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: attending: chief complaint: increased lower extremity edema and change in mental status major surgical or invasive procedure: none history of present illness: this is an 84 yo female with a history of dementia, htn, hypothyroidism, tia () who is being transferred to the ccu for hypotension, hypoxia, and altered mental status. she was initially admitted overnight on to the general medicine service. she presented from a long term care facility with increased confusion and new lower extremity edema. her daugheter expressed that her mother had decreased appetite and confusion over the last 10 days. doctors at nursing home started her on remeron. per her nursing facility records she gained 10 lbs in 2 days. presumably for this reason she was referred for a cardiology evaluation (appt scheduled with dr. .) however, she became increasingly confused and unable to take , she was referred to ed. . in the ed, vs: 96.4 73 123/91 18 97% on 4l. patient agitated and given haldol 5mg iv x 1. she also received 1mg iv ativan prior to ct head which was negative. a cxr showed bilateral pleural effusions l>r and moderate pulmonary edema. ecg was read as unchanged from prior tracing . troponin was .29, rising to 0.36. bnp was >8000. cardiology was consulted and felt this troponin bump most likely attributed to heart failure rather than acs. patient admitted to medicine for further work-up of chf. . upon arrival to the floor, patient had a 4 l o2 requirement and appeared volume overloaded. abg 7.44/73/32 on 4l. she was given 80 mg iv lasix, after which she made 700 cc urine within 1 hour. sbp fell from baseline 140s to a low of 67. her mental status continued to be arousable but drowsy. she was given ~100 cc ns and sbp rose into the 80s. notably, her respiratory status apparently improved and o2 sats rose to upper 90s on 4l. . there was suspicion for pulmonary embolism as a cause of her hypoxia. ct for pe could not be done secondary to poor renal function. echocardiocardiogram was done to evaluate for signs of r heart strain, and indeed demonstrated severe rv dilatation and abnormal septal motion consistent with rv pressure/volume overload new compared to prior echo 10/. pa pressures could not be estimated. small pericardial effusion was also noted. heparin gtt without initial bolus was started for empiric treatment of pe. . the patient's urine output trailed off to ~15cc/h, her sbp remained in the 80s, and her mental status continued to be suboptimal. transfer to the ccu was initiated for workup of new rv dilatation, apparent r sided heart failure, further diuresis in the setting of borderline hypotension and preload dependence, and altered mental status. . on arrival to the ccu, patient was initially lethargic and could provide only limited information. she denied any difficulty breathing or chest pain. she further denied nausea or abdominal pain. her only complaint is feeling extremely cold. past medical history: (per nursing facility records and omr): htn tia dementia hypothyroidism, hx disease, s/p rai rx anemia urge incontinence osteopenia vitamin b12 deficiency social history: patient currently resides at nursing center in after being hospitalized at for burns she sustained on her legs 2/. at that time she was found to be living in sub-optimal conditions with her daughter in a run-down house which was poorly insulated therefore needing a lot of space heaters that led to pts burns. pt was also appointed a healthcare proxy. current tobacco, alcohol, or ivda. (per omr) family history: per daughter: brother with cancer in his 60s or 70s. sister with breast cancer in her 70s. another sister with thyroid cancer, ?kidney/pancreas mass. per omr: her mother "dropped dead" in her 40s/50s in front of her (sudden death). her sister "dropped dead" at age 23 in front of her (sudden death). her father died in his 50s of unknown cause, and had a history of arthritis. she has 11 siblings who have died, none suddenly or from known cardiac causes. physical exam: vitals - temp 99.6 rectally bp 146/53 hr 71 rr 23 sat 99% 3l nc general: lethargic appearing african american female, arousable to sternal rub and drowsy during examination heent: normocephalic, atraumatic. no scleral icterus. pupils constricted bilaterally. mmm. op clear. neck supple, no lad cardiac: regular rhythm, normal rate. normal s1, split s2. no murmurs, rubs or gallops. no pericardial knock. appropriate decrease in jvp with respirations. no pulsus parodoxus. no hepatojugular reflex appreciated. lungs: dependent crackles currently laying on the left side. decreased breath sounds at the bases. abdomen: normal active bs. soft, nt, nd. no hsm extremities: 2+ le edema r>l dopplerable dp/pt bilaterally. skin: no rashes/lesions, ecchymoses. scar on right shin well healed. neuro: aox 1 (person) she is under the impression that she's currently at "." moving all 4 extremities. unable to perform rest of neurologic evaluation given pt would not comply. grossly face is symmetric. pertinent results: labs on admission: 07:45pm blood wbc-4.7 rbc-5.97*# hgb-14.8 hct-44.3# mcv-74* mch-24.7*# mchc-33.4 rdw-17.7* plt ct-144* 07:45pm blood neuts-71.8* lymphs-20.8 monos-6.8 eos-0.4 baso-0.2 11:30am blood pt-15.7* ptt-40.1* inr(pt)-1.4* 07:45pm blood glucose-131* urean-21* creat-1.3* na-134 k-4.6 cl-104 hco3-22 angap-13 07:45pm blood free t4-1.3 07:45pm blood tsh-3.7 07:45pm blood calcium-8.8 phos-3.7 mg-2.1 cardiac enzymes: 07:45pm blood ck(cpk)-55; ck-mb-5 