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: sotalol / lidocaine attending: chief complaint: shortness of breath, bilateral arm pain and palpitations major surgical or invasive procedure: peripheral arterial catheterization left brachial artery exploration and thrombus removal left lung thoracentesis history of present illness: patient is a 75 year old female who presented to an outside hospital on with complaints of feeling her heart racing and pain running down both arms for about 1-2 hours prior to admission. she had associated nausea and vomiting at that time, and mild shortness of breath. she denied any chest pain, fevers, chills, back pain, abdominal pain, or diaphoresis. her son had called 911 and en route to the hospital, she was given sublingual nitroglycerine x1 with good effect. upon arrival to the emergency room she was found to be in atrial fibbrilation with rapid ventricular response to 153bpm. ekg was reported to have no st segment elevations, but was notable for st segment changes consistant with digitalis in the inferior leads. patient's chest x-ray showed increased vascular markings consistant with congestive heart failure. she was given 325mg of asa and dosed with cardizem drip. total ck was normal at 25, troponin i of 0.1, bnp of 647. she was started on a heparin drip and admitted. during her admission, she developed some st elevation which was thought to be related to demand ischemia. her heart rate was well controlled on the cardizem drip and she was loaded with digoxin. on she developed a white count of 22.5k and worsening renal function (creat 0.8->2.1), and steadly increasing tropoins (0.1 -> 1.75 -> 2.37 -> 2.53). urinalysis showed brown granular casts with + blood, 10-25 wbcs and 2+ bacteria for which she was given one dose of levoquin 500mg on day of transfer. echocardiogram showed an ef of 20% with all segments being akinetic except the base and inferior-lateral wall. she had a normal echo on . on day prior to admission at , patient was developing worsening renal failure, increasing o2 requirement, and impression was for cardiogenic shock. she was started on dopamine and transfered to for further management of her condition on . . on review of symptoms, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she 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, syncope or presyncope. past medical history: 1. afib with rapid ventricular response in - on digoxin, coumadin, lopressor 2. copd 3. gerd s/p esophegeal dilitation in 4. alcoholic hepatitis 5. ? of mi 2 years ago social history: patient is a widowed female who lives with her son . she is capiable of performing her adl at home. social history is significant for the absence of current tobacco use (quit 10 years ago). she drinks 8-10 beers per day. family history: her father had a history of heart disease that started in his 60s of unknown eitology. her mother had cad in her 70s and survived until her 90s. physical exam: vs: t 95.8, bp 92/38 , hr 94 , rr 21 , o2 94 % on nrb gen: elderly female in nad, oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp of cm. cv: rr, normal s1, s2. no s4, no s3. chest: no chest wall deformities, scoliosis or kyphosis. resp were labored using accessory muscles. wheezes anteriorly, crackles at bases. abd: obese, soft, ntnd, no hsm or tenderness. no abdominial bruits. ext: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ without bruit; femoral 2+ without bruit; 1+ dp left: carotid 2+ without bruit; femoral 2+ without bruit; 1+ dp pertinent results: echo : 1. severely depressed left ventricular systolic function consistent with takotsubo type of cardiomyopathy with severe hypokinesis/akinesis of the mid to apical left ventricle. elevated filling pressures. 2. apical thrombus maybe present. 3. apical to mid severe hypokinesis/akinesis of the rv. 4. small to moderate anterior echodense pericardial effusion. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. 5. mild to moderate mr. 6. moderate tr. 7. moderate elevations of estimated pulmonary artery systolic pressure. echo : the right atrial pressure is indeterminate. left ventricular wall thicknesses and cavity size are normal. there is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal half of the inferior wall, septum and anterior wall. the apex is mildly aneurysmal and akinetic. the basal segments contract best (lvef = 25 %). no masses or thrombi are seen in the left ventricle. the right ventricular cavity is mildly dilated. there is focal akinesis of the apical half of the free wall. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. 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. compared with the prior study (images reviewed) of , the severity of mitral and tricuspid regurgitation are now reduced. biventricular systolic function is similar. these findings are most c/w coronary artery disease (mid-lad infarction). the previously noted pericardial effusion is likely epicardial fat. no intraventricular thrombus is seen on review of the prior study. echo : the left atrium is normal in size. the right atrial pressure is indeterminate. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%) due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is dilated. right ventricular systolic function is borderline normal. there are three aortic valve leaflets. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is moderate thickening of the mitral valve chordae. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is moderate to severe pulmonary artery systolic hypertension. there is an echo dense mass adherent to the apical visceral pericardium that may represent hematoma (was not apparent in the prior study). there is a small pericardial effusion. the pericardium may be thickened. there are no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. compared with the prior study (images reviewed) of , left ventricular systolic function appears markedly improved (consistent with possible stress induced (takotsubo) cardiomyopathy). tricuspid regurgitation is now more prominent. estimated pulmonary artery systolic pressure is now much higher (raising concern for a possible intercurrent process such as pulmonary embolus). cta : 1. no evidence of pulmonary embolism. 2. large bilateral pleural effusions with associated bibasilar atelectasis. 3. -apical scarring. 4. 5-mm right lung nodule which may be inflammatory or infectious. attention should be paid to this area on follow-up exams. lower extremity venous doppler: bilateral- no dvt pleural fluid (left lung)- transudative. cytology pending upon discharge, please follow up in weeks post discharge. ct head : no evidence of hemorrhage or major vascular territorial infarction. ct c-spine : limited study due to patient motion. no large fracture is identified. no definite dislocation is present. multilevel degenerative changes particularly at the c4/c5, c5/c6 and c6/c7 levels. mild anterolisthesis of c4 over c5. if there is high clinical suspicion for cervical spine fracture consider a repeat cervical spine ct scan. hip x ray: no acute fractures or dislocations. ekg: atrial fibrillation with mean ventricular rate 111. low qrs voltage in the limb leads. diffuse non-diagnostic repolarization abnormalities. compared to previous tracing of multiple abnormalities persist without major change. : atrial fibrillation, mean ventricular rate 95. low qrs voltage in the limb leads. diffuse non-diagnostic repolarization abnormalities. compared to previous tracing of multiple abnormalities persist without major change. peripheral arterial cath: 1. successful ptca of the 100% occluded left cfa, sfa and profunda femoral artery vir 4 french left brachial approach with a 4.0x40mm baloon with restoration of good flow in the left cfa, profunda and sfa with slow flow to the shin. pt pulse at the end of the case. 2. left brachial artery thrombosis despite act 250 at sheath pull with loss of left radial pulse; patient going to or now for left brachail exploration and thrombus removal. cardiac cath: 1. selective coronary angiography of this right dominant system revealed no angiographically apparent significant coronary artery disease. the lmca had no angiographically apparent significant stenoses. the lad had a proximal 30% lesion. the lcx and rca were without angiographically apparent flow-limiting stenoses. 2. limited resting hemodynamics revealed mild systemic arterial hypotension of 85/43 mm hg. left sided filling pressures were mildly elevated with lvedp of 20 mm hg. there was no transvalvular gradient upon pullback of the catheter from lv to aorta. 3. left ventriculography was deferred. 4. arterial access was difficult to obtain on bilateral femoral arteries, even after multiple attempts under ultrasound and doppler guidance. arterial flow was obtained in the left femoral artery on multiple occassions with good arterial flow, but a wire could not successfully be passed into the iliac arteries. access was finally obtained on the left via the femoral artery. 5. distal aortagram revealed diffuse atherosclerotic disease of bilateral aortoiliac systems, with complete occlusion of the right iliac artery. distal vessels filled via collaterals. renal ultrasound: 1. no evidence of renal calculi or hydronephrosis bilaterally. 2. hyperechoic interpolar lateral right renal lesion with vascular flow within it. ultrasound characteristics may be suggestive of a benign angiomyolipoma, however, a neoplasm cannot be excluded given internal vascularity. further evaluation with dedicated mr examination is recommended if patient can tolerate. otherwise, non-contrast and contrast-enhanced ct examination can be considered. 3. moderate left pleural effusion. chest ct 1. collapse of the left lung with a very large pleural effusion. large right pleural effusion with partial collapse of the right lower lobe. collapsed left main stem bronchus with tracheal and bronchial secretions. 2. 1 cm right lower lobe pulmonary artery aneurysm seen on the study is not well evaluated on this study. 3. multiple low-density lesions in the spleen, likely cysts from remote trauma or infarct. brief hospital course: overall summary of course of illness 78 year old woman with history of cad, afib, smoking, alcoholism, gerd w/esophageal strictures, osteoporosis s/p hip fracture (), poor nutritional intake, presents as transfer from ccu after prolonged hospitalization at hospital and for chest pain that included cardiac catherization (complicated by brachial artery thrombosis), heart failure, remeron-induced delirium, iatrogenic renal failure, and finding of an incidental mass of kidney. . the patient was in the midst of a 1-month long program supervised by her primary care doctor to improve her nutritional intake when, one morning in early she developed nausea and pain up and down her arms. her son called an