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: beta-blockers (beta-adrenergic blocking agts) attending: chief complaint: slurred speech and altered mental status major surgical or invasive procedure: none history of present illness: dr is an 87 year old man with past medical history significant for systolic and diastolic heart failure, atrial fibrillation, hypothyroidism, presenting from rehab facility with volume overload and altered mental status. on presentation, history related by pts daughter due to altered mental status of the patient. patient was living at home until 1 month ago when chf acutely worsened. he had never spent a night in the hospital before that time. at that time he lived alone and performed all his adls. he had two trips to the er in one week for presumed chf and was given lasix and discharged. he was admitted to rehab 3 weeks ago, and since that time has had episodes of slurred speech, dysphonia, and angina and doe. unfortunately, he was not getting his synthroid the entire 3 weeks he was at rehab. during this time, he developed worsening doe, angina, and speech. denies cough, fevers, chills, syncope, but does report several recent falls. patient was living at home until 1 month ago when chf acutely worsened. he had never spent a night in the hospital before that time. at that time he lived alone and performed all his adls. he had two trips to the er in one week for presumed chf and was given lasix and discharged. he was admitted to rehab 3 weeks ago, and since that time has had episodes of slurred speech, dysphonia, and angina and doe. also per daugther, patient has had synthroid inadvertently held at rehabover last 3 weeks. at rehab he was tried on various doses of lasix (10-20 mg daily), as well as low dose coreg and an ace-i which he could not tolerate due to hypotension. lab tests showed an elevated bilirubin, and ruq u/s showed cholecystitis. he also per report had several falls, but reportedly no head trauma. he was given toprol xl 12.5 mg and nitro patch prior to transfer. daugther contact dr. who accepted him for cardiology admission. in the ed, labs were noteable for elevated cr 1.9, bnp 11,000 ( baseline per daughter), hct 55.1, wbc 8.1. did not receive any medications. cxr showed bilateral effusion with no infiltrate. vs on transfer were 98.0 hr 91 128/93 15 98% on 3l, 93% on ra. per ed documentation, patient was a and ox3 in the ed. patient was initially transferred to the floor, and was found to be somnolent. abg 7.29/62/106/31 and was transferred to icu for bipap initiation for presumed hypercarbic respiratory failure. repeat abg in icu with no intervention was 7.36/54/118/32. past medical history: diastolic dysfunction/systolic dysfunction ef35% on atrial fibrillation recently noted; not on coumadin hypothyrodism hypertension asthma bph/prostatis no h/o cad or cva social history: retired internal medicine physician. remote tobacco, no etoh/illicits. only moved 3 weeks ago to senior life. family history: no cad or cva. physical exam: on transfer to medicine: vitals: t: 96 bp: 160/90 p: 97 r: 17 o2: 98% 2l nc general: arousable, follows commands, taciturn appears to have difficult phonating. heent: sclera anicteric, mmm, oropharynx clear. neck: supple, jvp at pinna lungs: decrease bs at bases cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place. ext: 2+ le edema to knees bilaterally, cool, no clubbing, cyanosis pertinent results: laboratory data: 144 103 40 17.3 100 ---|-----|----<104 6.4 >------< 140 5.0 29 1.6 55.5 , : ck: 124 ->53 ast 31 : ck-mb: 4 alt 17 , : troponin: 0.05 -> 0.06 alk 86 : bnp 11,505 tbil 3.6 vit-b12:1792 folate:>20 other blood chemistry: iron: 77 caltibc: 299 ferritn: 136 trf: 230 pt: 15.2 ptt: 32.5 inr: 1.3 fibrinogen: 264 tsh t4 t3 13* 4.2* 33* telemetry: atrial fibrillation. occasional pvcs, pacs. hr 70-110s. ecg : atrial fibrillation 102 bpm. incomplete lbbb. low voltage. inferior q waves. loss of lateral r waves. not significantly changed from . no prior for comparison. transthoracic echocardiogram : the left atrium is dilated. the right atrium is markedly dilated. no atrial septal defect is seen by 2d or color doppler. there is severe symmetric left ventricular hypertrophy. the left ventricular cavity is small. overall left ventricular systolic function is severely depressed (lvef= 20 %) secondary to akinesis of the inferior and posterior walls and hypokinesis of the rest of the left ventricle. there is no ventricular septal defect. the right ventricular cavity is markedly dilated with depressed free wall contractility. the aortic root is moderately dilated at the sinus level. the ascending aorta is mildly dilated. there are focal calcifications in the aortic arch. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild to moderate (+) 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 tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. moderate tricuspid regurgitation is seen. there is no pericardial effusion. impression: severe biventricular systolic and diastolic dysfunction; severe concentric left ventricular hypertrophy with a small cavity cxr : large hiatal hernia, unchanged pulmonary edema, unchanged bilateral pleural effusions that distribute in a slightly different fashion but are overall unchanged in extent. unchanged moderate cardiomegaly. ct head : impression: no intracranial hemorrhage or edema. no fracture. note added at attending review: i agree with the above, but note apparent post surgical changes in the right mastoid bone. chest x-ray: findings: marked cardiomegaly, tortuosity of thoracic aorta and large hiatal hernia are again demonstrated. bilateral pleural effusions and bibasilar parenchymal opacities are not substantially changed allowing for positional differences. interval resolution of right upper lobe atelectatic changes. rue us: findings: -scale and doppler evaluation of the right internal jugular, axillary, brachial, basilic, and cephalic veins was performed. there is normal compressibility, flow and augmentation. impression: no evidence of dvt. ecg: atrial fibrillation with increased ventricular response. low voltage. consider inferior myocardial infarction. late r wave progression. consider anterior wall myocardial infarction. generalized low voltage. since the previous tracing of there is no significant change. brief hospital course: dr is an 87 year old man with systolic and diastolic heart failure, hypothyroidism, atrial fibrillation, presenting with altered mental status and volume overload. . # altered mental status: on presentation, patient noted to be profoundly somnolent and minimally responsive. broad differential diagnosis in this elderly gentleman. arterial blood gas revealed hypercarbia, and metabolic investigation revealed hypothyroidism. patient transferred to micu for potential initiation of non invasive positive pressure ventilation, however hypercarbia began to resolve with initiation of thyroid hormone and with stimuli. infectious workup was unrevealing with exception of concern for early pneumonia superimposed on pulmonary edema. overall impression was that this was due to hypothyroidism in setting of poor reserve secondary to congestive heart failure and volume overload as well as hypercapnia with possible central hypoventilation. neurology team was consulted to help in evaluation of altered mental status, comprehensive workup including mri of the brain was obtained and they did not feel this was due to a primary cns disorder. patient was carefully monitored while in house, no further infectious source was identified. patient improved significantly and at time of discharge is conversive and alert, although still disoriented. would continue to avoid all sedating medications, would also recommend continuous pulse oxymetry at night and would start night time supplemental oxygen for saturations less than 89%, with goal 92% to 94%. # hypothyroidism: for unclear reasons, patient had not been receiving thyroid hormone replacement, tsh on admission = 15, with low t4. endocrinology was consulted regarding supplementation dose and route, and after careful review of medical history and high potential risk of over supplementation, oral repletion was started. patient tolerated 88mcg of synthroid brand supplementation without any complications, and as listed above began to experience improvement in mental status, volume status and blood pressure. would not expect to achieve repletion levels until 4 weeks of treatment, therefore would recommend obtaining thyroid function panel in one month. # acute systolic and diastolic heart failure exacerbation: patient with gross volume overload on admission, with mild hypoxia and relative bradycardia. evidence of myocardial injury found on serial cardiac enzymes. echocardiogram obtained revealing severely depressed ejection fraction when compared to prior from , with global pattern suggestive of metabolic process. heart failure team consulted in icu, and confirmed above impression. given patients hypothyroidism and decompensated state, did not start beta blocker therapy. given hypertrophied left ventricle and very small ventricular size, did not initiate intravenous diuretics to avoid abrupt reduction in preload and cardiac output. patient was maintained on a heart healthy diet and kept to 1.5l fluid restriction. with continuation of hormone repletion, volume status began to improve and patient achieved auto diuresis, significantly mobilizing peripheral edema and with resolution of oxygen requirement. consensus in primary team after discussion with all consultants involved was to continue thyroid hormone repletion alone for at least two more weeks before evaluating need for beta blocker, diuretic or aldosterone inhibitor therapy. follow up has been arranged with dr in heart failure clinic. discharge weight = 99.4 kg # healthcare associated pneumonia: given very poor clinical condition on