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: amiodarone / quinidine attending: chief complaint: shortness of breath major surgical or invasive procedure: pacemaker placement history of present illness: mr. is a 77-year-old man with cad s/p cabg (lima-lad, rima-rca, svg-om in ) and pci (des to svg-om in ), multiple atrial arrhythmias and tachybrady syndrome s/p multiple ablations and pacemaker placement in , chronic systolic heart failure, stage iv crf, recently admitted in for chf exaceration who presents for chf management prior to biv pacemaker upgrade on . . per dr. note mr. has had increasing cardiac dysfunction primarily due to cardiac dyssynchrony secondary to chronic ventricular pacing. his ejection fraction has over the past four years progressively gone from normal to about 40% with measurements of synchrony being distinctly abnormal. he has hypokinesis of his septum, which is primarily related to his pacemaker. he has increasing fluid retention and inability to get the fluid to his kidneys and perfuse them well. an attempt to decrease the fluid accumulation and increasing lasix has caused the deterioration of his kidney function, such that his bun is 101 and creatinine 3.2 with concurrent hypokalemia and hypochloremia despite the concomitant use of aldactone. decision made to place biv pacemarker in attempt to improve cardiac function and secondarily increase his renal perfusion. . on direct presentation from home patient reports ~5lb weight gain with abd distension since appt. no changes made to medications, no dietary or medications non-complinance. denies any worsening peripheral edema; stable 2 pillow orthopnea, no pnd, no palpitations. . patient admitted on ; biv unable to be placed on due to technically difficult therefore epicardial leads placed on . intra-op recevied received total of 15cc contrast. patient underwent procedure successfully. placed on coumadin and hep gtt. patient received a dose of vanco during procedure; keflex continued x2days post. post-operative course complicated by acute renal failure, nephrology consulted deterioration in function secondary to poor forward flow. . of note on night prior to transfer patient s/p mechanical fall while walking - denies any preceding dizziness, chest pain, palpitations. . current cardiac review of systems: denies dizziness, chest pressure, shortness of breath, stable abdominal distention. denies diaphoresis, n/v. . on review of systems, reports pain at operative when coughing,he reports prior history of stroke, gi bleed in the setting of asa, plavix; denies bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. . past medical history: 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: cad sick sinus syndrome chronic and diastolic chf ef 40-45% paroxysmal afib s/p multiple dccv, aflutter ablations, and pvi in -cabg: lima-lad, rima-rca, svg-om in -percutaneous coronary interventions: des to prox svg-om in -pacing/icd: pacer in for sss pm settings: dddr mode with a lower rate of 60, an upper track rate of 100, and an upper sensor rate of 110 beats per minute. the mode switch function is on for atrial rates greater than 145 beats per minute. of note, the pvarp time is set at 400 milliseconds. 3. other past medical history: stage iii-iv chronic renal failure (baseline cr 2.7-3.0) h/o cva with bilateral lacunar infarcts in with residual left paresthesias and gait dysfunction osa on cpap h/o gi bleed on plavix (now off asa and plavix) h/o scarlet inflammatory bowel disease? gout obesity fatty liver left ear deafness social history: lives in with his wife. formerly worked at a dialysis medical device company. - alcohol: drinks wine weekly - tobacco: 80 pack-year history but quit 12 years ago - drugs: none family history: multiple family members with diabetes. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory physical exam: vs: t 97.7 100/61 58 94%ra wt: 109.4 kg - 107.6 (on admission) todays i/o: 530ccin/1235cc uop general: wdwn in nad. speaking in full sentences without problems. oriented x3. , affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. central line in place. neck: supple, unable to assess jvp due to cvl placement cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4, minimal pretibial edema, + abd distension. chest: well-healed midline incision scar ppm site: -- bandage on the left anterior chest chest: minimal tenderness, dressing in place: c/d/i -- bandage on the posterior flank, dressing in place: c/d/i lungs: resp were unlabored, no accessory muscle use. decreased bs at b/l bases with overlying crackles, no wheezes or rhonchi. abdomen: distended, nontender. no hsm or tenderness. extremities: cool, 1+ pitting edema, skin changes consistent with chronic venous insufficiency. pulses: right: carotid 2+ femoral 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ dp 2+ pt 2+ . on discharge: vs: t 97.7 100/61 58 94%ra wt: 104 kg - 107.6 (on admission) general: wdwn in nad. speaking in full sentences without problems. oriented x3. , affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. central line in place. neck: supple, unable to assess jvp due to cvl placement cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4, 1+ symmetric le edema, + abd distension. chest: well-healed midline incision scar ppm site: -- bandage on the left anterior chest chest: minimal tenderness, dressing in place: c/d/i -- bandage on the posterior flank, dressing in place: c/d/i -- wound on left knee: dressing in place - c/d/i lungs: resp were unlabored, no accessory muscle use. decreased bs at b/l bases scant overlying crackles, no wheezes or rhonchi. abdomen: distended, nontender. no hsm or tenderness. extremities: wwp, 1+ pitting edema, skin changes consistent with chronic venous insufficiency. pulses: right: carotid 2+ femoral 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ dp 2+ pt 2+ pertinent results: on admission: 09:33pm wbc-9.2 rbc-3.53* hgb-11.8* hct-33.3* mcv-94 mch-33.6* mchc-35.6* rdw-17.0* 09:33pm plt count-172 09:33pm glucose-170* urea n-104* creat-3.4* sodium-135 potassium-3.4 chloride-94* total co2-25 anion gap-19 09:33pm calcium-9.4 phosphate-4.0 09:33pm pt-19.3* ptt-30.3 inr(pt)-1.8* . on discharge: 06:05 wbc rbc hgb hct mcv mch mchc rdw plt ct 7.4 3.26* 11.1* 31.3* 96 33.9* 35.3* 16.6* 241 . urean creat na k cl hco3 angap 138 3.9* 130* 3.8 88* 28 18 . inr: 2.2 . studies tte: 1. no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. 