ambulance and the patient received nitroglycerin in transit with some relief of her symptoms. upon admission to the osh, patient was in afib with rvr and reported st changes concerning for digitalis toxicity. she was started on aspirin, diltiazem drip, and heparin drip. she developed st elevations thought secondary to demand ischemia. her hr improved with diltiazem drip and she was loaded with digoxin. she was felt to be in heart failure with and was aggressively diuresed with furosemide. . shortly after admission to osh, her wbc increased to 22, creatinine increased from .8 to 2.1, and troponins increased from .1 to 2.53. the patient was admitted to the icu for her renal failure. ua demonstrated 10-25 wbcs with 2+ bacteria and she was started on levofloxacin. additionally, an echo demonstrated ef 20%, akinesis except base and inferior-lateral wall. she also became hypotensive and was started on dopamine. during the course of her stay, she pulled out her nasogastric tube and ivs, possibly representing alcohol withdrawal. . per the patient's son's request, she was trasnferred via med flight to the on for further management. she was transferred to the ccu team for further management of her chf and likely cardiogenic shock. her initial echo demonstrated a takotsubo cardiomyopathy. subsequent echos have demonstrated improvement in ef. she also underwent catheterization which demonstrated clean coronaries. she was transitioned from dopamine to dobutamine with the addition of a lasix gtt. she had a moderate diuresis with improvement in both her blood pressures and her creatinine. she has had occasional episodes of hypotension with low urine output for unclear reasons. differential includes persistent chf and poor po intake. regarding her atrial fibrillation, she was started initially on diltiazem gtt and was transitioned to oral metoprolol. her vital signs have remained stable. as a complication of the catheterization, she developed a femoral thombus. she underwent emergent thrombectomy and as a complication developed brachial thrombus as well. she underwent a thrombectomy for the brachial thrombus. following surgical thrombectomy, the patient complained of pain her abdomen and was found to incidentally have a growth on her kidney on renal ultrasound. . while the abdominal pain resolved, the patient was felt to have a depressed appetite and was started on a trial of the antibiotic remeron. the single dose of remeron pushed the patient into a "demented state" and the patient has gradually improved back to baseline after withdrawal of the remeron. the patient's hospitalization was further complicated by a fall for which she had head imaging that was not concerning for an acute bleed. . over the past week, the patient and family underwent consultation with palliative care physicians because of her overall failure to thrive and the patient was awaiting placement to a rehabiliation facility when she develoepd an elevated white count (13). a chest x-ray showed a question of a consolidation and she was started on treatment for a presumed hospital acquired pneumonia. the patient was transferred from the ccu team to the medicine service for continuing management. other issues during admission -apical thrombus her echo on admission demonstrated a possible apical thrombus and she was maintained on anticoagulation for this (in addition to her atrial fibrillation) - e.coli uti and possible pyelo - she was started levofloxacin on for an e.coli uti and then transitioned to cipro. the patient developed abdominal pain and an elevated wbc on raising the concern for pyelonephritis; however her pain and leukocytosis improved. she received 10 day course of levo/cipro () - nutrition assessment - patient has been followed closely with nutrition and geriatrics regarding her decreased po intake. initial nutrition assessment on recommended ngt with tube feeds, supplements, and a bedside speech and swallow on demonstrated no aspiration but concerns of stricture causing her poor intake. she received a short course of tpn () for poor po intake but after she pulled her ngt. this was discontinued and patient has been on a po diet. - acute renal failure - patient was admitted with elevated creatinine. her creatinine improved steadily with diuresis, making pre-renal renal failure secondary to poor forward flow most likely. - etoh - patient's malnutrition and many of her medical problems are thought most likely secondary to her alcoholism. she is pre-contemplative about abstaining from alcohol and states repeatedly that she wants beer or to go to the bar. - s/p fall and hypotension - on , she triggered after she fell and also for hypotension with sbp in the 80s. an echo that day demonstrated elevated pa pressure concerning for pe. differential for her fall and hypotension were concerning for pe, decreased po, and infection. cta chest was negative for pe. - thoracentesis on - patient has been noted to have persistent bilateral pleural effusions and she underwent a thoracentesis on without complication. - altered mental status - on the day of transfer to medicine (), patient developed hypoxia requiring 2l nasal canula and leukocytosis to 15, raising concern for hospital-acquired pneumonia. she was started on vanco/zosyn for treatment of presumed hospital acquired pneumonia. ============================== system specific review ============================== cardiac: she was seen