presentation and concern about infiltrate on admission imaging, patient was treated with 5 day course of high dose levofloxacin, dosed per renal function. course completed at time of discharge. # coronary artery disease / angina: on presentation, patient had been noted to have severe episodes of angina. patient ruled out for myocardial infarction by serial cardiac enzymes and did not have new ecg changes noted. patient likely suffering from demand ischemia in setting of decompensated chf. as clinical condition improved, patient has remained angina free, even when transferring to and from bed. echocardiogram and ecg suggestive of prior inferior myocardial event. once stable, would consider initiation of statin therapy for secondary prevention. would continue daily aspirin 81mg. # cholelithiasis: gallstones found on outpatient ultrasound for workup of hyperbilirubinemia. these findings were confirmed on an inpatient ultrasound, however no evidence of biliary duct dilatation or obstruction. elevation found to be indirect, and may be due to decreased hepatic conjugation in setting of metabolic derangements. defer further workup to facility team, however would wait until thyroid function normalizes. # atrial fibrillation: patient has recently diagnosed atrial fibrillation with good rate control although he is not being treated with any nodal agents. given severely depressed systolic function, would not initiate any calcium channel blockers, and for the acute exacerbation period would continue to hold off on beta blocker therapy as rate permits. this was discussed with inpatient cardiologist (dr ) and outpatient cardiologist (dr . ). lastly, in spite of very high risk of thromboembolic complications, and discussing thoroughly with family, we continued to hold anticoagulation but maintained aspirin therapy. # acute kidney injury: admission serum creatinine to 1.6 in setting of poor forward flow from acute systolic failure. with improvement in cardiac function and volume status, serum creatinine improved to 1.2 on day of discharge. would continue to monitor kidney function at least weekly. # sleep disordered breathing: noted during admission, however in setting of decompensated condition as above. inpatient sleep consult obtained, confirming very high risk of hypoventilation and need for further outpatient evaluation after acute illness is treated. follow up arranged. # communication: daughter hcp # code: full code confirmed with hcp medications on admission: home medications: glucosamine sulfate 500mg daily vitamin d2 unit q2 weeks albuterol 2 puffs qid prn hydrocortisone 1% oint colace 100mg qam fluticasone 110mcg 2 puffs acetaminophen 650mg q6h prn discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever . 2. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: two (2) puffs inhalation q6h (every 6 hours) as needed for dyspnea. 4. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 5. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. heparin (porcine) 5,000 unit/ml solution sig: 5,000 units injection tid (3 times a day). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary: acute systolic heart failure hypothyroidism delirium sleep disordered breathing secondary: atrial fibrillation asthma discharge condition: mental status: confused - sometimes level of consciousness: alert and interactive activity status: out of bed with assistance to chair or wheelchair discharge instructions: you were hospitalized for worsening of your heart failure and altered mental status. during your admission, we found your thyroid hormone levels to be low. we resumed levothyroxine supplementation and monitored you as your condition improved. the cardiologists did not feel that you required additional heart medications at this time. over the course of your stay, your mental condition improved dramatically. your physical condition and capacity to carry out daily activities has also deteriorated; for this you will have physical therapists at your rehabilitation center who will work with you to improve your strength. medication changes: start: levothyroxine 88mcg daily followup instructions: dr specialty: cardiology date/time: 9:00 phone: dr. specialty: pulmonary and sleep disorders date/ time: 11:20am location: building , ma phone number: procedure: non-invasive mechanical ventilation diagnoses: pneumonia, organism unspecified coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation asthma, unspecified type, unspecified hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) chronic kidney disease, unspecified diaphragmatic hernia without mention of obstruction or gangrene acute respiratory failure other and unspecified angina pectoris calculus of gallbladder without mention of cholecystitis, without mention of obstruction jaundice, unspecified, not of newborn acute on chronic combined systolic and diastolic heart failure sleep disturbance, unspecified 

Answer: The patient is high likely exposed to