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: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral arm paresthesias major surgical or invasive procedure: none history of present illness: 81 yo f w/ htn, dm, chronic constipation, hyperchol, p/w bilateral arm pain. in ed had cta which ruled out dissection. while getting scanned became increasingly sob and hypoxic to 60-70%s; n/v with possible aspiration vs. flash pulmonary edema. pt was intubated for respiratory distress and hypoxia and sent to the ; had a difficult intubation. was given lasix o/n for possible flash pulm edema and abx for aspiration pna. in the , pt was diuresed for pulmonary edema, ce were checked and she ruled in (peak tnt=0.72, peak ck=524); enzymes are now trending down. pt with possible st elevations in precordial leads, and tte showed ef=60%, moderat pe systolic htn, and could not exclude focal wall motion abnormalities. pt was seen by cardiology who recommended non-invasive cardiac testing as an initial evaluation. pt was then transferred to (extubated, doing well from respiratory standpoint) for pharmacologic stress test. other important events in the included sputum positive for mrsa (pt now on vanco) and hct drop (?unexplained). on admission to , pt denies any symptoms at this time; no cp/sob/n/v/f/c; she does not remember much of her course in the /whether she had chest pain at any time. she does state that she has a cough, non-productive. pt transferred to floor for p-mibi and possible intervention based on the results of this test. past medical history: 1past medical history: 1. hypertension. 2. noninsulin-dependent diabetes. 3. chronic constipation. 4. acoustic neuroma. 5. status post cataract removal. 6. status post cholecystectomy. 7. history of polyp/internal hemorrhoid found at colonoscopy in . 8. hearing loss in left ear. 9. chronic dizziness. 10. hypercholesterolemia. meds on transfer: asa 325 lipitor 40 vanco 1000 qd colace 100 senna dulcolax ntg drip metoprolol 100 tid captopril 75 tid ssi amlodipine 5 qd social history: social history: moved from , lives by herself, has a homemaker helping her out in her home, has a daughter in city, a son in , denies tobacco or alcohol use. patient walks with a walker and a cane. family history: non-contributory physical exam: hr 70, bp 160/80, r15, sao2 50%ra, 85%nrb gen: intubated, sedated. heent: mmm, jvd not appreciated cv: rr, distant heeart sounds, no m/r/g lungs: b/l diffuse rales and crackles abd: s/nt/distended. +la, +bs ext: no le edema, trace dp pulses b/l. exam on transfer from : as above w/ following exceptions: 99.7 169/56 20 96% 2l gen: alert, oriented, russian speaking, comfortable, on 2l nc cv: regular s1,s2. ii/vi sem at rusb. lungs: b/l basilar crakles to base of scapula pertinent results: cbc: 07:45pm blood wbc-8.1 rbc-3.89* hgb-11.7* hct-33.0* mcv-85 mch-30.0 mchc-35.4* rdw-15.2 plt ct-207 04:31am blood wbc-7.9 rbc-3.25* hgb-9.3* hct-27.6* mcv-85 mch-28.7 mchc-33.9 rdw-15.5 plt ct-177 05:37am blood neuts-66 bands-22* lymphs-8* monos-1* eos-0 baso-0 atyps-3* metas-0 myelos-0 coags: 03:52am blood pt-12.7 ptt-26.3 inr(pt)-1.0 chem-7 07:45pm blood glucose-355* urean-26* creat-0.9 na-140 k-3.8 cl-103 hco3-24 angap-17 04:31am blood glucose-186* urean-18 creat-0.6 na-142 k-4.1 cl-108 hco3-26 angap-12 cardiac enzymes: 07:45pm blood ck-mb-3 ctropnt-<0.01 05:37am blood ck-mb-17* mb indx-3.6 ctropnt-0.54* 01:33pm blood ck-mb-10 mb indx-1.9 ctropnt-0.62* 05:58pm blood ck-mb-8 ctropnt-0.72* 03:31pm blood ck-mb-5 ctropnt-0.38* 03:52am blood ck-mb-4 ctropnt-0.48* 04:31am blood calcium-8.8 phos-2.2* mg-2.1 : p-mibi:. impression: 1) mild, reversible apical perfusion defect. 2) normal wall motion. comparison is made to prior study of . the apical defect does not appear significantly changed in the interval brief hospital course: plan: 1. resp failure: pt initially intubated in ed following episode in ct scanner. cxr c/w asymmetric pulmonary edema vs. pna, so pt was started on aggressive diuresis and covered w/ ceftriaxone and azithromycin. respiratory failure felt to be secondary to acute onset pulmonary edema from bolus iv contrast injection. following admission to patient remained relatively hypotensive, requiring pressors and volume support to defend blood pressure. weaned off pressors on hd1, but remained on vent, undergoing active diuresis. received significant amounts of fluids during hypotensive episode and was net 3l positive on . has been undergoing active diuresis, responding to lasix 40mg iv. on the morning of the patient self extubated, but has done well from a respiratory standpoint since that time. upon transfer to the floor, diuresis was continued with iv lasix prn, with goal of 500-1000cc negative per day. her nc o2 was weaned as tolerated, and she had no complaints of shortness of breath. lasix should be continued at 40 mg qd, and volume status should be maintained as negative. lung exam should be monitored to ensure that she is not developing increased crackles on exam/pulmonary edema. the lasix should be continued until she follows up with her pcp. that she is on lasix, her electrolytes should be checked and repleted as necessary. 