Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: no known allergies / adverse drug reactions attending: chief complaint: leg swelling, sob major surgical or invasive procedure: temporary dialysis catheter placement tunneled dialysis catheter placement history of present illness: hmed attending admission note . admit date: admit time: 0200 . pcp: . . 72 yo f with ckd stage 5 peri-rrt, copd, dm ii with complications and hypertension who presents to the ed complaining of lower extremity edema nad shortness of breath. . patient is a poor historian. reports increased fatigue and lethargy x several days. also with new dyspnea on exertion, lower extremity edema and orthopnea. mild dry cough. no chest pain or fevers. reports increased salt intake. . patient was initially seen at , bp was 206/102 - given 1 inch of ntp, 20 iv labetalol and 40 lasix with improvement in symptoms. bilateral leni's were negative. patient transferred to for further evaluation. . ed: 97.0 76p 197/106 20 98%4lnc; wheeze on exam thought to be consistent with copd exacerbation - given albuterol neb, ipratropium neb, methylprednisolone 125 iv and azithromycin 500mg. . ros as per hpi, 10 pt ros otherwise negative past medical history: 1) type ii dm: neuropathy, nephropathy 2) atypical cp x 16 years: evaluated in in with a stress test and cardiac catheterization, which the patient reports were normal 3) hypertension 4) emphysema 5) s/p discectomy 6) s/p bunionectomy and hammer toe repair 7) s/p hysterectomy and removal of one ovary/fallopian tube 8) ckd (cr. 2.9 in per ed) 9) myasthenia - diagnosed 1 year ago, on pyridostigimine - sees neurologist dr. 10) diverticulosis social history: retired police dept detective. lives with husband and two grandchildren. smokes 1 ppd x 50 years. no etoh or illicits. family history: mother's sisters with myeloma and leukemia physical exam: admission exam vs: 97.4 157/88 18 93p 98%4l nc -> 87% on ra appearance: drowsy but arousable, aaox3 eyes: eomi, perrl, anicteric ent: op clear s lesions, mmd, neck supple, difficult to assess jvd cv: +s1, s2 -m/r/g, 2+ peripheral edema, 1+ dp/pt bilaterally, left ue avf with palpable thrill pulm: diminished at bases, scattered wheeze abd: soft, obese, nt, nd, +bs msk: 5/5 strength throughout neuro: cn 2-12 grossly intact, no focal deficits skin: no rashes psych: appropriate, pleasant heme: no cervical . discharge exam vs - 98.3 154/62 (145/66-196/97) 56 (56-72) 18 97% ra general - african american female comfortable in nad lungs - decreased breath sounds at bases bilaterally. respirations unlabored, no accessory muscle use heart - rrr, nl s1-s2, 2/6 systolic murmur abdomen - nabs, soft. nt/nd. abdominal hernia noted. no rebound or guarding extremities - wwp, 1+ pitting edema bilaterally, 2+ dp pulses skin - no rashes or lesions; right chest with tunneled line in place -no surrounding erythma neuro - awake and interactive, a&ox3. pertinent results: admission labs: 10:29pm lactate-0.7 10:20pm glucose-168* urea n-48* creat-5.6* sodium-145 potassium-3.8 chloride-117* total co2-14* anion gap-18 10:20pm estgfr-using this 10:20pm ctropnt-0.18* 10:20pm probnp-greater th 10:20pm wbc-4.7 rbc-2.65*# hgb-7.1*# hct-24.4*# mcv-92 mch-26.9* mchc-29.2* rdw-17.4* 10:20pm neuts-75.3* lymphs-16.2* monos-5.0 eos-3.0 basos-0.4 10:20pm plt count-355 10:20pm pt-11.8 ptt-28.1 inr(pt)-1.1 . discharge labs: 08:20am blood wbc-5.0 rbc-3.10* hgb-8.6* hct-27.9* mcv-90 mch-27.8 mchc-30.8* rdw-17.0* plt ct-322 08:20am blood glucose-109* urean-18 creat-3.5* na-140 k-3.2* cl-104 hco3-29 angap-10 08:20am blood calcium-7.7* phos-3.1 mg-1.8 . micro: blood cultures x 2 - no growth cdif - negative . ekg: nsr 81, twi v4-v6, i, ii - unchanged from prior ecg . pa/lat cxr: increased cardiomegaly with mild engorgement of pulmonary vessels and basilar atelectasis and trace pleural effusion. findings may represent early failure. tte (complete) done at 4:18:14 pm final the left atrium is mildly dilated. the estimated right atrial pressure is 5-10 mmhg. there is moderate symmetric left ventricular hypertrophy. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve appears structurally normal with trivial mitral regurgitation. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: trivial pericardial effusion. moderate symmetric left ventricular hypertrophy with preserved regional and global systolic function. mild right ventricular dilatation and global hypokinesis. large pleural effusion. compared with the prior study dated (images reviewed), pulmonary pressures are higher. right ventricular systolic dysfunction is new. a large pleural effusion is now noted. . cxr severe cardiomegaly is stable. worsening left lower lobe consolidation is worrisome for progression of pneumonia. left mid lung plate-like atelectasis is unchanged. there is no pneumothorax. if any, there is a small left pleural effusion. there is no evidence of pulmonary edema. . ir procedure impression: successful conversion of temporary to tunneled hemodialysis catheter through the right internal jugular vein approach. the tip is located in the right atrium and the catheter is ready for use. brief hospital course: 72 yo f with ckd stage 5 peri-rrt, copd, dm ii with complications and hypertension who was admitted with hypertensive emergency, volume overload, hypoxemia, demand ischemia and worsening uremia. . # demand ischemia/nstemi: patient intially presented with hypertensive urgency and was found to have an elevated troponin with flat