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: lipitor / bactrim attending: chief complaint: bradycardia major surgical or invasive procedure: - implantation of permanent pacemaker - corevalve (aortic valve) placement history of present illness: this is a 89 year-old female with a pmh significant for cad (with 2-vd on cardia cath without pci, s/p nstemi in ), history of systolic chf (now ef 60%), htn, hld, severe aortic stenosis (av gradient 44 mmhg, 0.56 cm^2 with valvuloplasty performed ), mr, dementia, hypothyroidism who was recently scheduled for corevalve placement (on ) but this was post-poned given that she experienced a mechanical fall from her wheelchair on presentation to the hospital. her walker slipped backward and her head hit the floor. a ct head was negative. her procedure was re-scheduled for , but she presented to 's er on for a syncopal episode and she was found to be in sinus bradycardia with hr in the 50s. . this am the patient's vna noted that the patient had some abdominal discomfort. she started to feel better and went to move her bowels at 11am and during valsalva she developed lightheadedness and pre-syncopal concerns without loc or head injury. ems responded and the patient was evaluated at ed where her labs were reassuring, but she had episodes of sinus bradycardia to the 50s. she was without further lightheadedness, dizziness or chest pain. . of note, she was initially thought to be too fragile and her dementia too severe for her to unfergo corevalve placement, but by her appointment with dr. , she had markedly improved and was reconsidered for the corevalve procedure. . the patient's most recent hospital admission was on to the ed for chest pain attributed to demand ischemia from her severe aortic stenosis. she was discharged on with her previous cardiac medications and the addition of lasix 20 mg po twice daily. . on arrival to the floor, the patient is without chest pain or trouble breathin. she has no nausea or vomiting, no abdominal complaints. she denies lightheadedness or dizziness. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or pre-syncope. . ros: the patient denies a history of prior stroke/tia, deep venous thrombosis or pulmonary embolus. they deny bleeding at the time of prior procedures or surgeries. denies headaches or vision changes. no cough or upper respiratory symptoms. denies chest pain, dizziness or lightheadedness; no palpitations. denies shortness of breath. no nausea or vomiting, denies abdominal pain. no dysuria or hematuria. no change in bowel movements or bloody stools. denies muscle weakness, myalgias or neurologic complaints. no exertional buttock or calf pain. past medical history: cardiac history: cad, hyperlipidemia, hypertension * cabg: none * percutaneous coronary interventions: s/p several cardiac caths in the past without pci (2-vd disease on ) * pacing/icd: none . past medical & surgical history: 1. coronary artery disease (s/p several cardiac caths - most recent ); s/p nstemi () 2. severe aortic stenosis (av gradient 44 mmhg, 0.56 cm^2 with valvuloplasty performed ; 2d-echo showing < 0.8 cm^2 () 2. hyperlipidemia 3. hypertension 4. moderate mitral regurgitation (on 2d-echo ) 5. (?) chronic systolic congestive heart failure (2d-echo showing improved ef 60%) 6. chronic iron deficiency anemia (baseline hct 28-30%) 7. chronic renal insufficiency (baseline creatinine 1.8) 8. recurrent urinary tract infections (on suppressive therapy) 9. hypothyroidism 10. hepatitis c infection (inactive, contracted from prior blood transfusions; normal lfts with preserved hepatic function) 11. dementia 12. h/o back and neck surgeries 13. h/p right shoulder reconstruction 14. h/o tia (not clear if tia vs. stroke occurred; periventricular white matter disease) 15. gerd, reflux esophagitis social history: patient lives at home by herself; and recently had moved from an facility. denies tobacco use (never smoker) or alcohol use; no recreational substance use. ambulates with a walker. cooks for herself and has four children. support from her two daughters. a life line at home. family history: denies family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission physical exam vitals: 97.8 195/66 54 18 96%ra general: appears in no acute distress. alert and interactive. heent: normocephalic, atraumatic. eomi. perrl. nares clear. mucous membranes moist. no xanthalesma. neck: supple without lymphadenopathy. jvd at low-neck while at 30-degrees. cvs: pmi located in the 5th intercostal space, mid-clavicular line. regular rate and rhythm, 4/6 systolic ejection murmur peaking early with radiation to the carotids; no rubs or gallops. s1 and s2 normal. no s3 or s4. resp: respirations unlabored, no accessory muscle use. clear to auscultation bilaterally without adventitious