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: percocet / ciprofloxacin attending: chief complaint: chest pain & shortness of breath major surgical or invasive procedure: cardiac catheterization with drug eluting stents x2 to ostial and mid rca. history of present illness: mr. is a 70 year old man with a complicated history including cad s/p cabg in , pvd, systolic chf (ef 45-50% in ) w/ diastolic dysfunction, severe copd, severe as (0.8cm2) & ai who presents as a transfer from for respiratory failure. mr. has been hospitalized multiple times in the last several months for respiratory failure and has been intubated 3 times over the past 3 months most recently in early at . following his most recent discharge, he was seen by his pcp, . on for persistent upper respiratory symptoms and placed on a z-pack. his symptoms improved, but the patient's wife called the patient's pcp 3 days prior to this admission stating that the patient had developed worsening cough productive of thick yellow-green sputum and worsening shortness of breath on his home 2l o2, as well as chest tightness that resolved after sl ntg x 2. at that time, his wife reported that he had no chest pain, nausea, sweating, , chills, vomiting or dizziness and he was directed to for further evaluation. . for unclear reasons, he did not seek care until the day prior to admission when his breathing and chest pain symptoms worsened. he was taken to by ambulance and found to be non-verbal in the ed. cxr was negative and pbnp was 3969. he was initially treated for presumed systolic chf exacerbation and copd with cpap, iv solumedrol, nebulizers, lasix, and nitrates. he was also given a dose of iv levaquin out of concern for infection but his respiratory rate declined and his abg's demonstrated severe respiratory acidosis so he was intubated in the ed. in the icu, ekg's demonstrated sinus tachycardia with left anterior fascicular block and st depressions in ii, v3, v4. ce's rose with ck's peaking at 229 and troponin levels peaking at 0.45. he was placed on a heparin gtt, asa, beta-blocker, and a statin. the following morning, his respiratory status improved and he was extubated and placed on bipap before being transferred to the at family request. . on arrival to the ccu, the patient was noted to be on bipap, but not in respiratory distress. he was able to speak with the health care team, but demonstrated a visible left hand tremor and was relative immobile. on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: diabetes, +dyslipidemia, +hypertension 2. cardiac history: -cabg:cabg ' (lima -> lad, svg -> d2, om2, rca; stent to rca graft '). has three vessel coronary disease -percutaneous coronary interventions: -pacing/icd: 3. other pmh: - severe aortic stenosis (mean gradient 47 mmhg) - h/o (unclear when) - hyperlipidemia - obstructive sleep apnea - gerd - anxiety - colon cancer s/p sigmoid colectomy w/ colorectal anastomosis ' and adjuvant xeloda therapy - pvd - b12 deficiency anemia - ascending aortic aneurysm (4.2x4.2 in ) - anterior wall abdominal hernia - copd - htn - asthma social history: tobacco: 150 pk-year smoker (currently smokes 1ppd and more in the past), still smoking. etoh: greater than 50 years of significant etoh (previously reported 4 tumblers of vodka/day, recently reporting 2-4 beers per day). illicits: none used to work in security and at a mattress factory, has not worked for several years. walks without assistance at baseline. family history: dad died of mi at 57. 2 brother had mi. one brother had emphysema. one other brother with brain tumor. physical exam: vs on admission: t 97.3 bp 128/73 hr 89 rr 8 o2 sat 98% on bipap at 30% fio2 general: well-developed elderly man in nad. oriented x3. mood, affect appropriate. heent: nc/at. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: jvd not able to be assessed soft tissue obscuring anatomy cardiac: rrr, normal s1, s2. no murmurs audible. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities. ctab, no crackles, wheezes or rhonchi. abdomen: soft, nt/nd, large ventral hernia with multiple abdominal scars throughout the abdomen. no hsm. abdominal aorta not enlarged by palpation. no abdominal bruits. positive bowel sounds. