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 59 year old female was referred in by her primary care physician to the hospital and admitted to the medical service on , presenting with increasing dyspnea on exertion and lower extremity edema. she had a known history of breast cancer with moderate severe aortic stenosis. she was feeling fine until she developed symptoms approximately two weeks prior to admission after a trip to new . she felt she had some unusual chest sensations and no dyspnea at that time but she went to her son again three weeks ago and had noticed increasing dyspnea, as well as palpitations with walking but no lower extremity edema. then in the prior two weeks to admission, she developed some orthopnea and paroxysmal nocturnal dyspnea over one week. she also noticed she had a ten pound weight gain in one week and decreased urine output times one week with dark urine and increased thirst. her primary care physician noted her increasing lower extremity edema. she had no chest pain at that time and was admitted into the hospital on the medical service. past medical history: breast cancer, stage ii hormone positive, status post lumpectomy, chemotherapy and radiation therapy with chemotherapy in , to , with adriamycin, cytoxan and taxol, and radiation therapy , to , thirty-three visits. bicuspid aortic valve. prior echocardiogram at in , revealed mild to moderate aortic stenosis with two plus aortic insufficiency and one plus mitral and tricuspid regurgitation. at the time, she had a peak aortic valve gradient of 43 mmhg and a mean of 28 mmhg. benign positional labyrinthitis. diverticulosis. hypothyroidism. hiatal hernia with gastroesophageal reflux disease. past surgical history: in addition to her lumpectomy includes a tonsillectomy, appendectomy and removal of a benign nevus. allergies: she has no known medical allergies although she says she is sensitive to adhesive tape. medications on admission: 1. levoxyl 50 mcg p.o. one daily. 2. trazodone as needed. 3. tamoxifen 10 mg p.o. twice a day. 4. hydrochlorothiazide 25 mg p.o. daily. 5. desipramine 50 mg p.o. twice a day. 6. lipitor 10 mg p.o. every other day. 7. zoloft 100 mg p.o. twice a day. 8. ativan 1 mg p.o. daily. 9. prilosec 20 mg p.o. twice a day. 10. aspirin 81 mg p.o. daily. 11. clonidine 0.1 mg p.o. twice a day. 12. sudafed and rhinocort as needed. 13. she also stated that she periodically took sulfamethoxazole as well as vitamins, calcium, vitamin e, multivitamin, fibercon and a stool softener. she additionally uses vioxx p.r.n. and flexeril p.r.n. social history: she quit smoking 24 years ago, having started at the age of 16 and smoking up to two packs per day. ho course: the patient was treated by the medical service and cardiology for her congestive heart failure that she presented with in preparation for cardiac catheterization and repeat echocardiogram. she was followed by dr. , her primary care physician. patient was diuresed and ultimately received echocardiogram on , which showed global left ventricular hypokinesis, bilateral atrial enlargement, moderate aortic stenosis with two plus aortic insufficiency, one to two plus mitral regurgitation, and depressed right ventricular function. cardiac catheterization was performed on , which showed 30 percent left main lesion, two plus mitral regurgitation, left ventricular ejection fraction of 20 percent with severe diffuse hypokinesis and severe aortic stenosis with a valve area of 0.5 centimeter squared, a peak gradient of 45 mmhg. the patient additionally had low cardiac output in the catheterization laboratory. the patient was referred to dr. of cardiothoracic surgery for aortic valve replacement with a question of mitral valve replacement versus repair. she was seen by dr. of cardiothoracic surgery who noted her prior history of bicuspid aortic valve, mitral valve prolapse and her history of left breast cancer, status post chemotherapy, radiation therapy and surgery with adriamycin. of note, the patient also had left upper extremity lymphedema from her prior lumpectomy and axillary node dissection. the patient was seen by dr. who noted her prior medical history. on examination, she was in no apparent distress but slightly short of breath in bed. she had mild jugular venous distention. the heart was regular rate and rhythm with a grade ii/vi systolic ejection murmur heard best at the left upper sternal border and apex. her lungs were clear bilaterally without any wheezes, rhonchi or rales. she had a soft, nontender, nondistended abdomen. her extremities were without any cyanosis, clubbing or edema but her hands bilaterally were slightly cyanotic. her neurological examination was nonfocal. she had two plus bilateral carotid pulses, no palpable radial pulses, and one plus bilateral femoral, popliteal, dorsalis pedis and posterior tibial pulses. preoperative laboratories were as follows: white blood cell count 8.1, hematocrit 30.4, platelet count 403,000. prothrombin time 14.9, partial thromboplastin time 24.8, inr 1.4. sodium 138, potassium 4.6, chloride 103, creatinine 1.0, blood sugar 119. prothrombin time 33.9, partial thromboplastin time 57, inr 0.9. ck 141, troponin less than 0.01. hepatitis antibody was negative. chest x-ray showed cardiomegaly. additional laboratories were as follows: alt 339, ast 173, alkaline phosphatase 67, total bilirubin 0.9. preoperative electrocardiogram