mb likely elevated in the setting of ckd and possible demand ischemia. however despite improvement of blood pressures, she subsequently experienced chest pain that was not responsive to antacids but improved with nitroglycerin. patient found to have elevated troponin and ck-mb without ecg changes. given concern for acs, she was evaluated by cardiology and it was felt that elevated biomarkers were most likely to poor bp control and volume overload. patient was treated for 48 hours with a heparin gtt. troponins continue to be elevated but ckmb downtrended and patient remained chest pain free. she was medically managed with asa, statin, bblocker, imdur and improved blood pressure control. she was discharged with plans to establish care with a cardiologist. . # ckd stage v: patient presented with symptoms of volume overload and lethargy likely to worsening renal function. patient had l. fistula placed but not yet mature. renal team was consulted in the icu and agreed dialysis likely necessary, but did not see urgent need for dialysis as medication non-compliance large component to volume overload, pleural effusions, and hypertensive urgency. however, patient continued to be somnolent and the decision was made to place a tunneled line and start dialysis. patient underwent 3 sessions of dialysis and somnolence and volume status improved. she was continued on bumex 2 mg daily given that she still makes some urine. she was also continued on calcium carbonate, sevelemer and nephrocaps. she was set up at an outpatient dialysis center and has plans for mwf dialysis. . #hypertensive emergency: patient has history of medication noncompliance prior to presentation. patient presented with with +troponin and pulmonary edema, bp 200/106 upon arrival to with likely flash pulmonary edema that responded to lasix/nitro/labetalol; all in the setting of near-end stage renal disease and dietary indiscretions. antihypertensive regimen was adjusted and volume was removed during dialysis. blood pressures improved to the 140s-160s. at time of discharge her antihypertensive regimen included labetalol 600 mg tid, amlodipin 10 mg daily, lisinopril 2.5 mg daily, imdur 60 mg daily. . # toxic metabolic encephalopathy uremia - patient was noted to be very lethargic and somnolent on presentation. she was initially transferred from and admitted to the hospitalist service. however, given increasing somnolence she was transferred to the . myasthenia crisis was considered, and patient was evaluated by neurology. neurology felt that myasthenia crisis was unlikely the cause of her symptoms. abg did not show evidence of hypercarbia. she was then transferred to the medicine service. she underwent 3 sessions of dialysis and mental status improved making uremia most likely cause of somnolence. undiagnosed osa may also be contributing to daytime lethargy, and patient was noted to have witnessed hypoxia overnight. patient was discharged with plans to continue dialysis and to undergo an outpatient sleep study evaluation. . #hypoxemia: when patient was transferred from to , there was initial concern that patient was having a copd exacerbation. in the ed, she was treated with steroids and antibiotics. however this was discontinued when patient reached the floor. while in the icu, patient briefly was on 3-4l oxygen due to pulmonary edema/ volume overload/ pleural effusions. there was low suspicion for copd exacerbation as patient not bronchospastic on exam. during icu stay, patient was weaned onto room air. she was given bumex, up to 4mg during the course of the day to increase urine producrtion with little effect. patient eventually underwent dialysis and some volume was removed on session 2 and 3. patient continued to remain stable on room air through the remainder of her admission. . # diarrhea - chronic x1 year. unclear etiology. diarrhea unlikely infectious given duration of symptoms, and absence of leukocytosis and fevers. cdif negative. patient was treated with immodium prn with symptomatic relief. . # myasthenia - continued pyridostigmine . # diabetes - continued lantus at reduced dose due to renal function and insulin sliding scale. . # anemia - likely to worsening renal function and missed aranesp dose. there may also be component that is dilutional to volume overload. guiac negative in the ed. pt now s/p 1 unit prbc in . hct continued to remain stable through duration of hospital course. . # copd - contined albuterol and ipratropium nebs . # depression - venlafaxine was held given renal function . # hld - continue simvastatin, but had to reduce dose with the addition of amlodipine. . # gerd - continued ppi . transitional issues: - no labs pending at time of discharge - patient will need outpatient sleep study evaluation - patient will need further outpatient workup of chronic diarrhea - patient's dose of simvastatin was reduced given the addition of amlodipine. lipids should be followed and an alternative statin should be considered. - patient's venlafaxine was discontinued given renal function. this should be addressed at follow up - patient was full code on this admission - hcp: (husband) medications on admission: meds per omr - patient does not recall her medications albuterol prn bumetanide 2mg qam, 1mg qpm calcitriol 0.25mcg qmwf aranesp diltiazem 360mg daily folic acid 1mg daily hydralazine 50mg lantus 14 units qam isosorbide mononitrate 120mg daily labetalol 400mg reglan 10mg q8h prn modafinil 200mg oxybutynin 5mg daily protonix 40mg daily pyridostigmine 30mg renvela 800mg tid simvastatin 40mg daily terazosin 10mg daily venlafaxine 37.5mg asa 325mg daily discharge medications: 1. simvastatin 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. pyridostigmine bromide 60 mg tablet sig: 0.5 tablet po bid (2 times a day). 