and evaluated by the ccu team upon arrival. she was on dopamine drip on arrival with systolic pressures in the mid 90s and heart rate in the 70s. she was saturating 95% on 100% o2 nrb. a swan-ganz catheter was placed and showed a wedge of 32 and a pa systolic in the low 50s. cardiac index was below 2.0 initially. she was switched to dobutamine and initial index was 2.04 and a svr of 1300. index rose to 2.9 and a svr in the 800s on 4mcg of dobutamine. echocardiography showed a decresed ejection fraction (30%) with distal akinesis of lv and rv. also noted a mural thrombus. she was previously on anticoagulation via heparin drip for her atrial fibbrilation and that was continued. patient was transferred to the floor for management with plan for cardiac cath. cath was deferred initially due to increasing wbc count and flank pain concerning for possible pyelonephritis. ua c/w persistent uti although not overly suggestive of pyelonephritis. renal usd was obtained that showed no evidence of perinephric abscess, stones or hydronephrosis. patient remained afebrile, and cardiac cath was performed on demonstrating peripheral arterial disease without significant coronary disesase, she developed a brachial artery thrombus post procedure and required surgical exploration and successful removal of thrombus from the brachial artery. her initial two echocardiograms revealed a depressed lvef and a takatsubo pattern to her contractility, this resolved, also consitent with this entity. unclear as to whether this was associated to her etoh use. she developed pleural effusions which were large (especially on the left) during her stay and responded slowly to diuresis, she had a left thoracentesis and subsequently was sating 100% on room air, though this rapidly reaccumulated secondary to her low albumen and poor nutritional status. she underwent a second thoracentesis with again good improvement in her respiratory status. in consultation with the pulmonary team, her pleural effusions were thought to be worsened by recurrent mucous plugging causing left lung collapse. treatment with mucomyst, albuterol, and chest pt greatly improved her lung aeration. cxr prior to discharge showed persistent bilateral effusions. her chronic atrial fibrillation was rate controlled with metoprolol throughout her course. she had one episode of afib with rvr 2d prior to discharge which was quickly rate controlled with the administration of 10mg of iv diltiazem. she was started on po diltiazem with improved rate control and maintained this for the next 48hrs. it was thought that this episode may have been secondary to either albuterol nebulizer treatments or the recently started ritalin dosing. given her lack of response in terms of appetite (although she was more alert and awake), it would be advisable to stop this medication should she experience another episode of rapid ventricular respose to her atrial fibrillation. . gu/renal: patient initially with uti (e-coli which was pan-sensitive), treated with levofloxacin, treatment complete, follow up urine cultures neagtive. creatinine increased to 2.3 upon admission, likely atn, cardiogenic shock possibly post cath and contrast nephropathy in the setting of heart failure, with improvement of heart failure her renal function improved. responded well to diuretics. renal usd demonstrated a probable angiomyolipoma and radiology recommneded rec'd ct abdomen or mri for further evaluation, she should have this as a follow up as an outpatient in the future. her cr was normal on d/c. . gi: patient with poor po intake (200 cal/day), and dysphagia, she states she doesn't eat because she has a poor appetite, not because of the dysphagia or because of dyspepsia or any other reason. during hospitalization it was learned patient has history of esophageal dilation in past (x2). plan for outpatient evaluation. as far as her diet, she was repeatedely encouraged to eat and with some encouragement she does make small steps and take in some po and some ensure, her family members were helpful in this regard. at home she takes in most of her calories from beer but here without beer she is not taking in much po at all. she wishes to go home and continue drinking despite encouragement of etoh cessation from multiple physicians. no signs of etoh withdrawal during admission. both she and her family refused any more definitive treatment such as peg or ngt for increased nutritional repletion. she was given tpn for approximately one week, however, began to exhibit signs of volume overload, therefore this was discontinued. additionally, a family meeting was held on attended by family, ccu team and palliative care. at that time, a decision was made to attempt a trial of po for 10 days to determine if patient can replete her own nutrition. patient also had a trial of methylphenidate with minimal improvement in oral intake (but increased wakefulness and interaction with family and staff). although her po intake continues to be poor, her family believes that her po intake might improve if she had additional physical therapy. she was evaluated by pt and ot who thought she was an adequate rehab candidate. she is recommended to go to rehab and follow her po intake there. if her po intake continues to be poor, she and her family will again need to consider the role for hospice. . mental status: the patient had a waxing and mental status for the majority of her stay, she would