showed atrial fibrillation. preoperative gallbladder ultrasound showed a right pleural effusion and just minimal fluid around the gallbladder attributed to her congestive heart failure. th was referred to dr. for evaluation of double valve surgery with additional studies to be done including the completion of her echocardiogram which was done on . please refer to the above results. the elevated ast and alt were again noted the following morning to be elevated as well as inr of 1.4. hepatology consultation was called to evaluate the patient. it was recommended that the patient have some vitamin k subcutaneously and repeat liver function tests and inr check in the morning. carotid ultrasound was also ordered. the patient remained on the medical service and was seen by the hepatology fellow. please refer to the official consultation note dated , which was completed preoperatively. additional studies were recommended by hepatology service. preoperatively on , the patient had an episode of left sided chest pain and was given intravenous morphine and a bolus of normal saline. this was then stopped after the patient complained of worsening dyspnea. the patient was evaluated again. inr the next day rose to 2.2. the patient was appropriate at that time with no asterixis and continued to be followed on the medical service in preparation for her surgery. the patient was also seen by dr. of the heart failure service and cardiology for the patient's worsening congestive heart failure. the patient was loaded with digoxin per dr. . swan-ganz catheter was placed and the patient was then intubated on , by anesthesia given her aortic stenosis and increasing respiratory distress with respiratory rate over 30 and an unobtainable peripheral oxygen saturation. at the time, her potassium was 5.8. the patient was intubated successfully and transferred to the coronary care unit from six. central venous line and swan-ganz was placed as mentioned previously. given the patient's worsening hemodynamic status and worsening transaminases, as well as recent intubation, the plan was discussed to possibly have the patient have a valvuloplasty the following morning and manage her volume. at the time of cardiac catheterization on , the patient underwent aortic valve balloon valvuloplasty in the catheterization laboratory. the resulting mean gradient was 25 and the aortic valve area was increased from 0.5 to 0.65 centimeter squared. liver function tests continued to trend upward with alt of 1450, ast 1406, ldh 1380. this was discussed with dr. and cardiothoracic surgery service continued to follow from a distance preoperatively for potential aortic valve surgery. a postprocedure echocardiogram also noted by the congestive heart failure fellow was that the patient's echocardiogram showed some worsening of her aortic insufficiency which was now moderate. sn np was started by the cardiology heart failure service. the patient was also evaluated by clinical nutrition given her abnormal liver function. her creatinine rose slightly with sodium nitroprusside but the goal was to get her to an index of 2.6. she continued to run slightly negative for her diuresis. she was transfused two units of packed red blood cells. the patient was also evaluated by the case manager for cardiothoracic surgery in preparation for her hospitalization and potential surgery. dr. evaluated the patient on , and noted that her situation was improving but was planned for surgery only once her liver function tests recovered. he also encouraged aggressive attention to nutrition and general condition as the patient is preoperative for high risk surgery. preoperative stroke risk was also evaluated by the stroke attending who recommended carotid ultrasound and mri/mra of the brain as well as tight glucose control. the patient had some slight disorientation after her extubation on , and some right sided weakness was also noted. stroke service was immediately called. the patient was also evaluated by dr. of the heart failure service covering for dr. and was seen by dr. of the heart failure service also. hepatology service also continued to follow the patient daily. kub was negative for obstruction. blood cultures on , showed no growth to date. fungal and acid fast bacilli also showed no growth to date. sputum had some polymorphonuclear cells with four plus gram positive cocci in pairs, chains and clusters, as well as sputum culture showing moderate oropharyngeal growth. please refer to the official report dated . electrocardiogram showed occasional premature ventricular contractions with short runs of trigeminy. the head ct with contrast showed a small hypodense focus seen adjacent to the left side of the left angle commissure consistent with a virchow- space. this was noted on prior mra examination of 06/. no mass effect, midline deviation or hemorrhage was seen. chest x-ray , showed left hemidiaphragm opacity likely a combination of small pleural effusion, atelectasis and consolidation. ativan was discontinued and neurologic examination was followed daily. magnetic resonance imaging was also ordered to help better determine possible cerebrovascular accident. preoperatively also the patient had some supraventricular tachycardia versus atrial fibrillation which was relieved by lopressor. she also had her magnetic resonance imaging done with an improved examination. her congestive heart