion of left kidney. full evaluation of renal artery not performed due to the patient's inability to hold her breath. on , the patient's creatinine was up to 5.8. she began to have uremic symptoms prompting surgical evaluation for arteriovenous fistula placement and perm-a-cath placement for dialysis. on , the patient went to the operating room to have perm-a-cath placed and arteriovenous fistula placed. this was complicated by bradycardia, and she was admitted to the coronary care unit for obstetrician overnight. hemodialysis was initiated on . she was started on calcium carbonate t.i.d. with meals and nephrocaps. the patient received a second session of hemodialysis on . on , arrangements were made for her to have outpatient dialysis three days per week in , near where she lived. 3. infectious disease: the patient's white blood cell count was elevated on admission, but there was no obvious infectious source. she was afebrile. she remained afebrile throughout her hospitalization; although, three days prior to discharge, she did complain of mouth and throat pain. on the day of discharge she was found to have moderate oral thrush, and she was started on clotrimazole troches q.i.d. for this. 4. gastrointestinal: the patient presented with right upper quadrant tenderness. this was thought to be secondary to right-sided cardiac congestion. liver function tests and alkaline phosphatase were checked and were within normal limits with only a mild elevation of her alt at 50. the patient was on protonix. on , the patient was found to have an elevated alt and ast at 74 and 71. hepatitis serologies were sent off. because of this elevation, her statin was discontinued; especially since her lipid panel was within normal limits. her alkaline phosphatase was also slightly elevated at 277. she can be re-evaluated as an outpatient for hypercholesterolemia. 5. endocrine: the patient was continued on her home dose of insulin. however, she had early morning hypoglycemia. she was also continued on her home synthroid dose. because she continued to have early morning hypoglycemia despite a decrease in her nighttime nph, consultation was requested who felt that her low a.m. blood glucoses may be secondary to her high a.m. nph dose which had not been decreased and which may had stayed longer in her system secondary to her renal insufficiency, as insulin is cleared renally. thus, their recommendations were followed, and her nighttime nph was discontinued and her morning nph was decreased. her blood sugars became more stable after that point. prednisone was continued for a question of a past history of temporal arteritis. she was also on a regular insulin sliding-scale. 6. hematology: the patient's hematocrit was noted to drop from 33 to 28 between and despite aggressive diuresis. her hematocrit was rechecked that afternoon, and she did not require a transfusion. iron studies revealed anemia of chronic disease. the renal team felt that at this time she did not need to be started on epogen. her b12 level was also low normal. she may need supplementation as an outpatient. when the patient was admitted to the coronary care unit on , she was noted to have a drop in her hematocrit from 30 to 24 which was confirmed on recheck. estimated blood loss during surgery was only 250 cc, and she received only 500 cc of intravenous fluids. she was transfused, and her blood pressure remained stable after that point. her hematocrit bumped appropriately to 27.4. she was transfused a second unit at hemodialysis the following day with no evidence of active bleeding. 7. fluids/electrolytes/nutrition: the patient's phosphorous began to become elevated on to 5.6. she also became progressively hypocalcemic, and this was repleted in the coronary care unit on . she was started on calcium carbonate t.i.d. and nephrocaps once hemodialysis was initiated and encouraged to eat. 8. psychiatry: on , the patient expressed suicidal ideation with potential plans; although, she did not seem serious about executing them, but had some plans in mind. a psychiatry consultation was called and evaluated the patient. they did not recommend a one-to-one sitter at this time and recommended starting a trial of ritalin for antidepressant effect starting at 2.5 mg p.o. q.a.m. and eventually titrating to b.i.d. q.a.m. and q. noon without being taken after noon as it can have a very stimulating effect and cause insomnia. a thyroid-stimulating hormone was recommended and was normal. they also recommended psychotherapy; however, the patient was not able to follow up here given the distance from her house. thus, ritalin was started at 2.5 mg p.o. q.a.m. and eventually increased to 5 mg p.o. q.a.m. in the coronary care unit, her ritalin was held given her bradycardia. 9. code status: full. condition at discharge: condition on discharge was stable. discharge status: home with and home safety evaluation. medications on discharge: 1. synthroid 37.5 mcg p.o. q.d. 2. prednisone 5 mg p.o. q.d. 3. nph 15 units subcutaneous q.a.m. 4. cepacol one lozenge p.o. q.6h. p.r.n. 5. metoprolol 12.5 mg p.o. q.d. 6. lisinopril 5 mg p.o. q.d. 7. calcium carbonate 500 mg p.o. t.i.d. with meals. 8. nephrocaps 1 capsule p.o. q.d. 9. methylphenidate hcl 5 mg p.o. q.a.m. and q. noon (not past noon). 10. clonidine 0.2 mg p.o. t.i.d. 11. clotrimazole one troche p.o. q.i.d. discharge diagnoses: 1. diastolic heart failure. 2. end-stage renal disease, on hemodialysis. 3. diabetes mellitus. 4. hypertension. 5. hypercholesterolemia. 6. peripheral vascular disease. 7. depression. 8. history of lyme's disease. 9. status post appendectomy. 10. status post cholecystectomy. 11. hypothyroidism. 12. question of history of temporal arteritis. , m.d. dictated by: medquist36 procedure: hemodialysis venous catheterization for renal dialysis arteriovenostomy for renal dialysis diagnoses: anemia in chronic kidney disease congestive heart failure, unspecified personal history of tobacco use hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other specified cardiac dysrhythmias major depressive affective disorder, single episode, unspecified atherosclerosis of native arteries of the extremities, unspecified diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled sympatholytics [antiadrenergics] causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to