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: penicillins attending: chief complaint: sob major surgical or invasive procedure: intubation picc line placement bronchoscopy history of present illness: 89yof russian speaking with cad, ef 45% on last echo , htn, afib on coumadin who was admitted to cardiology for progressive sob/doe for the past wks, progressing to sob at rest; also with increased wt, upper and lower extremity swelling, pnd, orthopnea such that has been sleeping straight up; but no cp, syncope, or palpitations. failed outpt management of chf exacerbation with increase of po lasix 60 mg to 120mg. vna noted low o2 sats, sent her to clinic where she had cyanotic lips, and then sent to ed where she was 121/68 p76 and 100% on 4l nc. cxr consistent with a very large heart, bilateral patchy opacities and l > r pleural effusion; also with bnp 5500 (no baseline) and cr 2.3 up from 1.7 back in , and baseline appears to be mid 1's. . she was given 80 mg iv lasix in the ed, and through admission to cardiology was given 60 mg iv lasix instead of the intended 120 mg iv due to concern for hypotn. review of her floor vitals shows progressive decrease in her sbp's from 110's to 90's, reported 70's by the primary team this am, and is 85 on evaluation most recently. . through her course, she was diuresed as above; acei, beta blocker, and coumadin have been held; echo has just been done this am; ce's have been trended which are only minimally elevated trop's (0.1-0.11) with negative mb's. there was also of note a concern for lll pna vs atelectasis for which she was given iv levaquin x1, but this was not continued on the floor (she denies cough, fever, and wbc's are low) . she is transferred to ccu for aggressive monitoring of blood pressure while being diuresed. . ros as above, otherwise negative. past medical history: 1. coronary artery disease; nuclear stress test in showed fixed inferolateral wall defect. 2. chronic diastolic congestive heart faliure (ef 50% on echo, apical akinesis, also 4+ tr at that time but grossly overloaded) -> admitted to ccu with cardiogenic shock 3. htn 4. afib- on beta-blocker, coumadin 5. hyperlipidemia 6. migraine 7. breast cancer, status post left mastectomy, radiation, chemo; residual left upper extremity lymphedema. 8. right hip fx s/p replacement, and left hip fx s/p surgery x2, and 9. kidney stones 10. mild depression 11. hip fracture s/p replacement 12. shoulder fx social history: lives at , denies any alcohol or cigarettes. son is health-care proxy and is very involved, cell and home family history: lung cancer (father), gi cancer (mother) physical exam: on admission: 96 p68 91/44 28 93-99% 3l nc elderly woman laying upright in bed, able to understand and speak some english, no distress but looks tired, able to speak short sentences, not in extremis but her lips, tongue, and fingertips are notably cyanotic. eomi, no scleral icterus, mouth appears moist. external jugulars is grossly distende, internal jugular pulsations noted about 4.5 cm above her earlobe for total jvp ~12cm above ra level at ~45 degrees, +hjr back is notably kyphotic, lung sounds very diminished with poor respiratory effort but gross wet sounding crackles noted diffusely and gross expiratory wheezes as well irregular s1/s2 but no murmurs appreciated, nor s3/s4 abdomen is soft but obese, nt nd, benign ble with gross anasarca to the thighs, and bilateral shins exhibit gross chronic lymphedematous changes reminischent of elephantiasis with scaly hyperkeratosis on a diffuse background of chronic erythematous hyperpigmentation; also with pitting edema. cn 2-12 grossly intact, alert and attentive to conversation; full neuro exam deferred at present on discharge: sitting in bedside chair. cyanosis has resolved, appears much improved. minimal jvd and basilar crackles. ble edema and chronic venous stasis changes are improved. pertinent results: 1:12 pm bronchoalveolar lavage **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): positive for pneumocystis jirovecii (carinii). time taken not noted log-in date/time: 5:24 pm bronchoalveolar lavage das acu added on on . acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): t lymphocyte subset wbc lymph abs cd3% abs cd3 cd4% abs cd4 cd8% abs cd8 cd4/cd8 7.0 3* 210 30 62* 26 54* 4 9* 6.1* renal & glucose glucose urean creat na k cl hco3 angap 07:07 108*1 153* 2.7* 142 4.0 91* 40* 15 echo : the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is at least 15 mmhg. there is mild basal left ventricular hypertrophy with a suggestion of "burnt out" apical left ventricular hypertrophy and associated aneurysm versus prior apical infarct (1.5 x 1.7 cm apical aneurysm without thrombus seen). the left ventricular cavity size is normal. overall left ventricular ejection fraction is borderline as other segments are hyperdynamic (lvef= 50%). there is a 1.0 cm spheroid/sessile mass (clips ) seen in the lvot about the anterior mitral annulus which is mixed calcified/non-calcified in appearance (suggestive of atypical caseating mitral annular calcification but tumor is also part of the differential). there is no lvot obstruction. there is no ventricular septal defect. the right ventricular cavity is moderately dilated with mild global hypokinesis suggested. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). trace 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. severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the degree of tr has increased. rv size has probably increased with new evidence of volume overload. the apical aneurysm and overal lvef are similar (lvef underestimated on prior report), the lvot mass was present but is now more prominent (likely due to different angulation rather than major changes). if indicated, a cardiac mri would be ebst to characterize all of the elements mentioned above. cxr : portable upright view of the chest: endotracheal tube terminates 4.2 cm above the carina. right-sided picc terminates in the mid svc. again noted is massive enlargement of the cardiac silhouette. probable bilateral pleural effusions and associated compressive atelectasis is unchanged. there is mild-to-moderate central vascular engorgement. there is no new consolidation or pneumothorax. atherosclerotic calcification of the aortic arch is noted. bones are diffusely demineralized. the study and the report were reviewed by the staff radiologist. . . . : 04:16am blood wbc-10.4 rbc-3.05* hgb-9.1* hct-26.2* mcv-86 mch-29.8 mchc-34.6 rdw-19.0* plt ct-131* 04:16am blood wbc-10.4 rbc-3.05* hgb-9.1* hct-26.2* mcv-86 mch-29.8 mchc-34.6 rdw-19.0* plt ct-131* 04:16am blood plt ct-131* 04:16am blood pt-26.4* inr(pt)-2.5* 09:15pm blood wbc-7.0 lymph-3* abs -210 cd3%-30 abs cd3-62* cd4%-26 abs cd4-54* cd8%-4 abs cd8-9* cd4/cd8-6.1* 04:16am blood glucose-122* urean-135* creat-2.9* na-141 k-4.2 cl-93* hco3-37* angap-15 05:37am blood alt-13 ast-32 ld(ldh)-236 alkphos-65 totbili-1.3 05:30pm blood ck-mb-7 ctropnt-0.11* probnp-5510* 01:00am blood ck-mb-6 ctropnt-0.10* 07:00am blood ck-mb-5 ctropnt-0.10* 05:30pm blood ck-mb-7 ctropnt-0.11* probnp-5510* 04:16am blood mg-2.7* 06:16am blood calcium-9.5 phos-3.3 mg-2.6 05:37am blood caltibc-272 ferritn-179* trf-209 09:15pm blood hiv ab-negative 12:17pm blood type-art po2-89 pco2-68* ph-7.41 caltco2-45* base xs-14 09:42am blood lactate-1.3 06:16am blood htlv i and ii, with reflex to western blot-pnd 09:15pm blood b-glucan-test brief hospital course: briefly: ms. is a 84 yo f w/ coronary artery disease ( nuclear showing fixed inferolateral wall defect), atrial fibrillation (chronically on coumadin), chronic diastolic chf (ef 50%) and htn who presents with progressive sob/doe likely due to chf exacerbation, and was found to be in cardiogenic shock and transferred to ccu where she was aggressively diuresed; course was complicated by hypercarbic respiratory failure for which she was intubated, worsening renal failure and uremia, and bal while intubated positive for pnuemocystis jirovecii (carinii) currently being treated and low cd4 count. . by problem 1. acute on chronic diastolic chf exacerbation: pt presented with cyanosis, cool extremities, volume overload, pulmonary edema, hypoxia, acute renal failure. she had failed outpatient increase in lasix from 60 to 120 daily. unclear precipitant of decompensation. . she was admitted to regular cardiology floor then trasnferred to ccu for hypotn where cvl was placed and she was started on lasix drip and required dopamine drip hypotension. after 9l diuresis, dopamine was weaned off she was transitioned to po furosemide. she was diuresed a total of 17.5 litres and returned to her presumed dry weight of 60.1 kg. at time of discharge will be on torsemide 40 mg daily and will stay on metoprolol titrate 12.5 mg . lisinopril was being held for but can likely be restarted as outpatient. she was also started on isosorbide dinitrate and hydralazine for afterload reduction. . 2. hypercarbic respiratory failure: on hd 5 patient was noted to have increased work of breathing and over sedation. blood gas suggested poor ventilation and patient was emergently intubated. patient continued to be diuresed and had improvement in her oxygenation. while ventilated patient developed an acute metabolic alkalosis presumably from diuresis and was started on acetazolamide. patient's intubation was complicated by abscence of a cuff leak which was assessed by ent and pulmonology. patient was started on 2 days of decadron with spontaneous development of a cuff leak and extubation, which she tolerated well. post-extuabtion patient continued to have hypoxia off of nasal cannula. bal was sent, which grew out pcp (pneumocystis jirovecii/carinii). . 3. pcp: extubation, bal was collected and sent for gram stain and culture, which was positive for pcp. cd4 count was 50, hiv was negative. to rule out acute hiv infection, htlv- and hiv viral load was sent and was pending at time of discharge. pt reported no significant risk factors for hiv infection except for a blood transfusion in that happened many years ago. she was started on bactrim ds tid for three days and transitioned to bactrim ds and will need a total of 21 days of treatment to end on . she did not require any steroids, as she was not hypoxic post extubation. after 21 day course pt will need to be started on pcp prophylaxis unless etiology of immunodeficiency is determined and reversable . # arf: pt had a cr of 2.3 on admission up from a baseline of 1.5. the presumed etiology was from poor forward flow and increasted out patient