failure became better compensated. head mr showed no evidence of a cerebrovascular accident. the patient did have some chest pressure briefly with tachycardia that resulted from the atrial fibrillation and was given diltiazem and beta blocker with relief. at this time, though, on , the patient did have some persistent right sided weakness despite any evidence that she had had a cerebrovascular accident. on additional review by neurology, it was determined that the patient probably did have an abnormality that seemed like motion artifact. please refer to the final mra report. the patient did continue to have some right arm weakness but was then referred on to cardiothoracic surgery, was also seen and evaluated by physical therapy. nitropride was stopped on . captopril was started with a goal systolic arterial blood pressure of greater than 110. the patient also had several more visits by the clinical nutrition team. urine culture showed e. coli with bactrim resistance. the patient's antibiotics were changed to ciprofloxacin with a four to seven day course and was given miconazole cream. the patient was reevaluated by cardiac surgery on , who noted her decreasing liver function tests and the fact that she had been cleared by neurology for cardiac surgery and heparinization. the patient was also increasing her activity level and was doing much better. the plan was discussed with dr. . the patient's preference was for mechanical valve and the plan was to schedule the patient for aortic valve replacement and mitral valve replacement on the following friday. the patient was seen again by the stroke service on , and was evaluated again by the congestive heart failure service to make sure her diuresis and volume status had been optimized. additional preoperative laboratories on , prior to surgery were as follows: white blood cell count 11.6, hematocrit 35.8, platelet count 348,000. prothrombin time 13.7, inr 1.2. potassium 4.3, blood urea nitrogen 21, creatinine 0.5, alt 194, ast 34, alkaline phosphatase 72, total bilirubin 1.2. urinalysis showed some leukocytes with 6-10 white blood cells and no bacteria. repeat urinalysis and culture was ordered. antibiotics were given empirically prior to her valve replacement. preoperative carotid ultrasound showed no significant disease. please refer to the official report. the patient remained on ciprofloxacin also in addition to her usual medications prior to surgery. on, the patient underwent aortic valve replacement with a 23 millimeter pericardial valve and mitral valve replacement with a 29 millimeter pericardial valve by dr. and was transferred to the cardiothoracic intensive care unit in stable condition on an epinephrine drip of 0.03 mcg/kg/minute, nitroglycerin drip at 1.0 mcg/kg/minute and propofol drip at 20 mcg/kg/minute. on postoperative day number one, the patient was in sinus tachycardia in the 120s and blood pressure was 126/66. cardiac index 2.9 on an esmolol drip. other drips had been weaned off. the patient was given aspirin and toradol for pain. lungs were clear bilaterally. the abdomen was soft, nontender, nondistended. extremities were warm and well perfused. carvedilol was started. swan was discontinued. her chest tubes remained in place and lasix diuresis was begun. on postoperative day number two, the patient had spiked a temperature, continued with diuresis, had a run of atrial fibrillation and was converted. the patient in the morning was in atrial fibrillation again at 106 on p.o. carvedilol and amiodarone was started. the patient also continued with perioperative vancomycin and was otherwise alert and oriented in no apparent distress and doing well with an unremarkable examination. lisinopril was also started low dose at 2.5 mg. chest tubes were discontinued. foley remained in place. the plan was to increase carvedilol, double the dose, the following day. pacer wires remained in place with a plan for the patient to be transferred out to the floor the following day on postoperative day three. the patient continued to do very well and was alert and oriented and continued with lisinopril and carvedilol. pacing wires were discontinued. heparin and coumadin were both given. amiodarone was switched over to p.o. the patient's foley was discontinued and the patient was transferred out to the floor. creatinine was stable at 0.4, potassium 3.8 and inr 1.2. white blood cell count 12, hematocrit 32. on , the patient was transferred out to the floor where she could be evaluated by physical therapy and start her cardiopulmonary rehabilitation. the patient continued to be anticoagulated with heparin while her coumadin dose continued to raise her inr. the patient had some incisional pain which was medicated with tylenol number three. the patient was voiding well after foley. sternal incision was dry and clean and intact. the patient was ambulating with assistance, continued to make very good progress, did a level three on postoperative day four, was restarted on her preoperative medications with the addition of carvedilol and the amiodarone. the patient's creatinine was stable at 0.7. her postoperative atrial fibrillation had converted to sinus rhythm on amiodarone and lopressor. the patient also received milk of magnesia and an evening dose of coumadin 3 mg that day. amiodarone was decreased to 400 mg twice a day from three times a day. the patient remained on a heparin