4. folic acid 1 mg tablet sig: one (1) tablet po once a day. 5. isosorbide mononitrate 60 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). disp:*30 tablet extended release 24 hr(s)* refills:*2* 6. tylenol 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 7. modafinil 100 mg tablet sig: two (2) tablet po bid (2 times a day). 8. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 10. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). disp:*30 tablet, chewable(s)* refills:*2* 11. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). disp:*180 tablet(s)* refills:*2* 12. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 13. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 14. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest discomfort: take 1st tablet at onset of chest pain. if pain persists longer than 5 minutes take a 2nd pill. if pain persists longer than 10 minute take a 3rd pill and call 911. disp:*30 tablet, sublingual(s)* refills:*0* 15. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 16. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 17. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea. disp:*30 capsule(s)* refills:*0* 18. labetalol 200 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*270 tablet(s)* refills:*2* 19. amlodipine 10 mg tablet sig: one (1) tablet po at bedtime. disp:*30 tablet(s)* refills:*2* 20. bumetanide 2 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 21. insulin glargine 100 unit/ml solution sig: six (6) units subcutaneous once a day for 1 months. disp:*qs units* refills:*2* 22. insulin aspart 100 unit/ml solution sig: as directed units subcutaneous four times a day: please take as directed by sliding scale before meals and before bed. 23. wheel chair standard wheelchair for community distances discharge disposition: home with service facility: vna discharge diagnosis: stage v chronic kidney disease, diastolic heart failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure caring for you while you were admitted to . you were admitted because you were lethargic, short of breath and had lower extremity swelling. you also had very high blood pressures. you were evaluated by the kidney doctors and eventually it was decided that you would benefit from starting dialysis. you tolerated three dialysis sessions well during your hospitalization. your blood pressure medications were altered and your blood pressures improved prior to discharge. . during your hospitalization, you experienced some chest pain and your heart enzymes were elevated in your blood concerning for heart damage. you were evaluated by the cardiologists and it was determined that you would benefit from medical management rather than intervention at this time. you were scheduled to establish care with a cardiologist after discharge for regular follow up. . you were noted to be very tired during the day. it is important that you schedule a sleep study to investigate if you have a oondition called sleep apnea that may be causing you to feel this way. . the following changes have been made to your medication regimen please start taking - lisinopril 2.5 mg daily - amlodipine 10 mg at bed time . please stop taking - clonidine - terazosin - metoclopramide - oxybutynin - diltiazem - venlafaxine . please change - simvastatin to 20 mg daily - labetalol to 600 mg three times daily - bumex to 2 mg daily - imdur to 60 mg daily - lantus to 6 units in the morning followup instructions: location: kidney center address: medical office bld m107, , phone: **your dialysis schedule is monday,wednesday, friday at 11:30am** specialty: pulmonary and critical care & sleep medicine location: medical center address: , phone: **please contact the pulmonary department to schedule a sleep study within 1 week of your discharge from the hospital.** name: brown, : internal medicine address: , , phone: appointment: tuesday at 1:45pm department: div. of gastroenterology when: tuesday at 2:30 pm with: , md building: ra (/ complex) campus: east best parking: main garage name: , specialty: cardiology address: , , phone: appointment: tuesday at 11:20am procedure: hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis diagnoses: anemia in chronic kidney disease hypocalcemia end stage renal disease nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere subendocardial infarction, initial episode of care esophageal reflux unspecified pleural effusion congestive heart failure, unspecified toxic encephalopathy chronic airway obstruction, not elsewhere classified acute on chronic diastolic heart failure diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes depressive disorder, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia long-term (current) use of insulin personal history of noncompliance with medical treatment, presenting hazards to health diarrhea pulmonary congestion and hypostasis diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled diverticulosis of colon (without mention of hemorrhage) other alteration of consciousness mixed acid-base balance disorder myasthenia gravis without (acute) exacerbation other fluid overload 

Answer: The patient is high likely exposed to