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 1+ left: dp 1+ neuro: cnii-cxii intact, able to follow commands, easily conversant, moving all extremities pertinent results: 2d-echocardiogram : osh, ef 45-50%, with aortic valve area of 0.8cm2 and + aortic insufficiency. . : the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild global left ventricular hypokinesis (lvef = 45-50%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. there is severe aortic valve stenosis (valve area 0.8cm2). an eccentric jet of mild (1+) aortic regurgitation is seen. the mitral valve leaflets and supporting structures are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: severe aortic valve stenosis. mild symmetric left ventricular hypertrophy with mild global hypokinesis. mild pulmonary artery systolic hypertension. mild aortic regurgitation. compared with the report of the prior study (images unavailable for review) of , the severity of aortic stenosis has progressed, mild aortic regurgitation is now seen, left ventricular systolic function is less vigorous, and the estimated pulmonary artery systolic pressure is higher. . cardiac cath : right atrium {a/v/m} -/ right ventricle {s/ed} 33/7 pulmonary artery {s/d/m} 33/10/20 pulmonary wedge {a/v/m} -/ left ventricle {s/ed} 143/11 aorta {s/d/m} 128/53/80 systemic vasc. resistance 1604 pulmonary vasc. resistance 214 . proximal lad 40% stenosis mid-lad 100% stenosis diagonal-1 100% stenosis diagonal-2 diffusely diseased om-2 90% stenosis . impressions: 1. three vessel native coronary artery disease. 2. known occlusion of all svgs. 3. patent lima-lad graft. 4. mild pulmonary arterial hypertension. 5. severe, but noncritical aortic stenosis. 6. normal biventricular diastolic function. ct abd/pelvis noncon ct abdomen without iv contrast: lung bases are clear without consolidation or pleural effusion. the heart size is normal without pericardial effusion. dense calcification of the coronary arteries is noted. in the abdomen, assessment of solid organs is limited in the absence of iv contrast. however, the liver is grossly unremarkable. a focal hypodensity anteriorly is unchanged and likely represents focal fatty infiltration. a small gallstone is present in a decompressed gallbladder. the pancreas, spleen, adrenal glands and kidneys are grossly unremarkable. there is no hydronephrosis in either kidney. perinephric stranding size is unchanged. the stomach and duodenum are distended with fluid and small amount of ingested material. the esophagus also contains fluid. there is no free air or free fluid in the abdomen. the abdominal aorta demonstrates atherosclerotic calcification, but is normal in caliber. there is no mesenteric or retroperitoneal lymphadenopathy by size criteria. ct pelvis without iv contrast: large bowel demonstrates residual oral contrast material, possibly from the ct of or from an outside hospital study. loops of small bowel are distended, extending to the distal small bowel. both small and large bowel extends into a large, wide-based ventral hernia. a transition in small bowel caliber is noted just adjacent to the ventral hernia, with a small segment of fecalization of contents of the dilated small bowel, measuring up to 4 cm. distally, there is marked decompression of the distal and terminal ileum. the colon is relatively decompressed, although still retained a small amount of stool and contrast material. there is no extraluminal fluid or air. the sigmoid colon demonstrates scattered diverticulosis without diverticulitis. there is no free fluid layering dependently in the pelvis. the urinary bladder contains excrete contrast material. there is no pelvic or inguinal lymphadenopathy by size criteria. a fem-fem bypass graft is in place. the patient has undergone prior low anterior resection and surgical material is present at the rectosigmoid junction. osseous structures: degenerative changes are present throughout the lower spine, with no interval change. there is no new fracture. impression: 1. high-grade small-bowel obstruction, with dilatation of proximal loops up to 4 cm, and complete decompression of the distal and terminal ileum. obstruction may be early, as there is residual oral contrast and stool within the colon, which is minimally decompressed. no evidence of perforation. obstruction occurs adjacent to the mouth of the large ventral hernia. however, both dilated and decompressed loops pass into and out of the hernia sac. obstruction may be related to adhesions. 2. cholelithiasis without cholecystitis. 3. diverticulosis without diverticulitis. 4. no evidence of obstruction at the rectosigmoid anastomosis. 5. atherosclerotic disease. abd x-ray single supine portable abdomen radiograph was obtained. the radiograph demonstrates focal mild dilatation of small bowel loops in the epigastric region measuring 3.2 cm, consistent with the small bowel loops seen within the ventral hernia on the prior ct scan. air is seen within the descending colon and the rectum. the relative lack of air in the distal small bowel suggests likely partial or early small bowel obstruction. there is no intraperitoneal free air. the ng tube terminates at the gastroesophageal junction, and the sideholes likely are at the distal esophagus. recommended advancement of the ng tube. impression: 1. findings suggestive of early/partial small bowel obstruction. 