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: no known allergies / adverse drug reactions attending: chief complaint: syncope major surgical or invasive procedure: pacemaker implantation history of present illness: 78 year old woman with history of atrial fibrillation on coumadin and h/o cva (residual mild right hemiparesis), presented initially to osh with syncope and bradycardia. she was found sitting on the floor without recollection of the events preceeding. denied preceeding chest pain, lightheadedness or diaphoresis. upon waking, had new right shoulder and right hip pain as well as a new ecchymosis on right forehead. . at the osh ( hosp), she was found to have a small right frontal parietal subcutaneous hematoma, ct head was without acute intracranial pathology. ecg showed afib with inferolateral scooping st depressions. inr was therapeutic at 2.4. she was hemodynamically stable despite brief epsisodes of bradycardia into the high 30s. her neurological exam was at baseline. xrays of right hip and right shoulder were negative. asa 325mg and nitropaste were administered and she was transferred to bimdc for further workup. she received nitropast and aspirin prior to admission. . her daughter left the hospital prior to patient arriving on the floor thus the history is somewhat abreviated. per report from the caridology fellow who saw her in the ed, she was recently confused and was aggressive towards her daughter which is unusual. . in the ed, initial vs: 99.8 67 148/57 18 97% 2l. labs notable for trop 0.07, creatinine 1.4, bun 33, digoxin 2.2, wbc 10.9, hct 29.9 with mcv 93, inr 2.5, k 3.6. ecg showed depressed scooped st segments in i, ii, avf and v3-v6. most recent set of vitals: 97.6 63 (in & out of afib with episodes of bradycardia to the 30's not causing hemodynamic or subjective compromise) 141/57 22 98% ra. . upon arrival to the floor, hr ranged from 33-70s without symptoms or evidence of av block. she denies chest pain, sob, palpitations, lightheadedness or dizziness. no vision changes or color changes in field of vision. she does not recall todays morning events (cannot remember waking up or eating breakfast). no paresthesias or weakness above her baseline. she has intermittent diarrhea, last occured 1 week prior to admission. poor appetite recently. past medical history: atrial fibrillation on coumadin cva with mild residual right sided hemiparesis dm2 hld htn social history: lives with her daughter, she is widowed. no tob, etoh or ivda. walks independently without walker or cane. adl independent. does not drive. family history: brother with throat cancer, no cad/dm2 or malignancy physical exam: admission exam vs - 98 175/77 63 sinus 20 97% ra general - nad, comfortable, appropriate, subtle poor short term memory heent - nc/at, perrla, eomi intact during interviwe, but upon testing eom she does not follow well on right indicating possible visual field deficit, sclerae anicteric, mm dry, op clear neck - supple, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored heart - rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout . discharge exam vs: 98.1, bp 120-140/50-70, hr 80, rr 18, o2 sat 97% on ra gen: nad, a & o x2 (person and place) neck: supple, jvd flat, heart: irregularly irregular, good s1, s2, no m/r/g lung: cta bl, no w/r/rh abd: soft, nt/nd, no hsm ext: no pitting edema, 2+ dp/pt bilaterally pertinent results: admission labs 07:55pm blood wbc-10.9 rbc-3.21* hgb-9.8* hct-29.9* mcv-93 mch-30.5 mchc-32.7 rdw-16.1* plt ct-242 07:55pm blood neuts-81.1* lymphs-15.0* monos-3.4 eos-0.1 baso-0.3 07:55pm blood pt-26.4* ptt-35.0 inr(pt)-2.5* 07:55pm blood glucose-206* urean-33* creat-1.4* na-137 k-3.6 cl-97 hco3-27 angap-17 07:55pm blood totprot-6.9 calcium-9.6 phos-2.4* mg-1.2* . discharge labs 06:00am blood wbc-9.6 rbc-2.90* hgb-9.1* hct-27.4* mcv-94 mch-31.3 mchc-33.2 rdw-16.3* plt ct-206 06:00am blood pt-25.8* ptt-31.3 inr(pt)-2.5* 06:00am blood glucose-183* urean-37* creat-1.4* na-135 k-4.2 cl-97 hco3-27 angap-15 06:00am blood calcium-9.4 phos-3.8 mg-2.3 . cardiac enzymes 07:55pm blood ck-mb-6 07:55pm blood ctropnt-0.07* 08:09am blood ck-mb-4 ctropnt-0.08* 04:17am blood ck-mb-3 ctropnt-0.05* . pertinent studies 06:45am blood alt-17 ast-46* alkphos-57 totbili-0.5 06:45am blood tsh-1.8 07:55pm blood free t4-1.7 09:13am blood lactate-1.8 07:55pm blood digoxin-2.2* 06:00am blood digoxin-1.5 . pertinent studies # cxr there is moderate cardiomegaly. there is mild vascular congestion. bibasilar atelectasis are larger on the right side. there is no evident pneumothorax or pleural effusion. . # ct noncontrast findings: there is no evidence of hemorrhage or recent infarction. regions of hypodensity in the left frontal, parietal, and occipital lobes as well as in the right parietal love (2; 23) represent sequelae of prior infarction; these appear similar to prior exam. the -white matter differentiation is preserved. there is no edema or mass effect. prominence of the ventricles reflects age-related atrophic change. subtle periventricular hypodensities represent chronic small vessel ischemic changes. the mastoid air cells are clear. the visualized paranasal sinuses demonstrate mild mucosal thickening of the sphenoid sinuses. impression: sequelae of old infarction but no evidence of hemorrhage or recent infarction. . # echo (tte) conclusions the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild to moderate regional left ventricular systolic dysfunction with apical aneurysm/dyskinesis and near akinesis of the anterior wall and distal septum. the remaining segments contract normally (lvef = 40%). the estimated cardiac index is normal (>=2.5l/min/m2). no masses or thrombi are seen in the left ventricle. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . impression: mild symmetric left ventricular hypertrophy with regional systolic dysfunction (mid-lad distribution) and apical aneurysm. mild pulmonary artery systolic hypertension. . # carotid series impression: on the right, minimal plaque with less than 40% carotid stenosis. on the left, possible ica occlusion; however, no confirmatory study. please review information above. . # cxr pa/lat the left-sided pacemaker has been placed with its tip terminating in the expected location of the right ventricle. there is no substantial change in the cardiomegaly. there is substantial interval improvement up to complete resolution of pulmonary edema. still present small bilateral pleural effusions are noted. there is no definite pneumothorax seen, but minimal amount of apical pleural air cannot be excluded. brief hospital course: 78 y/o woman with atrial fibrillation on coumadin and h/o cva, who was transferred from osh s/p syncope and was found bradycardic. . active issues: # digixin toxicity: pt presented with bradycardia in 40-50s, with occasional drop to 30s. although the cause of bradycardia is likely multifactorial, digoxin toxicity was high on the differential given her subacute worsening of diarrhea and personality changes in the past several weeks. her digoxin level on admission was 2.2, however, the digoxin level does not correlate with toxicity, especially in elderly. pt had a ~6 sec pause on the night of admission, and subsequently responded after one round of cpr. two vials of digoxin binder was given in this setting. her repeat digoxin level was 1.5. . # bradycardia: pt presented with hemodynamically stable bradycardia on admission. the causes of her bradycardia include digoxin toxicity, tachy-brady syndrome, and iatrogenic effect from nodal agents. her medication were held on admission, and digoxin binder was provided in the setting of asystole. a single lead ventricular pacemaker was placed. pt tolerated the procedure well with native atrial fibrillation rhythm in 70-80 bpm at the time of discharge. . # syncope: pt underwent unwitnessed fall at home, which she did not have recollection of, likely representing a syncopal episode. at osh, workup was notable for right frontal/parietal hematoma, but no evidence of subdural hematoma or fractures. her inr was therapeutic at 2.4. a repeat ct-head noncontrast was performed after the transfer, which again did not reveal intracranial bleed. the cause of her syncope was unclear, but could be explained by the bradycardia. . # altered mental status: pt presented with borderline mental status, was significantly worse than her baseline per family. there was a subacute process, notable for more aggressive behavior in the past 2-3 weeks prior to admission. there was also a more acute change to wax- confusion and somnolence. the etiology is felt multifactorial. digoxin toxicity could be responsible for the subacute changes. however, the more acute changes likely represents a delirious process. pt was found to have developed uti during this admission, which was treated with iv antibiotics. workup was notable for normal tsh, liver function. pt received monthly b12 infusion, thus unlikely the culprit. delirium in elderly going through acute stress of hospitalization is most likely explanation. however, acute on chronic vascular dementia secondary to a recent cva cannot be completely ruled out. . # uti: pt was found to have developed positive ua during this admission. she had no urinary symptoms. we decided to treat given her altered mental status. we avoided cipro and bactrim given she was on coumadin and treated her with iv ceftriaxone. . # systolic chf: pt was found to have worsened systolic function to 40% from 55-60% last year. echo also revealed lvh with regional systolic dysfunction (mid-lad distribution), apical aneurysm as well as mild pulmonary artery systolic hypertension. pt represented with mildly elevated troponin with no ckmb elevation. pt was otherwise asymptomatic, with no ekg changes. the elevated troponin most likely came from bradycardia in the setting of worsening kidney function. however, a subacute ischemic event could not be completely ruled out, especially given the new echo findings. pt may need repeat echo. . # hypoxia: pt developed pulmonary edema in the setting