drip. lipitor was discontinued given her recent elevated liver function tests without any evidence of coronary disease. she continued to work with physical therapy, had some incisional pain, a little bit of ankle edema as well as right arm edema and weakness which was known to the team from preoperative workup. the patient continued to stay on the floor and work with physical therapy and the nurses to improve her activity level and tolerance while we waited for her inr to rise. on postoperative day number five, her inr was 4.4, partial thromboplastin time was pending. as the partial thromboplastin time was drawn from the same arm as the intravenous heparin, so it was repeated. coagulation studies were rechecked. the patient continued to progress well. carvedilol was increased to 6.25 mg p.o. twice a day on postoperative day number five. the patient was moving all extremities and was increasing her activity level slowly. inr rose to 1.6 on postoperative day number six. on postoperative day number seven, her inr rose to 1.9 and her liver function tests approached normal range. the patient also had a small amount of back pain which was also medicated with tylenol number three. when her inr hit 2.1, her heparin drip was discontinued. the patient had one episode of hypotension after doing stairs. the blood pressure was 74/47 and she was completely asymptomatic. a liter of saline bolus was given and the patient was placed back in bed. she continued to do well on postoperative day number eight. on postoperative day number nine, the patient did a level five on the stairs and felt well doing that. a cortisol level was checked which was normal. she continued to drop her blood pressure every time she did the stairs but was retested. her lasix diuresis was discontinued. the patient was restarted on her home dose of hydrochlorothiazide 25 mg p.o. daily. the patient was seen again by case management on , in preparation for discharge, hopefully with vna services. the patient was also doing well on postoperative day number ten. she did continue to have this hypotension when she was doing stairs but otherwise asymptomatic. carvedilol was continued. the patient continued with lisinopril. on , the patient discharged to home with services. on the evening after discharge, teaching was done. die instructions: the patient was instructed to follow- up with dr. , her cardiologist, approximately two to three weeks postdischarge, to see dr. in the office in four weeks for her postoperative surgical visit, follow-up with dr. by telephone when she had her inr checked by the vna. dr. is to follow her inr and coumadin dosing, area code . medications on discharge: 1. colace 100 mg p.o. twice a day. 2. enteric coated aspirin 81 mg p.o. daily. 3. levothyroxine sodium 50 mcg one tablet p.o. daily. 4. zoloft 100 mg p.o. once daily. 5. tamoxifen citrate 10 mg p.o. twice a day. 6. lisinopril 5 mg p.o. daily. 7. tylenol number three with codeine one to two tablets p.o. q4-6hours p.r.n. 8. desipramine hydrochloride 50 mg p.o. twice a day. 9. amiodarone hydrochloride 400 mg twice a day for one week, then 400 mg once a day for one week, then 200 mg per day. 10. coumadin 2 mg per day until she spoke to her physician after her blood draw when she got home. the patient was to check with dr. for coumadin dosing. 1. hydrochlorothiazide 25 mg p.o. daily. 2. lipitor 10 mg p.o. daily. 3. prilosec enteric coated 20 mg p.o. twice a day. discharge status: the patient was discharged home with vna services in stable condition on . discharge diagnoses: status post aortic valve replacement and mitral valve replacement. breast cancer, status post chemotherapy with adriamycin and radiation therapy and lumpectomy. left upper extremity lymphedema. diverticulosis. hypothyroidism. history of migraines. congestive heart failure. atrial fibrillation. question cerebrovascular accident. condition on discharge: the patient was discharged home in stable condition on . , m.d. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified extracorporeal circulation auxiliary to open heart surgery combined right and left heart cardiac catheterization 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 insertion of temporary transvenous pacemaker system open and other replacement of aortic valve with tissue graft pulmonary artery wedge monitoring open and other replacement of mitral valve with tissue graft monitoring of cardiac output by other technique transfusion of packed cells percutaneous balloon valvuloplasty diagnoses: esophageal reflux pure hypercholesterolemia urinary tract infection, site not specified unspecified essential hypertension unspecified acquired hypothyroidism atrial fibrillation other chronic pulmonary heart diseases personal history of malignant neoplasm of breast depressive disorder, not elsewhere classified atrial flutter diaphragmatic hernia without mention of obstruction or gangrene rheumatic heart failure (congestive) acute respiratory failure mitral valve insufficiency and aortic valve stenosis iron deficiency anemia, unspecified congenital insufficiency of aortic valve diverticulosis of colon (without mention of hemorrhage) postmastectomy lymphedema syndrome nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] chronic passive congestion of liver labyrinthitis, unspecified antineoplastic antibiotics causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to