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: phenergan attending: chief complaint: chronic systolic diastolic heart failure major surgical or invasive procedure: hemodialysis placement of hemodialysis line placement of arterial line history of present illness: this is a 74 year old lady with a pmh of afib, chronic venostasis, cad, schf, htn, dm2 and dyslipidemia who was admitted to an osh on w/ afib w/ rvr and pleural effusion now transferred here for managment of acute decompensation of systolic and diastolic heart failure. . her initial complaint included increasing abdominal girth and progressive dyspnea on exertion for the last six months now apparent at rest. she had been evaluated by both her pcp and cardiologist sometime last fall and had been started on metolazone three months ago without improvement in her symptoms. . in the osh ed, she was found to be in atrial fibrillation with rapid ventricular response with heart rates in the 140s associated with nausea. she was given phenergan for management of her nasuea and subsequently had an anakathisic reponse for which she was given cogentin. for her rapid afib she was given one dose of iv diltiazem after which her sbp dropped to the 70s. she was given iv fluids. her vital signs on admission were 98.0 110-140 98/76 12 96% on ra. her initial labs were notable for a sodium of 129, creatiine of 2.0 (baseline 1.1), wbc 9.3 normal diff, hmg 1.6, hct 33.9, inr 2.1 and bnp of 874 with ce significant for ck-mb 4.3 ck 78. a noncontrast ct of her abdomen and pelvis demonstrated diffuse soft tissue edema of the abdominal flanks, moderate right sided pleural effusion and moderate ascites. a chest xray showed a right sided pleural effusion, atelectasis of the right lower lobe and moderate ascites. she was initially admitted to the general floors however was transferred to the ccu for low systolic blood pressures. . in the ccu she had an echo demonstrated an ef of 20%, representing depression since prior known ef of 50% and biventricular failure. a pulmonary artery catheter was placed and demonstrated co 5, sv 50, cvp 26-30, pa diastolic pressure was 25 abd mean pa pressure was 42. she was started on dobutamine and milrinone after which her co increased to 6. she was initially given lasix until low sbps prompted discontinuation. her beta blocker was held and digoxin continued. an ekg demonstated a wide qrs, 140 ms. were significant for rbbb w/ non specific st changes. . her course at the osh was complicated by a cxr significatnt for a right sided pleural effusion and atelectasis of the rll and cardiomegally and new oxygen requirement (4l nc) likely in the setting congestive hear failure. she was empirically started on moxifloxacin for cap. she had acute on chronic renal failure w/ presenting creatinine 2.0 above baseline 1.1, feurea 8.2 consistent w/ pre-renal state. a foley was placed w/ uop 40-60 cc/hr. she was noted to be hyponatremic on admission and was fluid restricted. she had a single generalized tonic clonic seizure which resolved spontaneously. neurology was consulted, and a ct scan of her head was negative and she was loaded w/ keppra and maintained on 500 . an eeg final report was pending at the time of discharge. lastly, chronic venous statis changes were noted on her bilateral lower extremities with concern for overlying cellulitis. she was started on vancomycin. . she was ultimately transferred to for management of severe biventricular heart failure. vitals on arrival were 96.3 104 117/58 23 98% on 4l nc. she complained of dyspnea and hip pain. past medical history: 1. cardiac risk factors: diabetes, dyslipidemia, hypertension 2. cardiac history: - cabg: s/p cabg apparently at in . - percutaneous coronary interventions: s/p pci in early 3. other past medical history: - atrial fibrillation (on coumadin) - chronic venous stasis - coronary artery disease - systolic congestive heart failure: last known ef 50% (unknown date) - hypertension - diabetes mellitus type 2 - dyslipidemia - thyroid mass of unknown etiology several years back. s/p surgery. social history: - tobacco history: no - etoh: no - illicit drugs: currently not working. she lives alone in a condominium on the . she uses a walker to walk. she lives a sedentary lifestyle per her own report, sitting on the couch or on her bed all day. she cooks all her own meals. no children. her next of is a niece who is also the health care proxy. she was full code prior to transfer. family history: non-contributory physical exam: admission physical exam: 96.3 104 117/58 23 98% on 4l nc general: pleasant, talkative, dyspneic w/ discussion, oriented and mood and affect appropriate. heent: ncat. sclera anicteric. eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp to ear. cardiac: irregrr, normal s1, s2. no m/r/g. no s3 or s4. lungs: anterior lung exam and limited by obesity, poor respiratory effort with shallow breathing and use of accessory muscles, crackles and scattered inspiratory and expiratory wheezes. abdomen: soft, nt, obese. pitting edema on flanks. impossible to palpate abdominal aorta. extremities: significant pitting edema to flank 2+. venous stasis changes bilaterally, with 2 1cm weeping skin tears on