2. subendocardial ischemia: following bolus of iv contrast dye in the ct suite, the patient developed significant anterior st depressions and subsequently evolved troponins, peaking on at 0.72. cardiology was consulted and felt that the event was diastolic hf leading to ischemia as opposed to a primary acs, since the patient had been having symptoms for 24 hours prior to admission and had not produced positive cardiac enzymes. pt received 48 h of heparin via gtt, but was dc'd secondary to drop in platelets, nadiring at 119 on (hit cked and was negative). she was continued on asa/bb/statin. on , secondary to ongoing elevated bp, the patient was started on captopril and both her acei and bb were titrated up. on , the patient was started on norvasc for additional bp control and for the beneficial effects of ca channel blockade on systolic htn. metoprolol, amlodipine, and lisinopril were titrated up as needed for goal sbp 140-150. her blood pressure should continue to improve as cardiac/respiratory issues continue to resolve. bp meds should not be titrated up further. p-mibi was unchanged from prior study in , and cardiology did not feel that she need further workup/intervention. she is discharged on beta blocker/ace/asa/statin. 4. mrsa unclear if cxr really c/w pna, but given high risk and positive sputum culture for pna felt that patient would benefit from 10d course of vancomycin. day 1 was , so vancomycin should be continued to . tip of left subclavian catheter was also sent for culture when the line was removed on , and was negative (but pending) at time of discharge. if culture becomes positive, rehab will be notified. 5. dm: initially started on insulin gtt, stopped , maintained on ss. started on low dose glargine for improved control w/ goal of bs 120. on the floor, her glyburide and metformin were restarted, glargine 10 qhs was continued, and she was covered with sliding scale. her blood sugars remain high on discharge, but they should improve (oral hypoglycemics restarted day of discharge). she should have fingersticks qid at rehab and covered with sliding scale regular insulin as necessary until her blood sugars are under better control. 6 pt w/ baseline hct in 28-30 range, fluctuating w/ volume status. have been deferring transfusion secondary to conflicting nature of evidence for and agains transfusion in cardiac and icu patients, respectively. she was transfused 1 u prbc upon admission to the floor, for hct 28. she bumped appropriately, and her hct has been stable since (31-32). her hematocrit should be maintained at 30 or above given her cardiac history. 7. constipation: bowel regimen. has not improved with enema and lactulose. on transfer, on bisacodyl, senna, docusate, psyllium, lactulose, and rec'd enemas. pt had bowel movement on admission to floor, but this regimen should be titrated to regular bowel movements. 8. px: protonix and pneumoboots were continued in house. sq heparin/heparin gtt was d/c'd secondary to a drop in platelets. her hit antibody came back negative. 9. access: right mid-line placed on (to facilitate vancomycin therapy) 10. communication: family (son, daughter in law) 11. full code 12. dispo: to center. medications on admission: 1. acetaminophen 325 mg tablet, one to two tablets, p.o. q. four to six for pain, aches, fever. 2. aspirin 325 mg p.o. q. day. 3. bisacodyl 5 mg, two tablets q. day. 4. docusate sodium 100 mg p.o. b.i.d. 5. senna one tablet b.i.d. 6. enalapril 10 mg two tablets p.o. q. a.m. 7. gabapentin 100 mg p.o. b.i.d. 8. metoprolol 50 mg tablet, 0.25 tablet p.o. b.i.d. 9. simvastatin 10 mg p.o. q. day. 10. lactulose 10 g packet, sig, three packets p.o. p.r.n. as needed for constipation. 11. fleet enema, sig, 130 ml p.r., prn as needed for constipation. 12. glucophage 200 mg p.o. q. a.m., 100 mg p.o. q. p.m. 13. glyburide 1.25 mg tablet, half a tablet p.o. once a day. discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (). 2. atorvastatin calcium 40 mg tablet sig: one (1) tablet po qd (). 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for fever. 5. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 9. psyllium 58.6 % packet sig: one (1) packet po tid (3 times a day) as needed. 10. amlodipine besylate 5 mg tablet sig: two (2) tablet po daily (daily). 11. lisinopril 20 mg tablet sig: three (3) tablet po daily (daily). 12. metformin hcl 500 mg tablet sig: two (2) tablet po bid (2 times a day). 13. glyburide 5 mg tablet sig: 1.5 tablets po daily (daily). 14. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 15. vancomycin hcl 1000 mg iv q24h 16. insulin glargine 100 unit/ml solution sig: 10 units subcutaneous at bedtime. 17. insulin reg (human) buffered 100 unit/ml solution sig: sliding scale injection four times a day: please do qid sliding scale, covering with regular insulin: bs 150-200, 2 units, 201-250, 4 units, 251-300, 6 units, 301-350, 8 units, 351-400, 10 units. 18. lasix 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: for the aged - discharge diagnosis: non-st elevation mi, pneumonia, respiratory distress discharge condition: stable discharge instructions: 1. please take all your medications as prescribed 2. follow up with dr. ; this appointment should be made through rehab/when the course of your rehab is determined. you should follow up 1-2 weeks after discharge from rehab 3. finish 10 day course of vancomycin; continue until 4. patient is prescribed lasix 40 mg qd. her i/o's should be followed closely to avoid volume overload. her volume status should be maintained as negative until she follows up with her pcp. pulmonary exam to ensure that she is not developing increased pulmonary edema/crackles on exam. followup instructions: follow up with dr. 1-2 weeks after you are discharged from rehab () md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube transfusion of packed cells diagnoses: subendocardial infarction, initial episode of care pure hypercholesterolemia congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute respiratory failure pneumonitis due to inhalation of food or vomitus methicillin susceptible pneumonia due to staphylococcus aureus acute diastolic heart failure 

Answer: The patient is high likely exposed to