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: indomethacin / heparin agents attending: chief complaint: shortness of breath major surgical or invasive procedure: left internal jugular vein dialysis catheter placement history of present illness: mr. is an 82y/o gentleman with critical as ( <0.8cm2), afib on coumadin, chf (ef 30-35%), htn, hld, dm ii, ckd iv (cr ~4 baseline), and cml who presented to the ed with shortness of breath and hemoptsysis and has been found to have chf exacerbation. of note, he was recently admitted to cardiology for chf exacerbation in the setting of dietary indiscretion. during that stay, he was diuresed with iv lasix and transitioned to 160mg po bid. his stay was complicated by hematuria (had cbi per urology and was d/c'd to rehab with no foley), so his warfarin had been held on discharge. also had on ckd (baseline cr is 2.5, bumped to 4.8 likely from cin, was down to 2.8 upon discharge). there have been ongoing outpatient discussions about tavi vs avr (he has seen dr. for consultation). he has been doing okay at rehab but developed worsening doe. has sob at rest and any exertion, fatigue. he reports a 7 pound weight gain in one week. also had hemoptysis last night, approximately 1 tablespoon, only once. he again notes dietary indescretions (including pork loins, etc). in the ed, initial vitals were 98.0 77 122/64 24 99% 2l nasal cannula. labs notable for wbc 17.2 (86.7%n, no bands), hct 29 (which is baseline), cr 2.7 (baseline 2.5), inr 2.6. troponin 0.14, bnp . lactate 1.2. ekg showed atrial fibrillation per report, although this ekg is not in the chart. cxr with bibasilar opacities and pulmonary edema that is significantly worse when compared to . he received cefepime 2gm, vancomycin 1gm, furosemide 100mg iv once, asa 325mg po once. a foley catheter was placed, which drained 800cc and dnr/dni status was confirmed. no major overnight events. his systolic bp has been ~100 so lasix gtt has been on and off. he is breathing ok this am. is hungry and tired from his long ed visit last night. review of systems: (+) red urine (but only since the foley was placed last night) (-) no chest pain, palpitations, lightheadedness. no constipation/diarrhea. no rash. no weakness, numbness/tingling. past medical history: 1. cardiac risk factors: htn, dm ii, hld 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd:none -chf ef 45% -afib on coumadin -severe as (peak velocity 3.8m/sec, calc 0.8cm2) -conduction system disease consisting both of sinus bradycardia with infrequent sinus pauses noted in up to 2.7 seconds in the frequent ventricular ectopy as well as short runs of supraventricular tachycardia. 3. other past medical history: -ckd stage iv (baseline ~4) -cml on hydroxyurea -gout -hyperparathyroidism -cva -fe deficiency -bph -gerd -hepatitis social history: -tobacco history: denies -etoh: denies -illicit drugs: family history: non-contributory physical exam: admission physical examination: vs: tm 97.9/tc 97.9, bp 100/60 (90-100)/(50-60), hr 85-90, rr 18, pox 94% 2l nc in: 450cc out: 500cc general: elderly gentleman sitting in chair, breathing comfortably heent: ncat. sclera anicteric. perrl, eomi. no xanthalesma. neck: supple with jvp of 16 cm. cardiac: rrr, normal s1, s2. pt with 4/6 crescendo/decrescendo murmur with loss of s2. no r/g. no thrills, lifts. no s3 or s4. lungs: no resp distress, ctab, no wheezes or rhonchi, but he has crackles bilaterally 1/2 up. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c. 2+ edema up to the thighs bilaterally. no calf tenderness. . discharge physical exam: expired pertinent results: admission labs: 07:00pm blood wbc-17.2* rbc-2.40* hgb-9.1* hct-29.0* mcv-121* mch-37.9* mchc-31.3 rdw-19.5* plt ct-166 07:00pm blood neuts-86.7* lymphs-6.2* monos-5.9 eos-0.4 baso-0.7 07:00pm blood pt-27.3* ptt-39.7* inr(pt)-2.6* 07:00pm blood glucose-126* urean-112* creat-2.7* na-131* k-4.2 cl-96 hco3-24 angap-15 07:00pm blood ck(cpk)-41* 05:30pm blood calcium-9.6 phos-4.0 mg-2.2 07:43pm blood lactate-1.2 . cardiac enzymes: 07:00pm blood ck-mb-4 probnp-* 07:00pm blood ctropnt-0.14* 05:30pm blood ck-mb-4 ctropnt-0.14* 07:38am blood ck-mb-4 ctropnt-0.14* . pre dialysis work-up: ppd negative 02:13pm blood hbsag-negative hbsab-positive 02:13pm blood hcv ab-negative . hematologic labs: 07:00pm blood wbc-17.2* rbc-2.40* hgb-9.1* hct-29.0* mcv-121* mch-37.9* mchc-31.3 rdw-19.5* plt ct-166 05:38am blood wbc-84.6* rbc-2.59* hgb-9.2* hct-31.3* mcv-121* mch-35.7* mchc-29.5* rdw-20.2* plt ct-185 05:38am blood neuts-82* bands-0 lymphs-4* monos-4 eos-0 baso-0 atyps-0 metas-3* myelos-4* promyel-1* blasts-2* 05:38am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-2+ microcy-1+ polychr-1+ schisto-1+ . u/a: 07:00pm urine color-yellow appear-clear sp -1.006 07:00pm urine blood-sm nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-tr 07:00pm urine rbc-1 wbc-1 bacteri-none yeast-none epi-0 urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- =>16 r vancomycin------------ =>32 r . urine cytology: negative for malignant cells. degenerated urothelial cells, neutrophils and many red blood cells. . cxr pa&lat : findings suggesting moderate pulmonary edema. incompletely characterized right basilar opacification, which may reflect a pleural effusion, but is not well characterized. . ct abdomen/pelvis : impression: 1. air outlines the anterior wall of the bladder which could represent cystitis in the appropriate clinical setting. additionally, there is a focal area of heterogeneous dense material within the bladder lumen which suggests a focal mass. urine cytology and further assessment with either ultrasound or direct urological evaluation should be considered. 2. minimal atherosclerotic calcification of the common and external iliac and common femoral vessels. 3. increased trabeculation of the right ilium, consistent with paget's disease. . cxr : findings: comparison is made to prior study from . there is a left ij central venous catheter with distal lead tip in the brachiocephalic vein. this could be advanced several centimeters for more optimal placement. there are persistent bilateral pleural effusions, left greater than right. there is unchanged cardiomegaly. there is mild pulmonary edema. . cxr : findings: a single portable chest radiograph is limitted by low lung volumes and mild rotation. mild pulmonary edema has improved but there is now a small amout of fluid in the right minor fissure. a left internal jugular catheter tip remains at the confluence of the left brachiocephalic and svc. apparent worsening of cardiomegally is likely secondary to technique. findings: slight improvement in pulmonary edema. . kub : findings: portable supine and upright frontal views of the abdomen demonstrate a nonspecific bowel gas pattern with gas in non-distended loops of small and large bowel. no air-fluid levels are seen. the right hemidiaphragm is excluded from view on these images which limits evaluation for free intraperitoneal air. however, there is no evidence of a large amount of free air within the abdomen. multilevel moderate degenerative changes are noted in the visualized lower thoracic and lumbar spine. the visualized right lung base is clear, but there is apparent rightward shifting of mediastinum. the left lung base is not well evaluated. recommend correlation with same day chest radiograph. impression: nonspecific bowel gas pattern without gaseous distention of the colon. ruq ultrasound: findings: note is made that only a partial ultrasound exam was performed as the patient refused to complete the examination. no biliary dilatation is seen. no focal liver lesion is identified. the gallbladder is contracted. the portal vein is patent with hepatopetal flow. the intrahepatic portion of the ivc is unremarkable. there is a right pleural effusion. impression: 1. contracted gallbladder with no biliary dilatation. no focal liver lesion is seen. 2. right pleural effusion. only a partial exam was performed as the patient refused to complete. brief hospital course: mr. is an 82 year old gentleman with critical aortic stenosis (as), afib on coumadin, chronic kidney disease (ckd) stage iv (cr ~2.5 baseline), and chronic myelocytic leukemia (cml) who presented with acute on chronic systolic heart failure. he was thought not to be a candidate for any aortic valve procedures including balloon valvuloplasty and his kidneys did not tolerate diuretics for the heart failure exacerbation. he was transferred to the ccu for cvvh which brought him back to euvolemia and he was transitioned to intermittent hd. his course was complicated by c.difficile diarrhea, development of peripheral blasts in the setting of his cml, and probable heparin-induced thrombocytopenia. he eventually expired on from a pea arrest after having chest pain during hemodialysis earlier in the day, he was dnr/dni so resuscitation was not attempted. active issues # acute on chronic systolic heart failure (schf): he presented with progressive dyspnea on exertion, orthopnea, and lower extremity edema consistent with acute on chronic schf. most recent tte from previous admission in showed ef 30-35%, likely due to critical as (see below). (cardiac cath during previous admission showed no clinically significant coronary artery disease.) he was started on iv lasix gtt, however diuresis was difficult due