of iv fluid on the presumption of hypovolemia on admission. she was treated with iv lasix which she responded well. . chronic issues # atrial fibrillation: pt has paroxysmal atrial fibrillation with chads score . we continued her warfarin at home dose, and adjusted her rate control with metoprolol 50 mg daily. . # renal insufficiency: pt's cr during this admission is 1.2-1.4, which were close to her recent value of 1.4-1.5. . transitional issues # code status: full code # contact: (daughter, hcp ) # pending studies at discharge: - urine culture on - no growth to date # medication changes: - stop digoxin - stop diltiazem - start ceftriaxone 1 g iv once dose on - start metoprolol succinate 50 mg qd - start valsartan 40 mg - start aspirin 81 mg qd - decrease allopurinol to 100 mg qd given current gfr # follow up plan - please give one more dose of iv ceftriaxone 1 g iv on - please closely monitoring electrolytes given pt is on diuretics and recently started on valsartan - consider uptitrate valsartan as bp tolerates given pt has chf - please follow up with dr. for pacemaker placement - please arrange pcp followup at the time of leaving rehab - will recommend repeat echo for new worsening in schf - pt has calculated gfr of 33, may not be a good candidate for metformin if her creatinine continue to deteriorate medications on admission: metformin 850mg daily simvastatin 20mg daily digoxin 0.125mg daily folic acid 1mg daily allopurinol 200mg daily diltiazem 240mg daily metoprolol succinate 25mg daily glipizid 2.5mg daily bumetanide 1mg daily warfarin 2.5mg on m/th, 2.0 mg on rest omeprazole 20mg daily . discharge medications: 1. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 2. metformin 850 mg tablet sig: one (1) tablet po once a day. 3. glipizide 2.5 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 4. warfarin 2 mg tablet sig: one (1) tablet po 16 pm on tue, wed, fri, sat, sun (). 5. warfarin 2.5 mg tablet sig: one (1) tablet po q16pm on mon, (). 6. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 9. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 10. bumetanide 1 mg tablet sig: one (1) tablet po once a day. 11. valsartan 40 mg tablet sig: one (1) tablet po twice a day. 12. ceftriaxone 1 gram piggyback sig: one (1) intravenous once a day for 1 days: please give on . discharge disposition: extended care facility: healthcare center at discharge diagnosis: primary diagnosis - digoxin toxicity - tachy-brady syndrome secondary diagnosis - atrial fibrillation - bradycardia - diabetes mellitus type 2 - hypertension discharge condition: mental status: alert and confused (oriented x place and person) at times level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , . you came to our hospital after having a fall and striking your head. you were found to have low heart rate as well. you were found to have elevated levels of digoxin which were likely contributing to your symptoms. your digoxin was stopped and you were also given a medication to decrease the level of medicaiton. you had a pacemaker placed for your low heart rate. you also repeated an cat scan of your head and this was reasurring that there was no bleeding or other acute changes. you were then discharge to a rehabilitation facility. we have made the following changes to your medications: - please stop digoxin - please stop diltiazem - please increase metoprolol succinate to 50 mg tablet by mouth daily - please start ceftriaxone 1 g iv for one additional dose on for urinary tract infection - please start valsartan 40 mg by mouth twice a day - please start aspirin 81 mg by mouth daily - pleaes decrease allopurinol to 100 mg tablet by mouth daily - please continue to take the rest of your medication we also recommend that you discuss with your pcp the change of your anti-diabetic medications given your age, creatine clearance and chf. . please continue your routine followup at clinic at after leaving the rehab. it has been a pleasure taking care of you here at . we wish you a speedy recovery. followup instructions: when: friday at 11:10 am with: dr. address: , , telephone: procedure: cardiopulmonary resuscitation, not otherwise specified initial insertion of single-chamber device, rate responsive initial insertion of transvenous lead [electrode] into ventricle diagnoses: urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified atrial fibrillation other chronic pulmonary heart diseases unspecified fall other and unspecified hyperlipidemia cardiac arrest long-term (current) use of anticoagulants retention of urine, unspecified late effects of cerebrovascular disease, hemiplegia affecting unspecified side sinoatrial node dysfunction dehydration acute on chronic systolic heart failure syncope and collapse delirium due to conditions classified elsewhere cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use contusion of face, scalp, and neck except eye(s) unspecified adverse effect of other drug, medicinal and biological substance 

Answer: The patient is high likely exposed to