2. no spontaneous echo contrast is seen in the body of the right atrium. a small mobile echodense mass associated with a pacing wire is seen in the right atrium near the interatrial septum. 3. no atrial septal defect is seen by 2d or color doppler. 4. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with dyskinesis of the apical anteroseptal and inferoseptal walls, and severe hypokinesis of the mid septum. overall left ventricular systolic function is mildly depressed (lvef= 45 %). 5. right ventricular chamber size is normal with borderline normal free wall function and focal hypokinesis of the apical free wall. 6. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. there are simple atheroma in the aortic arch. the descending thoracic aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. 7. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. 8. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. 9. the tricuspid valve leaflets are mildly thickened. 10. there is a very small pericardial effusion. dr. was notified in person of the results at the time of the study. . cxr right jugular line ends in the region of the superior cavoatrial junction, as before. as far as one can tell from a frontal view alone, the right atrial lead ends low in the right atrium and right ventricular lead along the floor of the right ventricle. two epicardial leads projecting over the left heart border are unchanged since . that procedure was presumably responsible for new small left pleural effusion. pulmonary edema has resolved since , and lung volumes have improved. mild cardiomegaly is unchanged, and there is no pneumothorax. . tte: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild global left ventricular hypokinesis (lvef = 45 %). dyssnchrony is not visually apparent. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size is normal. with borderline normal free wall function. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal left ventricular cavity size with mild global hypokinesis. moderate pulmonary artery systolic hypertension. increased pcwp. compared with the prior study (images reviewed) of , left ventricular systolic dysfunction appears more diffuse/global and the estimated pulmonary artery systolic pressure is highe brief hospital course: is a 77-year-old man with cad s/p cabg (lima-lad, rima-rca, svg-om in ) and pci (des to svg-om in ), multiple atrial arrhythmias and tachybrady syndrome s/p multiple ablations and pacemaker placement in , ckd, and chronic systolic heart failure s/p epicardial lead placement via left mini-thoracotomy w/st. pacer with hospital course complicated by acute on chronic renal failure. . # chronic systolic chf: ef ~50 via tte. patient is s/p epicardial lead placement on . hypothesized that patients worsening chf symptoms secondary to ventricular dyssynchrony and placement of placemarker will improve forward flow and improve symptoms. post-procedure patient with persistent volume overload. patient intermittently diuresised with iv lasix with good response. patient transitioned to po lasix on with continued diuresis (~1l/day). patient discharged on lasix 60mg po bid, spironlactone 25mg qd and metalozone 2.5mg po every tuesday and friday. patient continued on metoprolol xl. repeat tte demonstrated stable ef ~45% with ventricular synchrony. surgical site clean, intact with no sign of infection at time of discharge - patient completed 7 day course of keflex. 1. monitor weights daily, adjust diuretics as needed for volume optimization. 2. monitor surgical site, wound care as needed . # acute on chronic kidney failure, stage 4. baseline creatinine: 2.7-3.0. on admission patient's creatinine 3.4. after diuresis creatinine improved to 3.0. after procedure, creatinine peak to 4.0 on . etiology of : poor perfusion secondary to poor forward flow vs contrast-induced nephropathy (however patient received minimal dye load) vs ain in setting of ppx abx. urine and differential without eosinophilia. renal consulted - hypothesized that elevation secondary to poor forward flow and recommended to continued diuretic use. patient maintained good uop throughout stay. creatinine at time of discharge: 3.9. outpatient issues: 1. monitor creatinine regularly and i/o. . # coronaries: patient with history of cad. last cardiac catheterization with stenting of svg to om. due to h/o gi bleed not currently on asa, plavix. patient cites 2-3x weekly exertional angina as well as infrequent episodes of angina at rest. patient with 1/11 stress echo: rest and stress perfusion images reveal decreased tracer uptake in the anterior apical region on both stress and rest images with associated apical wall motion abnormality. patient monitored on telemetry without event and continued on beta-blocker. outpatient issue: 1. monitor exertional symtoms and ascert need to repeat stress. . # rhythm. patient with history multiple atrial arrhythmias: atrial