to his low blood pressure and his preload dependence from as. also, his creatinine continued to rise. his urine output declined and on hd#6 he was transferred to ccu for initiation of cvvh for volume removal (see below). he did well and returned to on cvvh with removal of 10l of fluid. # acute on chronic renal failure: pt has stage iv ckd with most recent creatinine on discharge 2.5. his creatinine gradually increased from 2.7 on admission to 4.7 and bun 110-120. this was felt most likely due to decreased renal perfusion in setting of acute on chronic heart failure. his urine output declined and he began to demonstrate signs and symptoms of uremia with nausea/vomiting, ams and asterixis. the renal service was consulted and recommended trial of more aggressive diuresis with metolazone/lasix. his urine output did not improve and he was transferred to the ccu for placement of temporary dialysis line and cvvh. he did well and returned to on cvvh with removal of 10l of fluid. after discussions with dr. and family about no options for valve repair, he was trialed on intermittent hd. he did tolerate intermittent hd with blood pressures in the 70s/40s but he was mentating. he was started on 10mg midodrine prior to dialysis and a tunnelled hd line was placed to allow for outpatient hd. was continued on calcium tid, calcitriol daily, and sevalamer with meals. kayexelate was used for hyperkalemia between hd sessions. there had been discussions with renal and transplant surgery about transitioning to peritoneal dialysis which might be gentler on the patient's blood pressure. however, the patient developed hitt and then expired before this was carried out. # critical as: pt has known critical as (most recent <0.8cm2). he has been evaluated for his options to repair or replace aortic valve, including avr, tavi, or balloon angioplasty. he was deemed to be a high risk candidate for surgical avr, and unfortunately he does not qualify for the corevalve protocol because of his renal insufficiency (creatine clearance < 20 cc). the risks and benefits of valvuloplasty were discussed with the patient and his family, including likelihood that he would continue to be hd-dependent as well as risk of stroke. it was decided that he would not undergo balloon valvuloplasty and to transition to hd as above for fluid management. later in the hospitalization, the family again pushed for balloon valvuloplasty and there were discussions with the interventional cardiologist about possible valvuloplasty however the patient developed hitt and these discussions were held. # heparin-induced thrombosis and thrombocytopenia (hitt): after several days of heparin used for anticoagulation of afib as well as for dialysis, he developed thrombocytopenia. platelets were noted to decrease from 232 on to nadir of 66 on . this was in the setting of restarting hydroxyurea. he had no clinical evidence of thrombotic disease. his hitt antibody was positive at an optical density which suggested to hematology consultant that he did indeed have hitt. there was a serotonin release assay sent to confirm this diagnosis which was pending when he expired. he was taken off heparin and started on argatroban to stop thrombosis from hitt as well as prophylaxis for his afib with chads2 score of 6. all further discussions for balloon valvuloplasty and peritoneal dialysis catheter placement were on hold pending hitt work-up. # c.diff associated diarrhea: he developed large volume diarrhea and a c.diff was positive. he was initially treated with po vancomycin only because of his age, creatinine, and wbc count. however, his leukocytosis continued to worsen so iv flagyl was added to the regimen and his po vancomycin dose was increased to 500 mg q6h. when he continued to have rising leukocytosis on this regimen a repeat set of cultures was sent on all body fluids and his urine grew vre (see below). the antibiotic steward recommended use fo tigecycline to dual treat vre in the urine and c.diff. his diarrhea resolved, as well as abdominal pain and it was felt that his rising leukocytosis was due to leukemoid reaction of abnormal bone marrow from cml (see below). he was narrowed again to po vancomycin 125 po q6 hours to complete a 14 day course following completion of 7 days of tigecycline 50 mg q12h for vre in the urine. his course was supposed to finish on . # vancomycin-resistant enterococcus (vre): his urine culture did grow vre on two occasions. he was felt to be colonized with this pathogen because his urinalysis both times had 16 and then 3 wbcs, which would be expected to have a more robust pyuria if he was acutely infected. nonetheless, because of rising