sounds. no wheezing, rhonchi or crackles. stable inspiratory effort. abd: soft, non-tender, non-distended, with normoactive bowel sounds. no palpable masses or peritoneal signs. extr: no cyanosis, clubbing or edema, 2+ peripheral pulses derm: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: cn ii-xii intact throughout. alert and oriented x 3. dtrs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. gait deferred. pulse exam: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ . discharge physical exam vitals - tm/tc:98.1/98.1 hr: 59-60 bp: 133-172/69-71 rr: 18 02 sat: 97% 2l nc in/out: 1540/inc weight: 61.4 (63.2) general: 89 yo f in no acute distress, lying in bed heent: right ij line in place. op clear. chest: poor air movement bilaterally. crackles 1/2 up on left, unable to assess right, no wheezes or cough. cv: s1 s2 normal in quality and intensity rrr, 2/6 systolic soft murmur at lsb. abd: soft, slight ttp in b/l lower quadrants, non-distended, bs normoactive. no rebound/guarding. ext: wwp, no edema. dps, pts 2+. neuro: left side slighly stronger, from . speech garbled at times but can blurt out coherant sentence. cleared for po's by speech therapy. pertinent results: admission labs 06:30am blood wbc-7.2 rbc-3.01* hgb-9.5* hct-27.6* mcv-92 mch-31.5 mchc-34.3 rdw-13.8 plt ct-161 06:45am blood wbc-6.8 rbc-3.01* hgb-9.6* hct-26.8* mcv-89 mch-32.0 mchc-35.9* rdw-14.2 plt ct-154 06:45am blood neuts-68.7 lymphs-20.2 monos-6.4 eos-4.4* baso-0.3 06:30am blood pt-13.4 ptt-27.2 inr(pt)-1.1 10:28am blood fibrino-266 06:30am blood glucose-102* urean-40* creat-1.6* na-137 k-3.6 cl-103 hco3-25 angap-13 09:00am blood alt-9 ast-16 ck(cpk)-24* alkphos-50 totbili-0.3 06:30am blood ck-mb-2 ctropnt-0.02* 09:00am blood ck-mb-2 probnp-3184* 06:30am blood calcium-9.0 phos-3.7 mg-2.4 04:23am blood %hba1c-5.4 eag-108 04:23am blood triglyc-95 hdl-35 chol/hd-3.6 ldlcalc-73 ldlmeas-71 06:30am blood tsh-8.1* 06:30am blood free t4-1.1 . discharge labs: 09:28am blood wbc-9.0 rbc-3.10* hgb-9.6* hct-29.8* mcv-96 mch-30.9 mchc-32.2 rdw-15.4 plt ct-189 09:28am blood glucose-125* urean-40* creat-2.1* na-145 k-3.4 cl-113* hco3-20* angap-15 . microbiology urine cx (final): no growth , blood cx (final): no growth . ekg (): sinus bradycardia to 50s, ni/lad, no st-changes . 2d-echo (): the left atrium is moderately dilated. the right atrium is moderately dilated. moderate symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function (lvef > 55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp > 18mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta and aortic arch are mildly dilated. the aortic valve leaflets (3) are moderately thickened. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. . cardiac cath (): there was severe pulmonary hypertension with a pcwp = 30 mmhg. using rapid ventricular pacing at 180 bpm tow inflations were performed using a 22 x 6-cm balloon. this resulted in an improvement of the aortic valve area from 0.56 cm^2 to 0.86 cm^2 and a reduction of the mean gradient from 44 mmhg to 27 mmhg. echocardiography showed 1+ ai with valvular excursion improved from the baseline images. estimated blood loss < 100cc. the procedure was performed from the right femoral artery using ultrasound guidance and a preclose technique with a single perclose device. . imaging: ct head w/o contrast - there is no evidence of hemorrhage, edema, or shift of the midline structures. there is small vessel ischemic disease as evidenced by periventricular and right thalamic hypodensities. prominence of the ventricles and sulci is normal for age. carotid calcifications are noted. the mastoid air cells are well pneumatized. the imaged paranasal sinuses are normal. no suspicious osseous lesions or fractures. . cxr - new left chest wall pacer with transsubclavian leads extending to expected locations in ra and rv. however, there is a new 2-cm left apical ptx. no pulmonary edema or new focal consolidations. no effusion. stable cardiomegaly. . cxr - roughly 3-cm apical left ptx noted to the level of the 5th rib (or 4th intercostal space); preliminary report pending . chest (portable ap): the left chest tube has been removed. there is no evidence of residual pneumothorax. no other changes as compared to the previous examination. . carotid lmtd/ dpp: the patient was moving and central lines only on the left side were evaluated. the left carotid artery shows velocities 73, 71, 134 in the ica, cca, eca respectively. the ica/cca ratio is 1. this is consistent with less than 40% stenosis. antegrade flow in the left vertebral artery. . ct head w/o contrast: there is no acute intracranial hemorrhage, edema, mass effect, or acute territorial infarction. there are chronic lacunar infarcts in the basal ganglia, left greater than right. moderate confluent centrum