fib/flutter, tachybrady syndrome s/p multiple ablations and ppm in . - rate control. patient was monitored on telemetry and remained in normal sinus for majority of stay with occassional reversion into atrial fibrillation. rates consistently 50-70s. - anticoagulation. chads 6. patient maintained on lovenox daily when inr subtherapeutic. continued on coumadin. inr at time of discharge: outpatient issues: 1. monitor on telemetry for arrhytmias. . # h/o cva with bilateral lacunar infarcts in with residual left paresthesias and gait dysfunction. neuro exam monitored. patient ambulated without problems with the assistance of a walker. . # iddm. continue home regimen of lantus, humalog with meals and iss . # osa. home cpap continued. medications on admission: metoprolol succinate 50 mg po daily spironolactone 25 mg po daily rosuvastatin 20 mg po daily furosemide 60 mg metolazone 2.5 mg on tuesdays nitroglycerin 0.4 mg sl prn chest pain warfarin 2.5mg daily insulin glargine 25 units qam and 50 units qhs novalog 15 u with breakfast, 20-25 u with dinner, and 20-25 u at bedtime. he skips lunch. ? calcitriol 0.5 mcg po daily allopurinol 300 mg po daily colchicine 0.6 mg po daily prn omeprazole 40 mg po daily multivitamin 1 tab po daily calcium carbonate-vitamin d3 vitamin d2 iron 325 mg po daily ascorbic acid glucosamine magnesium zinc sulfate fish oil discharge medications: 1. metolazone 2.5 mg tablet sig: one (1) tablet po every tuesday and friday. 2. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 3. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 4. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 5. furosemide 40 mg tablet sig: 1.5 tablets po bid (2 times a day). 6. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed for constipation. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 8. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 9. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 10. multivitamin tablet sig: one (1) tablet po daily (daily). 11. rosuvastatin 20 mg tablet sig: one (1) tablet po hs (at bedtime). 12. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 13. calcitriol 0.5 mcg capsule sig: one (1) capsule po daily (daily). 14. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 15. bacitracin zinc 500 unit/g ointment sig: one (1) appl topical qid (4 times a day). 16. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 17. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 18. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 19. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for , pain. 20. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 21. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual as needed. 22. calcium carbonate-vitamin d3 oral 23. ascorbic acid oral 24. fish oil oral 25. glucosamine oral 26. ergocalciferol (vitamin d2) oral 27. insulin glargine 100 unit/ml solution sig: 25units in the am, 50units in the pm as directed subcutaneous as directed. 28. humalog 100 unit/ml solution sig: as directed units subcutaneous four times a day: 20units with breakfast, 25units at lunch, dinner and bedtime. 29. ipratropium bromide 0.02 % solution sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary: chronic congestive heart failure . secondary: hypertension hyperlipidemia diabetes discharge condition: mental status: clear and coherent ambulates without asssitance weight at time of discharge: discharge instructions: dear mr , it was a pleasure taking care of you . you were admitted to for optimization of volume status prior to biventricular pacemarker placement. unfortunately the initial attempt to place the pacemarker was unsuccessful and the decision was made to place your pacemarker surgically. you did well after the surgery. . at time of discharge it was determined that you would benefit greatly to participating in a cardiac rehab program to optimize your cardiac function after hospitalization. . changes to your medications stay taking metalozone every tuesday and friday. . no other changes were made to your medication. followup instructions: department: cardiac services when: tuesday at 3:00 pm with: , np building: sc clinical ctr campus: east best parking: garage department: cardiac services when: monday at 11:00 am with: echocardiogram building: sc clinical ctr campus: east best parking: garage department: cardiac services when: monday at 2:00 pm with: dr. building: sc clinical ctr campus: east best parking: garage department: cardiac services when: friday at 3:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage . department: west clinic when: wednesday at 10:30 am with: , rn building: de building ( complex) campus: west best parking: garage procedure: injection of steroid injection of anesthetic into peripheral nerve for analgesia proctostomy angiocardiography of venae cavae division of sympathetic nerve or ganglion implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [crt-p] venous cutdown injection of other agent, except neurolytic diagnoses: acidosis anemia in chronic kidney disease obstructive sleep apnea (adult)(pediatric) congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation aortocoronary bypass status percutaneous transluminal coronary angioplasty status abnormality of gait chronic kidney disease, unspecified other and unspecified hyperlipidemia long-term (current) use of insulin other late effects of cerebrovascular disease long-term (current) use of anticoagulants sinoatrial node dysfunction acute on chronic systolic heart failure fitting and adjustment of cardiac pacemaker epistaxis late effects of cerebrovascular disease, alterations of sensations 

Answer: The patient is high likely exposed to