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: bactrim / ciprofloxacin / percocet attending: chief complaint: dyspnea and fatigue major surgical or invasive procedure: av nodal ablation temporary pulmonary artery catheterization history of present illness: patient is a 75 year old male with significant cardiac history including cad s/p mi and cabg, chf (ef 20%), and aflutter, recently admitted in mid- for ? conversion of symptomatic aflutter; who now presents with worsening dyspnea and fatigue since discharge. pt reports feeling that he tires more easily and has to stop more frequently when ambulating. able to climb stairs "slowly". pt also notes increased swelling of his legs. denies any cough, fevers, or night sweats; no known sick contacts. however, last night has shaking chills, 'never felt so cold in my life'. also describes sx of orthopnea and orthostasis, no loc. pt has had a decrease in his appetite, no known weight loss. reports compliance with all medications on a daily basis. no n/v/diarrhea or abdominal pain. no dysuria, but pt does note a decrease in the quantity of urine output in the past 2 wks. . in the pt given 40 mg iv lasix with little effect and became hypotensive requiring dopamine gtt, after starting dopamine gtt, became more tachycardiac into 100's. patient's rhythym was thought to represent vtach for which the patient was given lidocaine without effect. dopamine gtt was discontinued with decrease of heart rate to low 100's. past medical history: #. cad s/p anterior wall mi (pci) #. cabg x 4 lima to d1, radial to lad, svg to pda #. chf - ischemic cardiomyopathy (ef 20-30% ) #. atrial fibrillation #. hyperlipidemia #. moderate pulmonary hypertension #. interstitial fibrosis #. recurrent dvt/pe s/p ivc filter #. s/p placement of biventricular icd #. hx renal cell carcinoma (), s/p left nephrectomy () #. hx bladder ca #. previous hypothyroidism, now hyperthyroidism () #. s/p right cea #. s/p tia with no residual symptoms () #. gerd #. s/p previous upper gi bleed #. skin cancers #. ckd - baseline appears to be 1.2-1.4 social history: patient is widowed and lives with his son and his family. he has a total of four children. family history: nc physical exam: vitals in ed: 96.1/ bp 96-104/ 40-50/ hr 104/ 99% on 2l, drops to 80% on ra during ambulation gen: elderly male, well developed, flat affect, nad heent: atraumatic, anicteric, clear op, dry mucous membrane neck: elevated jvp, no carotid bruits, no lad cardiac: distant heart sound, irregular, +systolic murmur, no rubs lungs: distant bs throughout, + crackles way up bilat. no accessory muscle use, no conversational dyspnea abd: distended, soft, nt, hypoactive bs ext: deeply pitting edema b/l up to groin. shiny skin, loss of hair. cool toes, faint dp pulses b/l neuro: a/o x3, cn ii-xii intact, no focal. 5/5 strength in all 4 extremities. pertinent results: admission labs: . 03:15pm pt-31.5* ptt-34.7 inr(pt)-3.4* 03:15pm plt count-256 03:15pm hypochrom-occasional anisocyt-occasional poikilocy-1+ macrocyt-3+ microcyt-normal polychrom-occasional ovalocyt-occasional schistocy-1+ 03:15pm neuts-66 bands-0 lymphs-17* monos-15* eos-1 basos-0 atyps-1* metas-0 myelos-0 nuc rbcs-3* 03:15pm wbc-7.4 rbc-4.22* hgb-14.1 hct-43.7# mcv-103* mch-33.5* mchc-32.4 rdw-15.7* 03:15pm t3-231* free t4-5.9* 03:15pm tsh-less than 03:15pm ck-mb-notdone probnp-* 03:15pm ck(cpk)-57 03:15pm glucose-110* urea n-72* creat-2.7*# sodium-136 potassium-5.7* chloride-103 total co2-18* anion gap-21* 03:17pm digoxin-<0.2 03:17pm tsh-<0.02 03:17pm ctropnt-<0.01 pertinent labs/studies: . creatinine: 2.7 ->> 2.1 ( to ) 06:00am blood pt-23.4* ptt-33.6 inr(pt)-2.3* . 57 -> 127 -> 36 -> 34 ctropnt- <0.01 -> <.01 -> <.01 -> >/01 . 03:15pm probnp-* . vitb12-1523* folate-greater th %hba1c-6.3* -done -done . thyroid: tsh-<0.02 t3-231* free t4-5.9* anti-tpo < 1 ; anti-thyroglobulin < 1 ; thyroglobulin - pending . stim test: cortisol t0 - 14.2 -> 28.6 (30min)-> 34.4 (60min) . imaging: : portable chest - chest, two views: comparison with . the patient is status post cabg. the pacer leads are unchanged in position. there is blunting of the right costophrenic angle consistent with a small pleural effusion and atelectasis. there is also blunting of the left costophrenic angle consistent with a pleural effusion. there is mild pulmonary, upper zone redistribution. impression: mild chf. . : renal us - the right kidney measures 13.1 cm and is normal in appearance with no hydronephrosis, stone, or mass. cortical echogenicity is normal. no perinephric collections are seen. the bladder is partially distended and normal in appearance. there is a fluid collection consistent with reservoir for penile prosthesis present with a catheter within it. impression: normal-appearing right kidney. . : echocardiogram - measurements: left atrium - long axis dimension: *5.2 cm (nl <= 4.0 cm) left atrium - four chamber length: *6.7 cm (nl <= 5.2 cm) right atrium - four chamber length: *6.9 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 1.0 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 