left anterior shin. erythema noted on right lower leg, not associated with warthm, not clearly delineated, not raised. pulses: right: only able to palpated carotid pulses. dopplerable lower extremity pulses. . discharge: patient expired and was declared dead at 04:05 on with telemetry showing no electrical activity for last 3 minutes. pt lying still and nonresponsive without spontaneous respirations for 2 minutes. on cardiac auscultation no heart beats are heard for 1 minute and no pulse felt on exam. pertinent results: admission labs: wbc-5.5 rbc-4.78 hgb-8.8* hct-28.9* mcv-61* mch-18.4* mchc-30.3* rdw-17.4* plt ct-194 pt-28.6* ptt-52.6* inr(pt)-2.8* glucose-299* urean-66* creat-2.2* na-123* k-4.7 cl-84* hco3-27 angap-17 alt-25 ast-32 ld(ldh)-290* ck(cpk)-61 alkphos-96 totbili-1.8* calcium-8.6 phos-4.8* mg-2.6 . discharge labs: * patient died on . studies: cxr : findings: no previous images. left ij swan-ganz catheter tip extends to the right pulmonary artery at the outer border of the mediastinum. there is enlargement of the cardiac silhouette with pulmonary edema and bilateral pleural effusions, more prominent on the right. . cxr : impression: worsened chf. . cxr : findings: this is a markedly rotated film, which limits comparison to prior. the heart continues to be moderately enlarged. swan-ganz catheter tip is probably in the pulmonary outflow tract but is difficult to assess due to rotation of the film. there continues to be a small-to-moderate right pleural effusion with pulmonary vascular re-distribution, perihilar haze, compatible with chf. . cxr : impression: slightly improved appearance of the chest. . cxr : impression: new left picc line terminating in the left internal jugular vein. these findings were discussed with dr. on at 10:30 a.m. . cxr : impression: new left picc line terminating in the left internal jugular vein. these findings were discussed with dr. on at 10:30 a.m. . tte : conclusions the estimated right atrial pressure is 10-20mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is moderate global left ventricular hypokinesis (lvef = 30-35 %). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular free wall thickness is normal. the right ventricular cavity is dilated with normal free wall contractility. there is abnormal septal motion (early diastolic shudder plus respirophasic septal deviation to left) suggestive of pericardial constriction. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: mixed myopathic/constrictive findings; consider constrictive pericardial disease . cardiac cath : prelim comments: 1. resting hemodynamics revealed severely elevated left and right sided filling pressures with rvedp 33 mmhg and pcwp 29 mmhg. there is moderate pulmonary arterial hypertension with pasp 56 mmhg. the cardiac output is depressed with cardiac index of 1.89 l/min/m2 (using assumed oxygen consumption). final diagnosis: 1. biventricular diastolic failure. 2. moderate pulmonary arterial hypertension. . pmibi : interpretation: 74 yo woman with h/o atrial fibrillation and s/p mi and cabg in , schf with drop in lvef from 50% to 20% on most recent tte, chronic venostasis was admitted in atrial fibrillation with rvr and decompensated chf was referred for evaluation. the patient was administered 0.142 mg/kg/min of persantine over 4 minutes. no chest, back, neck or arm discomforts were reported by the patient during the procedure. in the presence of baseline st-t wave abnormalities, no additonal st-t wave changes were noted during the procedure. the rhythm was atrial fibrillation with rare isolated vpds noted. the blood pressure response to the persantine infusion was appropriate. post-infusion, the patient was administered 125 mg aminophylline iv. impression: no anginal symptoms or additional st-t wave changes from baseline. appropriate hemodynamic response to the persantine infusion. nuclear report sent separately. . nuclear report: impression: 1. mild, fixed perfusion defects involving the inferior wall, apex and distal anterior wall. no reversible perfusion defects identified. 2. severe left ventricular enlargement. 3. diffuse left ventricular hypokinesis, with calculated lvef of 15%. 4. prominent right ventricular tracer uptake. . renal u/s : impression: 1. normal-sized kidneys without hydronephrosis. non- diagnostic doppler evaluation of the kidneys, an mra of the kidneys (without gadolinium) can be obtained for further evaluation. 