become delerious (disoriented and somnolent) without any clear cause, toxic / metabolic causes were ruled out and appropriate head imaging was performed with no yield. one episode may have been attributed to remeron use and this should be avoided in the future. the patient was back to her baseline aox3 with mild dementia upon discharge. if she is able to abstain from alcohol for several months at home, the geriatrics service reccommended cognitive/memory evaluation as an outpatient at a later date. . infectious disease: prior to transfer to the medicine service, the patient developed an increasing productive cough with a leukocytosis. given her hospital stay, her cxr appearing and her clinical status, she will be treated for hospital acquired pneumonia with vancomycin and zosyn for a 7 day course. she completed this course on and was afebrile for several days prior to discharge. medications on admission: 1. asa 81mg po daily 2. lopressor 25mg po bid 3. digoxin 0.125mg po daily 4. thiamine 100mg po daily 5. folate 1mg po daily 6. mvi 1 tab po daily 7. protonix 40mg po daily 8. combivent 2 puffs qid 9. warfarin 5mg po 4xweek 10. advair 250/50 1 puff 11. levaquin 500mg po x1 12. ntg sl x3 prn 13. solumedrol 80mg iv q8 14. cardizem iv @ 10mg/hr discharge medications: 1. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 2. folic acid 1 mg tablet : one (1) tablet po daily (daily). 3. acetaminophen 325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed. 4. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 5. aspirin 325 mg tablet : one (1) tablet po daily (daily). 6. atorvastatin 20 mg tablet : one (1) tablet po daily (daily). 7. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension : 15-30 mls po qid (4 times a day) as needed. 8. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours). 9. metoprolol tartrate 25 mg tablet : one (1) tablet po tid (3 times a day). 10. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 11. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po daily (daily). 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 13. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 14. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup : five (5) ml po q6h (every 6 hours) as needed. 15. furosemide 40 mg tablet : one (1) tablet po daily (daily). 16. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) inhalation q2h (every 2 hours) as needed. 17. methylphenidate 5 mg tablet : one (1) tablet po bid (2 times a day). 18. acetylcysteine 20 % (200 mg/ml) solution : five (5) ml miscellaneous q6h (every 6 hours): please mix with albuterol. 19. warfarin 2.5 mg tablet : one (1) tablet po at bedtime. 20. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) neb inhalation q6h (every 6 hours). 21. diltiazem hcl 30 mg tablet : one (1) tablet po qid (4 times a day). discharge disposition: extended care facility: country home and nursing discharge diagnosis: primary diagnosis: acute on chronic systolic congestive heart failure atrial fibrillation delerium malnutrition . secondary diangosis: etoh abuse discharge condition: stable, working with physical therapy and breathing room air discharge instructions: you were admitted to the hospital with a low blood pressure and decreased functioning of your heart. you underwent a peripheral arterial catherization and other multiple diagnostic procedures and were initially found to have a decreased pumping function of your heart which eventually improved. during your stay you had times during which you became somnolent and difficult to arouse, you underwent a very thorough workup that did not yield any positive results. you had also were shown to have fluid around your lung. this fluid was removed with a needle. it is felt that your medical problems are stable enough for you to go to a rehab facility. . please call your doctor or go to the emergency room if you have any chest pain, lightheadedness, shortness of breath, confusion or any other symptoms that worry you. . you should take your medications as prescribed and avoid alcohol use as this likely played a role in your malnutrition as well as your initial depressed cardiac function. . please follow the instructions of the physicians and other medical staff at the rehab facility followup instructions: please follow up with your primary care physician . within 10 days of your discharge from the hospital. the phone number for dr. office is please follow up with your cardiologist within 4 weeks of your discharge from the hospital. procedure: venous catheterization, not elsewhere classified coronary arteriography using two catheters parenteral infusion of concentrated nutritional substances left heart cardiac catheterization enteral infusion of concentrated nutritional substances angioplasty of other non-coronary vessel(s) thoracentesis incision of vessel, upper limb vessels repair of blood vessel with tissue patch graft destruction of cranial and peripheral nerves procedure on three vessels diagnoses: pneumonia, organism unspecified urinary tract infection, site not specified congestive heart failure, unspecified unspecified protein-calorie malnutrition chronic airway obstruction, not elsewhere classified atrial fibrillation alkalosis cardiogenic shock acute on chronic systolic heart failure arterial embolism and thrombosis of upper extremity vascular complications of other vessels 

Answer: The patient is high likely exposed to