5.1 cm (nl <= 5.6 cm) left ventricle - systolic dimension: 4.6 cm left ventricle - fractional shortening: *0.10 (nl >= 0.29) left ventricle - ejection fraction: 20% to 30% (nl >=55%) aorta - valve level: 3.3 cm (nl <= 3.6 cm) aorta - ascending: *4.2 cm (nl <= 3.4 cm) aorta - arch: *3.3 cm (nl <= 3.0 cm) aortic valve - peak velocity: 1.9 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 1.2 m/sec mitral valve - e wave deceleration time: 190 msec tr gradient (+ ra = pasp): *33 to 40 mm hg (nl <= 25 mm hg) . findings: left atrium: moderate la enlargement. right atrium/interatrial septum: moderately dilated ra. a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. dilated ivc (>2.5 cm), with minimal respiratory variation c/w elevated ra pressure of >20 mmhg. left ventricle: normal lv wall thickness. normal lv cavity size. severe global lv hypokinesis. no resting lvot gradient. no lv mass/thrombus. no vsd. right ventricle: normal rv wall thickness. dilated rv cavity. rv function depressed. aorta: normal aortic root diameter. focal calcifications in aortic root. moderately dilated ascending aorta. focal calcifications in ascending aorta.mildly dilated aortic arch. focal calcifications in aortic arch. aortic valve: three aortic valve leaflets. moderately thickened aortic valve leaflets. mild as. no ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild mitral annular calcification. mild thickening of mitral valve chordae. calcified tips of papillary muscles. no ms. moderate (2+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. normal tricuspid valve supporting structures. moderate tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. normal main pa. no doppler evidence for pda pericardium: no pericardial effusion. conclusions: the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is dilated. right ventricular systolic function appears depressed. the ascending aorta is moderately dilated. the aortic arch is mildly dilated. there are focal calcifications in the aortic arch. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is at least moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . compared with the findings of the prior study (images reviewed) of , no major change is evident. . discharge labs: . 06:00am blood hct-36.9* 06:00am blood pt-23.4* ptt-33.6 inr(pt)-2.3* 06:00am blood urean-66* creat-2.1* k-4.0 06:45pm blood alt-22 ast-31 alkphos-56 totbili-0.7 06:00am blood mg-1.9 06:00am blood t3-pnd free t4-pnd 11:11am blood type-art po2-60* pco2-32* ph-7.40 calhco3-21 base xs--3 11:11am blood o2 sat-90 brief hospital course: patient is a 75 year old male with significant cardiac history including cad, s/p mi and cabg, with a-flutter and a-fib, s/p -v icd, chf who presented to with persistent dyspnea and fatigue since discharge (approximately one month ago) found to be hypotensive and tachycardiac in ed. . #. cardiovascular 1. cad: the patient has known cad, s/p cabg in with previous placement if a -ventricular pacer/icd. on presentation the patient was dyspneic with evidence of chf thought likely to be ischemic cardiomyopathy with superimposed afib. given the patient's hypotension with sbp < 90, the patient was initially placed on a dopamine gtt in the ed. however, this caused worsening of the patient's rapid ventricular response with worsening of symptoms. in the ed the patient's rhythm was thought to represent vtach for which the patient was given lidocaine, without good effect. review upon admission to the ccu however revealed that the patient was not in vtach but had more likely aberrant conduction of his svt. dopamine gtt was discontinued and the patient was instead loaded with amiodarone in the e.d. on presentation the patient had a v-paced ecg without obvious changes consistent with ischemia. the patient did not report chest pain and the majority of his symptoms appeared to be consistent with chf. the patient ruled out for myocardial infarction by cardiac enzymes x 3. on admission to , the patient was already taking asa, lipitor, metoprolol and digoxin. initially the patient's digoxin was discontinued although his blood levels were not supra therapeutic on admission. on discharge the patient's metoprolol was changed to carvedilol given his depressed ef. . #. pump : the patient was known to have chf w/ systolic dysfunction secondary to ischemic cardiomyopathy on admission. a previous echocardiogram showed a lvef of 20-30%. on admission, cxr and physical exam were consistent with significant volume overload, but diuresis was limited by persistent hypotension. this hypotension was thought initially to be due to cardiogenic shock secondary to the patient's ischemic cardiomyopathy and afib as well as possible sepsis as the patient was noted to have warm extremities with evidence of peripheral vasodilation. however, the patient remained afebrile, without elevated white count or source of infection. the patient was found on admission to have suppressed tsh and elevated t3 and t4 however. it was thought that the patient's hyperthyroidism may have instead accounted for his