2. recommended further advancement of the ng tube. labs at admission: 9>31.8<142 (wbc peaked at 15.3 on in the context of steroids) n 90, l7.1, m2.2, e0.6, b0.2 pt 12, ptt 116, inr 1.0 (normalized at discharge) 137/3.8/99/30/25/1.3<171 (cr peaked at 2.6 on and was 1.2 at discharge) alt 46, ast 45, ld 262, ck 124, alk phos 48, tuberculosis 0.4 (this was peak ck), other lfts normalized before discharge brief hospital course: 70 year old man with a complicated history including cad s/p cabg, pad, systolic chf (ef 45-50% in ) w/ diastolic dysfunction, severe copd, severe as (0.8cm2) & ai and a severe ventral hernia who presents as a transfer from for respiratory failure. after rapid stabilization of his respiratory status, he went for a cath with pci with desx2 to the rca on . he had intermittent abdominal pain that progressed to an sbo on . patient made progressively less urine and was transferred to micu through . he was sent to the cardiology service on and the sbo subsequently resolved. # small bowel obstruction patient has history of severe ventral hernia s/p laparotomy for colon resection and intermittent abdominal pain, last on . he received a ct abd with contrast that was negative for sbo at that time. on he complained of abdominal pain that passed with ativan and simethicone. on he had constipation, he had obstipation, bilious emesis and acute renal failure. a ngt was placed. surgery was consulted. all po only medications were held except for plavix which was given down the ngt. surgery followed and his ngt drainage decreased and he started to have bms on . on the ngt was pulled. mr. then had intermittent nausea without vomiting which resolved with ranitidine. he continue to have bms and flatus. # arf: on he developed arf in the setting of sbo. patient made very little urine and was therefore transfered to a micu for management of fluid status given arf and aortic stenosis. ivf were started and a foley catheter was placed which was subsequently removed with voiding prior to discharge. his creatinine at d/c was 1.2, at his baseline. # respiratory failure/ copd patient with known history of copd, asthma, and osa as well as an extensive smoking history. he is on 2l of continuous o2 as well as albuterol, advair, and tiotropium at home and over the past 3 months has required multiple intubations for respiratory distress despite repeated courses of prednisone & antibiotics, most recently approximately 2 weeks pta. he was intubated on at for an abg of 7.12/91/62/32 and was extubated on am to cpap prior to transfer after improved respiratory status. etiology likely obstructive lung disease with systolic chf as patient did not demonstrate e/o infection. in the ccu, the patient was placed on bipap and eventually weaned to 2l of nc over approximately 24 hours. he received 40 mg of prednisone daily and a course of levaquin. by , he was on 2 litres, saturating at 97%. he was able to tolerate room air with good saturations on day of discharge. he was discharged with a slow steroid taper. # systolic heart failure diasolic heart failure aortic stenosis, severe aortic insufficiency patient with known systolic heart failure, last ef in demonstrated ef 45-50% with severe as (mean gradient 47 mm hg and area 0.8cm^2) and + ar. his ef is unchanged from echocardiograms, but as his ar has progressed significantly since his last echo one month prior, his true forward flow is likely more compromised than his ef would suggest. cxr's from osh have not demonstrated e/o congestion or effusions and clinical exam does not support fluid overload, but pbnp was elevated at 3969. patient possibly a candidate for percucanteous valve replacement vs valvuloplasty however this decision will be deferred to the outpatient setting. # coronaries: patient s/p cabg ' (lima -> lad, svg -> d2, om2, rca; stent to rca graft '). his last cardiac catheterization in demonstrated three vessel coronary disease with a patent lima, but occlusion of all vein grafts. patient with possible old inferior mi based on micro-q waves in ii, iii, avf, but ekg on admission does not demonstrate new st changes. ce's trended down from osh levels (peak ck 229) and patient was cp free. patient initially on heparin gtt, asa, statin, beta-blocker. he did not receive plavix at