semiovale and periventricular hypodensities consistent with sequela of chronic small vessel disease. there are only mild age-related involutional changes. paranasal sinuses are clear. the mastoid air cells are underdeveloped on the left side. no mastoid opacification. . chest (pa & lat): the patient is after recent transarterial aortic valve replacement. the replaced valve appears to be in expected position. cardiomediastinal silhouette is unchanged. patient is in mild interstitial pulmonary edema that appears to be improved since the prior study. there is also slight interval improvement in bibasal atelectasis and pleural effusion. right internal jugular line tip is at the proximal right atrium and might be pulled back for approximately 1.5/2 cm to secure its position above the cavoatrial junction. brief hospital course: 89f with a pmh significant for cad (with 2-vd on cardia cath without pci, s/p nstemi in ), history of systolic chf (now ef 60%), htn, hld, severe aortic stenosis (av gradient 44 mmhg, 0.56 cm^2 with valvuloplasty performed ), mr, dementia, hypothyroidism with complicated hospital course prior to and after corevalve placement on . # severe aortic stenosis s/p corevalve placement - she had severe/critical aortic stenosis with her most recent valvuloplasty procedure () showing improvement of the aortic valve area from 0.56 cm^2 to 0.86 cm^2 and a reduction of the mean gradient from 44 mmhg to 27 mmhg following valvuloplasty. however, she remained symptomatic for some time from her critical aortic stenosis with progression to congestive heart failure. she underwent successful placement of corevalve on . her corevalve procedure on was complicated by a cva (see below). . # coronaries - the patient presents with known 2-vessel disease with her last coronary angiography showing lmca with minimal irregularities, lad with 50% origin stenosis and 40% mid-vessel stenosis, lcx showing minor irregularities and her rca showing 90% mid-pda stenosis (but small). she was also noted to have severe pulmonary artery hypertension with a pasp of 75 mmhg. there was critical aortic stenosis with a mean gradient of 54 mmhg and a calculated of 0.5 cm^2 (12/). the patient had prior valvuloplasty at the time of her last cardiac catheterization. the patient was admitted without chest pain or dyspnea. on admission, her ekg was stable showing sinus bradycardia, ni/lad, and no st-changes. troponin was negative, per the outside hospital report. we continued her medical optimization with aspirin 81 mg po daily and pravastatin 40 mg po daily. she was monitored via telemetry. # chronic diastolic heart failure - her carvedilol was increased and her lasix dose was changed to 20mg daily. most recent echo from showed mild symmetric left ventricular hypertrophy with normal left ventricular cavity size and normal regional left ventricular wall motion. lvef>55%. right ventricular chamber size and free wall motion was normal. an aortic corevalve prosthesis was visualized with normal transaortic gradient for this prosthesis. . # sinus bradycardia s/p pacemaker placement complicated by pneumothorax and hematoma- the patient's syncopal episode was attributed to symptomatic sinus bradycardia (new onset) versus a vasovagal response. on she underwent pacemaker placement (mode: ddd) that was complicated a minimal amount of local hematoma which resolved with a compression dressing. this was achieved via a left subclavian approach and the patient was noted to develop a new oxygen requirement following the procedure with cxr showing a small apical pneumothorax. she eventually required revision of her pacer pocket procedure on which was successful, given some concerns for pacer pocket hematoma and bleeding. she did require placement of a left pigtail catheter (chest tube) for decompression of her apical ptx on prior to her corevalve procedure. she had no further rhythm issues after this. . # cerebrovascular accident: the patient's corevalve procedure on was complicated by a cva, resulting in left sided umn pattern facial droop and and umn pattern of left arm weakness, and difficulty swallowing. on , she was noted to have new left-sided hemianopia, with a non-contrast head ct showing no evidence of acute intracranial processes. carotid ultrasound was done, but was a difficult study, showing 40% stenosis on the left, and unable to assess on the right. the patient was initially given nutrition through an ng tube until she passed speech and swallow. . # pneumonia: following her corevalve procedure and cva, the patient was noted to be febrile with evidence of a left lower lobe pneumonia on chest x-ray. she was treated with intravenous metronidazole, cefepime and vancomycin for an 8-day course for a hospital-acquired pneumonia, likely secondary to aspiration. . # hypothyroidism - prior to admission, the patient's last tsh was 4.5 (slightly elevated) and she has been on levothyroxine 50 mcg po daily. she presented with no overt symptoms of inappropriate replacement. she was continued on her home dose. given her bradycardia, her tsh as rechecked and was elevated at 8.1. we increased her levothyroxine dose to 75 mcg po daily. she will need her tfts rechecked in weeks following her surgery. . # chronic renal insufficiency - the patient presented with a baseline creatinine in the 1.6-1.7 range; her admission creatinine was stable at 1.6 and was trended closely. we renally dosed her medications and avoided nephrotoxins. . # normocytic anemia - the patient presented with evidence of a chronic, normocytic anemia, with baseline hemoglobin in the range of 8.3-10 g/dl. given her recent left sublavian access site with oozing where her pacer was placed, her hematocrits were serially monitored and she required 2 units of packed rbcs this admission (see above), until her pacer pocket revision procedure on . hemoglobin 9.6 on the day of discharge. . # hyperlipidemia - we continued her pravastatin 40 mg po daily. . # dementia - per her daughters, her baseline mental status was stable with no changes reported, per her daughters. she remained alert and oriented to time, place and self. we continued her home dosing of respirdone and donepezil. . # gerd - we initially continued her omeprazole 20 mg po daily and then discontinued secondary to plavix therapy. . transition of care issues: 1. recheck tsh in weeks, following dose increase from levothyroxine 50 to 75 mcg po daily given her elevated tsh of 8.1 and bradycardia. medications on admission: 1. donepezil 10 mg po qhs 2. levothyroxine 50 mcg po daily 3. omeprazole 20 mg ec po daily 4. aspirin 81 mg po daily 5. ferrous sulfate 300 mg (60 mg iron) po daily 6. carvedilol 6.25 mg po bid 7. respirdone 0.25 mg po qhs 8. calcium carbonate 200 mg calcium (500 mg) 1 tab po tid prn dyspepsia 9. senna 8.6 mg po bid 10. pravastatin 40 mg po daily 11. vitamin d 1,000 unit capsule po daily 12. cranberry concentrate capsule po daily 13. lasix 20 mg po bid discharge medications: 1. donepezil 10 mg tablet sig: one (1) tablet po hs (at bedtime). 2. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: five (5) ml po daily (daily). 5. risperidone 0.25 mg tablet sig: one (1) tablet po hs (at bedtime). 6. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for dyspepsia. 7. senna 8.6 mg tablet sig: two (2) tablet po at bedtime. disp:*60 tablet(s)* refills:*0* 8. pravastatin 40 mg tablet sig: one (1) tablet po once a day. 9. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po daily (daily). 10. cranberry concentrate capsule sig: one (1) capsule po once a day. 11. furosemide 20 mg tablet sig: one (1) tablet po once a day: hold if sbp<100. disp:*30 tablet(s)* refills:*0* 12. carvedilol 25 mg tablet sig: one (1) tablet po twice a day: hold if sbp<100. disp:*60 tablet(s)* refills:*0* 13. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 14. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily): hold if sbp<100. disp:*60 tablet(s)* refills:*0* 15. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 16. acetaminophen 325 mg tablet sig: two (2) tablet po twice a day as needed for fever or pain: not to exceed 10 tablets/day. disp:*30 tablet(s)* refills:*0* 17. pantoprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 18. outpatient lab work please checked chemistry panel of labs on thursday, . have results faxed to dr. (fax: , phone: ), who will adjust medications as needed. discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses: 1. severe, symptomatic aortic stenosis, now status-post corevalve placement on . 2. coronary artery disease 3. hypertension 4. sinus bradycardia 5. left apical pneumothorax 6. aspiration pneumonia, now status-post 8-day treatment with broad-spectrum antibiotics. . secondary diagnoses: 1. hyperlipidemia 2. moderate mitral regurgitation 3. chronic renal insufficiency discharge condition: mental status: clear and coherent, though waxes and wanes (baseline). level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: patient discharge instructions: ms. , you were admitted to the cardiology-internal medicine service at on 3 regarding management of your heart issues. you were transferred from given your concerns of fainting as well as a resting heart rate that was in the low 40-50 range. you remained asymptomatic since this transfer. . while hospitalized here, your cardiac medications, including blood pressure therapy, were optimized. you had a pacemaker placed without issues or complications, and this was functioning well at the time of discharge. . you also underwent corevalve placement for severe aortic stenosis on . you were transferred