physical findings and all antibiotics were discontinued. after the patient's sbp stabilized on , gentle lasix diuresis was initiated to effect a net diuresis of 700cc. repeat echocardiogram performed on revealed an ef of 20-30% with moderate la and ra enlargement, severe global lv hypokinesis, mild as, mod mr/tr and moderate pa systolic hypertension. given an inability to control the patient's rhythm medically, the patient avn ablation (see below) with improvement in blood pressure and rate control. brief right heart cath performed during the av nodal ablation was consistent with left heart failure with a pcwp of 36. with improved rate control and pressure the patient was more effectively able to be diuresed with net diuresis of approximately 5-6 liters since admission with iv antibiotics, usually requiring lasix 40mg - 120mg iv qd to achieve goals of 500-1000cc/day. the patient was transitioned to po lasix with regimen of 60mg po bid to keep i=o. upon discharge patient appeared euvolemic to mildly fluid overloaded with more aggressive diuresis limited by patient's creatinine, which was 2.1 on day of discharge (2.7 on admission). prior to discharge digoxin was added back to the medical regimen for improved ionotropy and to help prevent repeat hospitalization. additionally, given the patient's depressed ef, his beta blocker was changed from his outpatient regimen of metoprolol to carvedilol. . 3. rhythm - on admission, the patient presented in a fib with rvr, which was thought to be exacerbating patient's hypotension given pre-existing lv systolic dysfunction. of note, the patient previously had a biventricular icd placed for depressed ef and ventricular dys synchrony. the rate on admission to ccu was low 100s. the patient was initially started on amiodarone for rate and rhythm control which unfortunately failed to control the patient's rhythm. given the patient already had a -v icd in place, he was thought to be a good candidate for avn ablation. additionally, given the patient's previous pulmonary toxicity secondary to amiodarone, he was thought not to be a good candidate for long term amiodarone therapy. av nodal ablation was performed on , with excellent effect. the patient is currently v/v/i paced with heart rate around 80. currently the patient is still in atrial fibrillation but obviously without conduction. however, given his persistent afib the patient will require anticoagulation. the patient is currently with a therapeutic inr of 2.3 with discharge medical regimen of coumadin 2mg po qhs. this will need to be monitored carefully and adjusted as needed given the patient's regimen had to be altered throughout his hospital course to allow for his procedures. in the future the patient may benefit from attempted conversion using quinidine and dccv to augment the patient's co with a normal atrial kick as per ep's recs. however, the goal of this hospitalization was stabilization of the patient with optimization of his current medical regimen. additional follow up with the patient's cardiologist for above considerations is already arranged. . #. hyperthyroidism : historically the patient has a history of hypothyroidism, thought originally to be secondary to amiodarone therapy. as noted above, the patient was actually found to be hyperthyroid on admission without clear precipitant. antibody testing was negative including anti-peroxidase and anti-thyroglobulin, making grave's disease less likely. additionally, the patient has not recently been treated with amiodarone therapy (greater than one year) making amiodarone effect not likely. to date, the exact etiology of the patient's hyperthyroidism is not known but the patient is receiving follow up with endocrine. the patient was seen in house by the endocrine service who made recommendations to treat the patient's hyperthyroidism given potential cardiac side effects. currently the patient is on methimazole 20mg po bid with scheduled follow up with endocrine. the patient has been warned of potential side effects of methimazole including agranulocytosis and has been instructed about warning signs such as sore throat, fever, chills. . # arf - patient is reported to have baseline creatinine of 1.2 - 1.4 on previous admission. this admission the patient suffered acute on crf with admission creatinine of 2.7 thought likely to be secondary to hypoperfusion given patient's hypotension on admission. with improved cardiac function the patient's creatinine began to decrease, even in the setting of fairly aggressive diuresis. on discharge the patient has a creatinine of 2.1 which will need continued monitoring as the patient continues therapy with lasix. of note the patient has a history previously of renal cell carcinoma s/p left nephrectomy. renal ultrasound of the remaining right kidney revealed no obstruction. . # pulm htn/ pulm fibrosis/chronic stable pe. patient with pulmonary disease likely secondary to amiodarone toxicity. patient was continued on outpatient regimen of advair, spiriva and prn albuterol (not used this admission). as noted, amiodarone