osh as he has a history of gi bleed and thrombocytopenia while on plavix. he was discharged with the addition of plavix and high-dose statin with high-dose aspirin. # rhythm: patient without known history of arrythmia, but micro-q waves in ii, iii, and avf suggest prior inferior infarct not seen on ecg from 11/. # hypertension: patient takes imdur sr 120 mg daily & metoprolol tartrate 25mg tid at home. blood pressures at osh and in ccu were well-controlled. given h/o as, patient likely pre-load dependent. imdur and metoprolol were restarted before discharge. # hyperlipidemia: patient takes simvastatin 20mg qhs at home. given question of acs, high dose statin warranted. fish oil was also continued. # alcohol abuse: patient with extensive etoh history and an episode of dt in requiring intubation. his etoh screen on at was negative and his wife reported that his last drink was on . patient was maintained on a ciwa scale and continued to get his home q8h prn ativan for anxiety. # anxiety: patient with h/o anxiety, on celexa 80mg daily, lorazepam 1mg tid:prn, and seroquel 12.5mg at home. per omr records, patient preferred not to take seroquel out of concern for side effects, so it is unlikely to be an active medication. home medications were continued. # peripheral vascular disease: patient with known pad s/p fem- bypass (unclear when). he also has a known ascending aortic aneurysm last measured at 4.2cm x 4.2cm in 5/. asa 325 and pentoxyfylline sr 400mg tid were continued. # anemia: patient with known vitamin b-12 deficiency anemia for which he receives daily supplementation. iron studies during this hospitalization were normal and he was continud on his home b-12 1,000 mcg daily. # gerd: patient was continued on his home omeprazole 20mg daily and then was switched to an h2b before discharge. ranitidine worked better than famotidine. # h/o recurrent c. difficile colitis: patient has failed multiple flagyl regimens in the past in the context of etoh use, and was ultimately successfully treated with an extended course of vancomycin. he did have an episode of diarrhea and abdominal pain during this hospitalization which resolved. he had multiple bowel movements after resolution of his sbo, likely thought to be due to just improved motility. # h/o colon cancer: s/p sigmoid colectomy w/ colorectal anastomosis ' and adjuvant xeloda therapy with resulting post-surgical anterior wall abdominal hernia. patient uses belt for hernia control, but this has exacerbated sob in the past, so it was not utilized during this hospitalization. # active smoking habit: patient smokes ~ 1ppd with >150 pack year history. he was given a nicotine td during this hospitalization and provided an rx and counseling prior to discharge. code: full code (confirmed with patient's wife) comm: & patient's wife (h), (c)) medications on admission: albuterol sulfate 90 mcg hfa inhaler 1-2 puffs q4-6h:prn amitriptyline 50 mg qhs citalopram 80mg daily fluticasone-salmeterol 500 mcg-50 mcg hydrocodone-acetaminophen 5 mg-500 mg :prn ipratropium-albuterol 2.5-0.5 mg/3 ml neb qid isosorbide mononitrate sr 60 mg daily lorazepam 1 mg tid:prn anxiety metoprolol tartrate 25mg nitroglycerin 0.4 mg sl prn:chest pain omeprazole ec 20 mg daily pentoxifylline sr 400 mg tid prednisone taper (taper unknown) quetiapine 12.5 mg tablet simvastatin 20 mg qhs tiotropium bromide 18 mcg, 1 puff daily aspirin 81 mg tablet cyanocobalamin 1,000 mcg daily omega-3 fatty acids 1,000 mg daily discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily): take every day for one year, do not miss or stop taking. . disp:*30 tablet(s)* refills:*11* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*28 tablet(s)* refills:*2* 3. simvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 4. amitriptyline 50 mg tablet sig: one (1) tablet po at bedtime. 5. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. 6. pentoxifylline 400 mg tablet sustained release sig: one (1) tablet sustained release po tid (3 times a day). 7. quetiapine 25 mg tablet sig: 0.5 tablet po twice a day. 8. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) puff inhalation once a day. 9. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (daily). 10. omega-3 fatty acids capsule sig: one (1) capsule po daily (daily). 11. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*28 patch 24 hr(s)* refills:*2* 12. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain: do not take more than 4 grams in 24 hours. 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: inhalation q4h (every 4 hours) as needed for shortness of breath, wheezing. 