diuretic dose. as patient was aggressively diuresed with lasix drip her creatinine initial rose to a max of 3.0 before trending down. urine electrolytes confirmed a prerenal etiology. at the time of discharge patient's creatine was 2.9, but stable. cr of 2.8-2.9 is likely a new baseline for her. . # a. pt on warfarin as outpt. inr was transiently increased to >5 at time of intubation despite withholding coumadin. inr was very slow to trend back to therapeutic level. at time of discharge inr was 2.5 on dose of 2mg daily. . #ams: with decreased rr and acidemia requiring intubation on . likely secondary to taking trazodone 75mg in setting of renal failure. after extubation, pt's mental status returned to baseline. . #anemia: hct dropped from 38.5 on admission to 29.8 by hospital day three. stool guiauc was negative and only active bleeding that she had was transient epistaxis. over last ten days of hospitalization her hct remained stable. hemolysis labs were negative, ferritin elevated likely secondary to acute inflammatory response. will need to have further workup as outpt. . fen: 1.5 l fluid restriction speech and swallow eval at discharge: recommendations: 1. po diet: nectar-thick liquids, moist, ground solids. 2. pills whole or crushed with puree or nectar as tolerated. 3. assistance with meals set up and feeding as needed. 4. encourage po intake. 5. tid oral care. 6. pt will benefit from swallowing services upon d/c. recommend repeat video swallow prior to considering upgrade of liquids given silent aspiration noted on today's exam. . transitional: - needs f/u for htlv and hiv viral load and immunodeficiency/anemia work up - inr needs to be checked in 3 days adjust coumadin as needed - bactrim ppx as above - holding lisinopril until resolves, should restart as outpt and transition from metoprolol tartrate to metoprolol succinate as well medications on admission: metoprolol succinate 25 mg tablet sustained release 24 hr daily furosemide 120 mg daily (newly increased from 60mg daily previously) warfarin 2 mg po daily zolpidem 5 mg tablet qhs prn calcium carbonate-vitamin d3 500 mg(1,250mg) - 400 unit po bid trazodone 75 mg qhs prn lisinopril 5 mg daily nystatin powder discharge medications: 1. warfarin 2 mg tablet sig: 0.5 tablet po once daily at 4 pm. 2. docusate sodium 50 mg/5 ml liquid sig: one (1) tab po bid (2 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for constipation. 4. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 5. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 6. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 7. hydralazine 10 mg tablet sig: one (1) tablet po q8h (every 8 hours). 8. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). 9. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day) for 16 days: last day . discharge disposition: extended care facility: health care center discharge diagnosis: pneumocystis jirovecii pneumonia acute pulmonary edema uremia gi bleed acute on chronic kidney injury discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you had a trouble breathing and was admitted to the ccu at . you were found to be fluid overloaded and required intravenous diretics to remove fluid. you also were diagnosed with a pneumonia and needed antibiotics to treat this. you were on a breathing machine to help you breathe and had some bleeding when the tube was removed. your kidneys worsened because you were so sick. you are at risk for fluid buildup again. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. you had some bleeding during your hospital stay and was started on pantoprazole. you will need to have an evaluation of your stomach and colon in the future to see where the bleeding is coming from. . we made the following changes to your medicines: 1. change metoprolol to 12.5 mg twice daily 2. please hold lasix for now with rising creatinine. 3. decrease warfarin to 1mg daily. goal inr is 2.0-3.0 4. discontinue zolpidem, trazadone and lisinopril. 5. start hydralazine and isordil to replace the lisinopril until your kidney function improves 6. start colace, miralax and senna to prevent constipation 7. start heparin injections to prevent blood clots 8. start bactrim to treat your pneumonia followup instructions: department: west clinic-nephrology when: tuesday at 1 pm with: , md building: de building ( complex) campus: west best parking: garage . department: cardiac services when: monday at 2:20 pm with: , md building: campus: east best parking: garage . department: infectious disease when: thursday at 1 pm with: , m.d. building: lm campus: west best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube arterial catheterization closed [endoscopic] biopsy of bronchus central venous catheter placement with guidance diagnoses: thrombocytopenia, unspecified anemia, unspecified coronary atherosclerosis of native coronary artery urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified atrial fibrillation personal history of malignant neoplasm of breast paroxysmal ventricular tachycardia acute respiratory failure pneumocystosis cardiogenic shock long-term (current) use of anticoagulants acute on chronic combined systolic and diastolic heart failure dysphagia, oropharyngeal phase 

Answer: The patient is high likely exposed to