leukocytosis, he was treated for vre with tigecycline which would dual-cover his c.diff above. he completed a 7 day course for complicated urinary tract infection since male gender and foley. even after treatment, his renal failure did not improve. # chronic myelocytic leukemia (cml): pt's wbc gradually increased from 17.2 on admission to peak of 84. infectious work up revealed c.diff infection and colonization of urine with vancomycin-resistant enterococcus (cultures positive but ua without pyuria indicating asymptomatic colonization). nonetheless, his white count continued to rise even after clinical resolution of c.diff and with empiric treatment of vre. felt most likely due to cml since his hydroxyurea was recently discontinued due to renal failure and thrombocytopenia. the atrius oncology service was consulted and recommended restarting hydroxyurea. he did also eventually develop a small percentage of his differential with peripheral blasts but this may have been a leukemoid reaction. given his overall poor prognosis it was decided to continue just the hydroxyurea without pursuing more aggressive work up such as bone marrow biopsy. his wbc gradually downtrended on hydroxyurea 1000 mg daily before reducing to 500mg daily in setting of thrombocytopenia. # hematuria: pt had hematuria during previous admission that required cbi and holding anticoagulation. warfarin was restarted at rehab facility and pt had gross hematuria on admission. he had ct abdomen/pelvis in the ed which showed question of focal density in the bladder lumen, which is most likely clot but raises concern for malignant lesion. the urology service was consulted and recommended sending urine cytology and outpatient f/u with cystoscopy in weeks after discharge. urine cytology was negative for malignant cells. # hemoptysis: pt reported one episode of hemoptysis on the night prior to admission (approx 1 tbsp). he did not have hemoptysis during admission, and it was felt that this most likely occured due to chf exacerbation and anticoagulation. # afib: chads2 score 6. rate was well controlled on home metprolol. inr was therapeutic on admission but warfarin was held for much of the admission while awaiting decisions on the aortic valve proceudres and for placement of dialysis catheters. he was maintained on heparin iv during this time with ptt 60-100. however, given concern for hitt later in hospital stay, patient was transitioned to argatroban infusion with the same target ptt. # hypertension (htn): systolic blood pressures during admission were ranging from 70s-90s even on intermittent hd. this was felt due to critical as and heart failure as above. his metoprolol was held due to low pressures and he was started on midodrine 10 mg mwf before hd sessions. # hyperlipidemia (hld): continued simvastatin # diabetes mellitus, type 2 (dmt2): diet controlled. maintained on sliding scale insulin in house. # gerd: continued home omeprazole # hyperparathyroidism: continued calcitriol # gout: allopurinol held due to acute on chronic renal failure. # insomnia/anxiety: continued home lorazapam 1mg hs prn and quetiapine qhs. transitional issues: expired medications on admission: 1) lasix 120mg 2) metoprolol 12.5mg po bid 3) simvastatin 40mg po bid 4) flonase 50mcg 1 spray daily 5) miralax 17gm daily 6) prilosec 20mg po daily 7) senna 17.2mg po daily 8) colace 200mg po bid 9) renagel 1600mg po tid with meals 10) allopurinol 150mg po daily 11) aspirin 81mg po daily 12) calcitriol 0.25mcg po daily 13) warfarin 2mg daily discharge medications: expired discharge disposition: expired discharge diagnosis: primary: acute on chronic systolic heart failure--ef 30% aortic stenosis acute on chronic renal failure hematuria secondary: atrial fibrillation discharge condition: expired discharge instructions: expired followup instructions: expired procedure: hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis arterial catheterization diagnoses: hyperpotassemia end stage renal disease esophageal reflux urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified hyposmolality and/or hyponatremia gout, unspecified atrial fibrillation aortic valve disorders hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia disorders of phosphorus metabolism intestinal infection due to clostridium difficile secondary hyperparathyroidism (of renal origin) personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] do not resuscitate status gross hematuria acute on chronic systolic heart failure heparin-induced thrombocytopenia (hit) chronic myeloid leukemia, without mention of having achieved remission hemoptysis, unspecified 

Answer: The patient is high likely exposed to