was used temporarily but without plans to continue now that patient is adequately rate controlled. the patient has an ivc filter in given history of previous pe. . # elevated mcv: etiology unclear, this has been present since . b12 and folate were checked this admission, both within normal limits. . # fen - patient was maintained on a low sodium/cardiac/renal diet with fluid restriction < 1200cc/day. the patient was instructed about a low sodium diet and instructed to weight himself daily to guide lasix therapy . # code status- code status was reviewed with the patient on admission. the patient is currently dnr/dni, not to receive compressions or intubation. however, the patient reports that should he develop an arrythmia, he would want to receive up to one external shock. however, again he would not want compressions or intubation. medications on admission: warfarin 2 mg qod escitalopram 20 mg niacin 1000 mg folic acid 1 mg atorvastatin 40 mg multivitamin furosemide 40 mg qod hydrocortisone 1 % cream zolpidem 5 mg metoprolol tartrate 50 mg aspirin ec 81 mg digoxin 125 mcg qod discharge medications: 1. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. methimazole 10 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 6. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 8. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). disp:*30 tablet(s)* refills:*2* 9. warfarin 2 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 10. furosemide 40 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* discharge disposition: extended care facility: for the aged - discharge diagnosis: primary: congestive heart failure atrial fibrillation hypotension hyperthyroidism . secondary: #. cad s/p anterior wall mi (pci) #. cabg x 4 lima to d1, radial to lad, svg to pda #. chf - ischemic cardiomyopathy (ef 20-30% ) #. atrial fibrillation #. hyperlipidemia #. moderate pulmonary hypertension #. interstitial fibrosis #. recurrent dvt/pe s/p ivc filter #. s/p placement of biventricular icd #. hx renal cell carcinoma (), s/p left nephrectomy () #. hx bladder ca #. previous hypothyroidism, now hyperthyroidism () #. s/p right cea #. s/p tia with no residual symptoms () #. gerd #. s/p previous upper gi bleed #. skin cancers #. ckd - baseline appears to be 1.2-1.4 discharge condition: good. patient is afebrile, hemodynamically stable with sbp > 100 with o2 sat > 90% at rest. patient has elevated creatinine from normal baseline which will be monitored as an outpatient. discharge instructions: 1. please take all medications as prescribed . 2. please keep all outpatient appointments. . 3. you have a diagnosis of congestive heart failure. it is very important that you weigh yourself every morning. if your weight increases by more than 3 lbs from your baseline, you should call your cardiologist immediately to see if a change in your medical regimen may be warranted. additionally it is important that you adhere to a strict diet with no more than 2g sodium per day. followup instructions: 1. you have an appointment to be seen with on thursday 23rd at 1:45p.m. you will need to have your inr checked at this time as your coumadin dose has been adjusted during your hospital course. please call the office of dr. at with any questions or scheduling needs. . 2. please have lab work drawn at your pcp's office within 2 to 3 days of discharge to have your inr monitored. you are being discharged with coumadin which requires careful monitoring of your blood levels. . 3. please follow up with your cardiologist, dr. . you have an appointment with dr. on at 10:00. please call his office at ( for any questions or scheduling needs. . 4. you were found to have hyperthyroidism during your admission to which may have been contributing to your heart failure and symptoms. you were seen by dr. who recommended treatment with methimazole. as you have been instructed, this medication is very effective but requires careful monitoring as it very rarely can have serious side effects such as decreasing your wbc count dramatically. please call the office of dr. at ( to make an appointment to be seen for follow up. she will monitor your response to therapy as well as monitor for any potential side effects such as those outlined above. procedure: excision or destruction of other lesion or tissue of heart, endovascular approach pulmonary artery wedge monitoring infusion of vasopressor agent diagnoses: esophageal reflux mitral valve disorders congestive heart failure, unspecified acute kidney failure, unspecified atrial fibrillation aortocoronary bypass status atrial flutter thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm chronic kidney disease, unspecified other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia old myocardial infarction postinflammatory pulmonary fibrosis personal history of malignant neoplasm of bladder automatic implantable cardiac defibrillator in situ acute on chronic systolic heart failure personal history of malignant neoplasm of kidney diseases of tricuspid valve 

Answer: The patient is high likely exposed to