2. a cystic left lateral abdominal wall fluid collection, most likely represents a hematoma. however, other cystic lesions cannot entirely be excluded. this can be evaluated at the time of the renal mra. . micro: urine culture (final ): sensitivities: mic expressed in mcg/ml _______________________________________________________ enterobacter cloacae | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- 2 i gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i piperacillin/tazo----- 8 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . multiple bcx: negative multiple ucx: negative (except cx as above) c. diff toxin: negative . brief hospital course: hospital course: ms. is a 74 year old lady with a pmh of afib, cad, schf, htn, hld, dm2 who was admitted to an osh on w/ afib w/ rvr and pleural effusion now transferred here for management of acute decompensation of biventricular heart failure. pt ultimately expired on after status being changed to cmo. . active issues: # acute decompensation of biventricular heart failure: presented with gross volume overload- elevated jvp, pulmonary edema, and significant peripheral edema. ef now 20% (compared to prior 50%) with echo findings showing anterior hypokinesis likely from an ischemic event. cardiac enzymes were trended and were flat. a pa catheter was placed, and tracings revealed low svr, with preserved ci. given these findings, there was initial concern for septic picture. however, pt did not spike temperature, and all cultures were negative. given low svr, relatively high cardiac output there was concern for thiamine deficiency. she was started empirically on iv thiamine, and switched to po. thiamine later resulted as normal. tsh was checked and was normal. initially medical diuresis failed despite maximum doses of lasix, and diuril. renal was consulted for cvvh; however, patient began producing adequate uop and no longer required supplemental oxygen to maintain adequate oxygen saturations. medical diuresis was restarted with lasix, diuril, and dopamine briefly. dopamine was weaned off. repeat tte demonstrated ef 30-35%. she was placed on a lasix drip with metolazone 5mg , with excellent diuresis. her lytes were repleted, and placed on 1l fluid restriction. . she was transitioned to the floors, and again began to fail medical diuresis. dr. was consulted, and recommended cardiac cath, which showed: comments: 1. resting hemodynamics revealed severely elevated left and right sided filling pressures with rvedp 33 mmhg and pcwp 29 mmhg. there is moderate pulmonary arterial hypertension with pasp 56 mmhg. the cardiac output is depressed with cardiac index of 1.89 l/min/m2 (using assumed oxygen consumption). final diagnosis: 1. biventricular diastolic failure. 2. moderate pulmonary arterial hypertension. . she was restarted on dopamine gtt with lasix, but failed diuresis. she was transferred back to the ccu for milrinone gtt. however, she failed to diurese, and became anuric. renal was re-consulted, and recommended cvvh which she received for two days. during the 2nd day she became hypotensive and coded. she was recussitated with 2 cycles of cpr and briefly placed on bipap due to low sats. due to end-stage heart disease, failing kidneys unlikely to improve due to heart disease, and very low likelihood of obtaining any quality of life on dialysis, health care proxy was and after coming to the hospital agreed with patient being changed to dnr/dni and cmo status. before she became unable to meaningfully respond, ms had also stated that she didn't want to stay in the hospital any longer and did not want to be in pain which seemed consistent with cmo decision. pt had been placed on dopamine gtt to help with renal perfusion and help maintain bp during hd. when decision was made to make cmo, dopamine gtt stopped and patient passed 4 days later. . # acute renal insufficiency: baseline creatinine 0.8-1.1, and presented at 2. peaked at 2.7 initially. unclear if patient may have had insult to kidneys, which made initial diuresis impossible. renal was consulted, and cvvh was initially considered. however, pt's urine output improved, and she was able to be diuresed. urine lytes reflected pre-renal state, likely poor forward flow. creatinine improved slowly given improved forward flow. however, as above, she began to fail diuresis, and her cr worsened. renal was consulted, and recommended cvvh which this time was initiated. pt tolerated the initial day of cvvh with 2l fluid taken off. however, the next day she became hypotensive during cvvh as noted above and coded. subsequently, renal felt that cvvh would not provide lasting benefit and were concerned that it would again make patient hypotensive and in danger of a 2nd arrest. decision was made to not pursue cvvh further in light of goals of care. . # rhythm: pt presented with afib with rvr. presented to osh w/ rapid afib w/ rvr that was responsive to iv diltiazem. chads2 score of (chf, htn, dm). she was kept on heparin gtt for anticoagulation.pt had several episodes of bradycardia overnight while she was sleeping, thought to be vagal, associated with ventricular escape. beta blockers were held given the bradycardia. pt had arrest as noted above and care was ultimately discontinued per request of healthcare proxy. . # coronary artery disease: history of cad s/p anterior mi w/ unsuccessful angioplasty of lad and subsequent single vessel cabg to lad in . ekg concerning for anterior infarct/ involvement of graft in the recent past. cad risk factors include diabetes and hypertension. prior lipid panel from last w/ ldl 89 and hbga1c 9.1. hbg a1c here was 7.8 here, and ldl 48 here. she was continued on asa 81mg daily, and atorvastatin 80 daily. . # uti: pt was found to have gnr's, and treated with augmentin initially. sensativities came back with enterobacter cloacae and pt was switched to tmp/smx. however, when cvvh was initiated pt switched to ctx due to concern for proper renal dosing of the tmp/smx in setting