probnp-8096*; ctropnt-0.29* 01:08am blood ck-mb-5; ctropnt-0.36* 11:30am blood ck(cpk)-135; ck-mb-5 ctropnt-0.43* 07:00pm blood ck(cpk)-114; ck-mb-5 ctropnt-0.44* 01:25am blood ck(cpk)-97; ck-mb-notdone ctropnt-0.46* 04:45am blood ctropnt-0.36* relevant interval labs 11:40pm blood lmwh-0.4 11:30am blood albumin-3.1* calcium-8.3* phos-3.5 mg-2.0 11:30am blood d-dimer-5451* labs at discharge: 07:30am blood wbc-4.4 rbc-5.37 hgb-13.1 hct-40.1 mcv-75* mch-24.4* mchc-32.7 rdw-18.7* plt ct-134* 07:30am blood pt-31.7* ptt-68.9* inr(pt)-3.2* 07:30am blood glucose-101 urean-20 creat-1.1 na-145 k-4.0 cl-110* hco3-26 angap-13 microbiology urine cx: no growth. blood cx: no growth. blood cx: no growth. studies: ecg : sinus rhythm. consider left atrial abnormality. indeterminate axis. there is an si-q3-t3 pattern. modest right ventricular conduction delay pattern. delayed r wave progression with late precordial qrs transition. diffuse t wave abnormalities. findings are non-specific but clinical correlation is suggested for possible right ventricular overload. compared to the previous tracing of findings as outlined are now present. echo : the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is markedly dilated. right ventricular regional function cannot be assessed. there is abnormal systolic septal motion/position consistent with right ventricular pressure overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is mild mitral valve prolapse. trivial mitral regurgitation is seen. the supporting structures of the tricuspid valve are thickened/fibrotic. there is at least borderline pulmonary artery systolic hypertension. there is a small pericardial effusion. the effusion appears circumferential. impression: suboptimal image quality. severe right ventricular dilation. abnormal septal motion consistent with right ventricular pressure/volume overload. pulmonary pressures cannot be adequately assessed. preserved global systolic function. small circumferential pericardial effusion. compared with the prior study (images reviewed) of , severe right ventircular dilation is now present. the right ventricle appears to have been mild to moderately dilated on prior study, but views were limited. cxr : ap chest compared to , 3:46 a.m., heterogeneous bibasilar opacification has worsened. in the setting of progressive moderate-to-severe cardiomegaly and upper lobe vascular engorgement, this is most readily explained by dependent pulmonary edema, but pneumonia particularly aspiration could be contributing. bilateral pleural effusion is at least small. leftward deviation of the trachea at the thoracic inlet developed since could be due to progressive tortuosity of the innominate artery or interval development of a space-occupying lesion, most commonly a goiter but not necessarily benign. when feasible, clinical evaluation is recommended. cxr : opacification at the lung bases is improving and moderate cardiomegaly may have improved as well all pointing toward decreasing cardiac decompensation and improving pulmonary edema. small bilateral pleural effusions persist left greater than right. the greater extent of opacification at the left lung base makes pneumonia a possibility. leftward displacement of the trachea at the thoracic inlet points to a space occupying lesion such as a goiter, but requires evaluation since this is a new finding since . dr. was paged. ekg : sinus rhythm. non-specific st-t wave changes. compared to the previous tracing of ventricular ectopy is resolved. cta chest : dilatation of the right atrium, ventricle, and pulmonary artery with filling defect in the main pulmonary artery which extends into the left pulmonary arteries. there is also bowing of the interventricular septum suggesting right heart strain. this filling defect in the pulmonary artery could represent a saddle embolism, however, due to the increased density of contrast and early bolus timing, mixing artifact in the pulmonary artery should also be considered. the case was discussed with dr. and a decision to anticoagulate and repeat the study at a later date was planned due to elevated creatinine. moderate-to-large bilateral pleural effusions. brief hospital course: 84 yo female with dementia (aao x ), cad s/p nstemi in , tia in , hypothyroidism, stable meningioma p/w increased lethargy, weight gain, and le edema, hypoxic to 94% 4l on presentation found to be in acute right sided diastolic failure secondary to pulmonary embolism. 1. acute diastolic right heart failure: on , pt with severe rv dilatation new since , at least borderline pa systolic htn, and nl lvef. lenis negative and subsequent cta equivocal (saddle-embolic v. mixing artifact w/ suboptimal study) but submassive-massive subacute pe most likely etiology of rv failure; lv failure may have been due to rv impingement of lv filling. pt was started on heparin for treatment of pe, and later transitioned to warfarin 5mg with lovenox bridging. lovenox was discontinued on given supratherapeutic inr of 3.2, and warfarin held and restarted at 2.5mg on . pt's inr to be monitored at longterm nursing facility with goal inr . she will likely require at least a one-year course of anticoagulation given her degree of cardiac impairment, with the duration to be weighed against the risk of bleed. her asa was decreased to 81mg daily given starting of warfarin. 