to the cardiac critical care service for observation after the procedure. as a complication of this procedure, you may have suffered an embolic stroke, which is when something like a clot or calcification travels up your arteries and restricts blood flow to parts of your brain. however, consultation with the stroke specialists and imaging of your brain showed no acute findings for which we would have intervened. . also during this hospitalization, you developed some trouble with swallowing food and liquids, possibly related to the stroke signs and symptoms described above. we had to insert a plastic tube through your nose into your stomach multiple times, in order to feed you and give you your medications. we believe that this difficulty swallowing may have led to some food or gastric fluid dropping into your lung, causing a pneumonia for which we treated you with strong antibiotics for 8 days. after you passed an evaluation by our speech and swallow team, your feeding tube was removed, and you were able to take an oral diet. . at discharge, you were in stable condition, with no fever or new signs/symptoms. . please call your doctor or go to the emergency department if: * you experience new chest pain, pressure, squeezing or tightness. * worsening swelling in your legs or a weight gain of 3 lbs or more, fatigue or excessive weakness. * you develop new or worsening cough, shortness of breath, or wheezing. * you are vomiting and cannot keep down fluids, or your medications. * if you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit, or have a bowel movement. * you experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * your pain is not improving within 12 hours or is not under control within 24 hours. * your pain worsens or changes location. * you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. * you develop any other concerning symptoms. . changes in your medication reconciliation: * upon admission, we added the following medications: you should start: amlodipine 10mg daily (for blood pressure) you should start: carvedilol 25mg po twice-daily (for blood pressure) you should start: clopidogrel 75mg daily (to prevent complications of corevalve). **this medication should be continued for three months.** you should start: furosemide(lasix) 20mg daily (for blood pressure) . * the following medications were discontinued on admission and you should not resume: discontinue: carvedilol 6.25mg twice daily (changed to increased dose above) discontinue: furosemide(lasix) 20mg twice daily (changed to decreased dose above) . * you should continue all of your other home medications as prescribed, unless otherwise directed above. thank you for allowing us to participate in the care of your medical needs during this time. followup instructions: department: west clinic when: wednesday at 1:30 pm with: , md building: de building ( complex) campus: west best parking: garage . department: gerontology when: tuesday at 12:00 pm with: , md building: lm campus: west best parking: garage . provider: lab phone: date/time: 10:30 . provider: , md phone: date/time: 11:15 . provider: phone: date/time: 9:00 . department: cardiac services when: friday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances initial insertion of dual-chamber device initial insertion of transvenous leads [electrodes] into atrium and ventricle open and other replacement of aortic valve aortography other incision with drainage of skin and subcutaneous tissue other incision of pleura percutaneous balloon valvuloplasty central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: thrombocytopenia, unspecified anemia, unspecified coronary atherosclerosis of native coronary artery esophageal reflux congestive heart failure, unspecified unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified chronic kidney disease, unspecified other and unspecified hyperlipidemia other specified cardiac dysrhythmias pneumonitis due to inhalation of food or vomitus iatrogenic pneumothorax peripheral vascular complications, not elsewhere classified old myocardial infarction cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure chronic systolic heart failure mitral valve insufficiency and aortic valve stenosis other complications due to other cardiac device, implant, and graft surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation hyperosmolality and/or hypernatremia accidents occurring in residential institution cerebral artery occlusion, unspecified with cerebral infarction examination of participant in clinical trial iatrogenic cerebrovascular infarction or hemorrhage aneurysm of artery of lower extremity homonymous bilateral field defects dysphagia, unspecified dementia, unspecified, without behavioral disturbance 

Answer: The patient is high likely exposed to