of cvvh. . # delirium: pt presented from outside with some delirium night of admission. she had been started on keppra for possible but unlikely seizure activity. intermittent episodes of aggression, likely icu sundowning and keppra. keppra was discontinued as below. she was initially treated with haldol, which was able to be stopped after a couple of days as her delirium resolved. she was monitored for s/s of infection, which was negative. her qtc was monitored on haldol and remained normal. pt continued to have intermittent mild delerium during her hospitalization until she becamse sick enough that delerium could not be evaluated due to minimal responsiveness. . # right sided pleural effusion: likely transudative effusion in the setting of acute decompensated heart failure. cap coverage discontinued. review of prior records revealed right sided effusion in on tte. she was medically managed for chf was above. . # hyponatremia: likely hypervolemic hypernatremia in the setting of chronic heart failure. diuresed as above, and hyponatremia resolved temporarily. as she failed diuresis as above, her na trended down. ulytes demonstrated appropriate adh given low una. as above, renal was consulted and cvvh initiated as noted above. . # reported seizure: history of single episode of tonic clonic seizure at osh now s/p eeg and loading with keppra 500mg at osh. keppra discontinued over the weekend given that seizure possibility at osh was thought to be unlikely. . # dm2: lantus 80mg qam at home. elevated blood sugars on admission with trace ketonuria. pt placed on insulin gtt initially with a1c 7.8. converted to lantus 25units with iss. she was placed on a diabetic diet during her hospitalization. . # anemia: severely microcytic mcv, 60. low hct on admission. prior hct in low 30s. iron studies suggestive of possible fe-deficiency anemia. given extremely low mcv, thalassemia or variant also very likely. hct stable. she was started on ferrous sulfate for supplementation. she should have outpatient follow-up for consideration of electrophoresis for thalassemia. she should also have workup with colonoscopy, endoscopy if clinically indicated given microcytic anemia. pt was guaiac negative here. . # depression: pt voiced depression and si during her hospitalization. psychiatry was consulted, and recommended no current antidepressants or antipsychotics. she did not require a 1:1 sitter. pt continued to make intermittent comments about wanting to leave the hospital but this seemed more driven by being tired of hospitalization and wanting to remain comfortable than suicidal ideation. . # leukocytosis: resolved initially with negative ucx, bcx. given low svr??????s in setting of normal co??????s, this would be concerning for sepsis. pt later found to have ucx and treated with augmentin transitioning to tmp/smx and then ctx as noted above. . # le ulcers: shallow, and likely chronic venous insufiiciency. abx discontinued on admission. wound care consulted. her weeping improved as she was diuresed. medications on admission: home medications: 1. lasix 80mg daily 2. digoxin 0.125 mg daily 3. 60mg daily prn 4. metolazone 2.5mg every other daily before lasix 5. reglan 5mg q8hrs 6. coumadin 5mg daily 7. bethanachol daily 8. lantus 80 units daily 9. aspirin ? (per pcp notes, but not in pt medication bag or on transfer med list) 10. zocor ? (per pcp notes, but not in pt medication bag or on transfer med list) . transfer medications: 1. moxifloxacin 400 mg iv daily 2. vancomycin (dosed daily on level) 3. keppra 500 4. aspirin 81mg daily 5. milrinone 0.25 mcg/kg/min iv continuous 6. dobutamine 7.5 mcg/kg/min iv continuous 7. digoxin 0.125 mg po every other day 8. protonix 40mg daily 9. phoslo 1334 mg po tid discharge medications: n/a discharge disposition: expired discharge diagnosis: patient deceased discharge condition: patient deceased discharge instructions: n/a followup instructions: n/a procedure: hemodialysis venous catheterization for renal dialysis cardiopulmonary resuscitation, not otherwise specified right heart cardiac catheterization central venous catheter placement with guidance diagnoses: end stage renal disease obstructive sleep apnea (adult)(pediatric) urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified hyposmolality and/or hyponatremia atrial fibrillation aortocoronary bypass status other chronic pulmonary heart diseases depressive disorder, not elsewhere classified cardiac arrest diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled old myocardial infarction iron deficiency anemia, unspecified other ascites do not resuscitate status gross hematuria urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure knee joint replacement delirium due to conditions classified elsewhere leukocytosis, unspecified hypotension of hemodialysis oliguria and anuria venous (peripheral) insufficiency, unspecified infection and inflammatory reaction due to indwelling urinary catheter other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms acute on chronic combined systolic and diastolic heart failure ulcer of lower limb, unspecified chronic passive congestion of liver suicidal ideation 

Answer: The patient is high likely exposed to