14. citalopram 40 mg tablet sig: one (1) tablet po twice a day. 15. lorazepam 1 mg tablet sig: one (1) tablet po every eight (8) hours as needed for anxiety. 16. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 17. prednisone 20 mg tablet sig: one (1) tablet po once a day. 18. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 19. isosorbide mononitrate 120 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 20. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 21. prednisone 5 mg tablet sig: 1-2 tablets po once a day: take 2 tablets (with your 20mg tablets to equal 30mg) through ; on start taking one tablet (with your 20mg tablets to equal 25mg). disp:*30 tablet(s)* refills:*2* 22. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing: use in place of your nebulizer. disp:*1 inh* refills:*0* discharge disposition: home with service facility: discharge diagnosis: acute on chronic systolic and diastolic congestive heart failure chronic kidney disease, stage 2 chronic obstructive pulmonary disease exacerbation aortic valve stenosis discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: you had trouble breathing and needed to be intubated at . you were extubated and transferred to your heart. you were treated with antibiotics for copd (emphysema) and given prednisone and nebulizer treatments to help your oxygen level. a cardiac catheterization showed blockages in your arteries which may have made your breathing worse. you had 2 stents placed in an artery in your heart. you will need to be on plavix for one year and possibly longer. it is extremely important that you take plavix and aspirin every day and not miss . missing could cause your stents to clot off and cause a heart attack or death while you were here some of your medications were changed. you should continue taking: -imdur 120mg daily -metoprolol 25mg three times a day -tylenol 325-650mg every 6 hours as needed for pain -albuterol nebs four times a day and every 2 hours as needed for shortness of breath or wheezing - amitriptyline 25mg nightly - celexa 20 mg twice a dy - advair 500/50 twice a day - multivitamin daily - trental 400mg three times a day - seroquel 12.5mg twice a day - spiriva 18 mcg daily - fish oil - vitamin b1 and b12 - ativan 1mg every 8 hours as needed for anxiety. you should not drive with this medication. you should start taking: - plavix 75 mg daily - take bactrim for pcp pneumonia prevention because of your steroids until your doctor tells you to stop it - you should stop smoking. use the nicotine patch once a day to help. do not smoke while using the patch since it can be even more dangerous for your heart. you should change: - instead of aspirin 81 mg daily start spirin 325mg and your cardiologist will let you know when to come down to 81mg - increase your simvastatin to 80 mg daily - stop prilosec and instead start ranitidine for reflux since prilosec an interfere with your new heart stents. - you should increase your prednisone to 30mg daily (one 20mg pill plus two 5mg pills) through . on , start taking a total of 25mg daily (one 20mg pill plus one 5mg pill) . weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. followup instructions: you have the following appointments: appointment #1 md: specialty: cardiology date/ time: , , 1:30 location: , phone number: special instructions for patient: appointment #2 md: specialty: internal medicine/ pcp date/ time: wednesday, :10am location: building, , atrium suite phone number: procedure: coronary arteriography using two catheters left heart cardiac catheterization insertion of drug-eluting coronary artery stent(s) transposition of cranial and peripheral nerves insertion of two vascular stents excision of lingual thyroid percutaneous transluminal coronary angioplasty [ptca] procedure on single vessel diagnoses: obstructive sleep apnea (adult)(pediatric) subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery tobacco use disorder congestive heart failure, unspecified acute kidney failure, unspecified thoracic aneurysm without mention of rupture coronary atherosclerosis of autologous vein bypass graft hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified aortic valve disorders other chronic pulmonary heart diseases acute respiratory failure personal history of malignant neoplasm of large intestine iron deficiency anemia, unspecified chronic obstructive asthma with (acute) exacerbation alcohol abuse, continuous leukocytosis, unspecified acute on chronic combined systolic and diastolic heart failure chronic kidney disease, stage ii (mild) other ventral hernia with obstruction 

Answer: The patient is high likely exposed to