2. left heart failure: pt fluid overloaded on presentation. showed nl ef although some degree of diastolic dysfunction was suspected. it was postulated that rv dilatation have been impinging on lv filling and forward flow due to the septal wall motion abnormality observed. pt was transferred to ccu initially as she became hemodynamically unstable in the setting of diuresis, likely due to her preload dependence. in the ccu, she was first diuresed with a furosemide drip, then transitioned to iv boluses and with good effect. she was transferred back to the floor after ~2.5l diuresis with stable bp and o2 sats 90-94% ra. she appeared to have improving forward flow and on discharge, o2sat 93% on ra and furosemide requirement 20 mg po daily, with possibility of weaning patient off furosemide in outpatient setting. patient did have some desaturation to 80s% during night, possibly osa, but cpap would not be tolerated due to her dementia. . 3. acute renal failure: baseline creatinine 0.9. on admission, it was 1.3, reaching a peak of 1.4 in the ccu. this was thought secondary to poor forward flow in the setting of chf. this improved back to baseline with diuresis. she did receive mucomyst for her cta chest, and all of her medications were renally dosed. . 4. confusion/lethargy: patient with waxing and level of consciousness on admission as well as intermittent disorientation. this was likely secondary to medication effect from ativan and haldol received in the ed as well as due to acute illness including hypoxia and hypotension. ct head negative; urine culture negative, and blood cultures with no growth; tfts nl; electrolytes nl; bun elevated but not frankly uremic level. her remeron (started recently for anorexia) was held. her mental status significantly improved within 48 hrs with pt becoming more animated and interactive although she was unable to state the season, dob, and where she currently resides. she did have several nights of agitation requiring soft restraints and iv haldol, but 2 nights before discharge, patient slept through the night and did not require chemical or mechanical restraints. patient was oriented x1 by discharge, which appears to be similar to baseline dementia. . 5. anorexia: daughter and hcp reported declining ability to take po. possibly secondary to worsening dementia vs. subacute medical illness. remeron was recently started for this, unclear if this had been helpful. as mentioned above her remeron was held since it was thought to possibly be contributing to her change in mental status. a nutrition consult was requested, and they recommended low sodium diet of pureed solids, thin liquids, and ensure supplements. because the patient did not consistently finish po meals, nutrition recommended 1584 kcal/70g protein tube feeds at 55 ml/hr if it was consistent with the patient's goals of care. the patient's guardian stated that tube feeds were not desired at this time. a speech and swallow consult was sought since patient has dementia and is at risk for aspiration. we encourage supervised feedings once the patient returns to her nursing home. . 6. bradycardia: pt had been on metoprolol per nh records although this had been discontinued per her most recent pcp note in due to possible role in tia. she also had been noted to have asymptomatic episodes of bradycardia to 30s in the past which were also observed on this admission. for these reasons, her metoprolol was once again discontinued on this admission. medications on admission: senna 2 tabs qhs asa 325 mg daily vitamin b12 1000mcg daily synthroid 125 mcg daily simvastatin 40mg daily colace 1 cap mylanta 30ml robitussin 10mg q4: prn cough tylenol 650mg q6hrs:prn milk of mag prn fleet enema prn remeron discharge medications: 1. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. senna 8.6 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for constipation. 5. cyanocobalamin 100 mcg tablet sig: ten (10) tablet po daily (daily). 6. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed for constipation. 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 8. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 9. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm. 10. milk of magnesia 400 mg/5 ml suspension sig: ml po twice a day as needed for constipation. discharge disposition: extended care facility: rehabilitation & nursing center - discharge diagnosis: primary: - massive pulmonary embolism - acute diastolic heart failure - non-thrombotic troponin elevation - acute renal failure - delirium secondary diagnosis: - hypothyroidism - hypertension - dementia discharge condition: stable discharge instructions: you were admitted with increased lower extremity swelling, increased weakness, weight gain, and decreased oxygenation. you were found to have a clot in your lung that was responsible for fluid overload. you were initially admitted to the cardiac intensive care unit and was treated with medications to decrease fluid overload. you were also started on blood thinning medications. please continue your home medications with the following additions and changes: - you need to take warfarin (coumadin) blood thinning pills. - you need to take furosemide (lasix) to prevent fluid buildup. - please stop taking your metoprolol due to slow heart rate. - please stop taking your remeron due to leading to increased sleepiness. please weigh yourself daily. please call your primary care physician or return to the hospital if you experience any increased shortness of breath, palpitations, chest pain, lower extremity swelling, if you gain more than 3 lbs, or for any other concerning symptoms. followup instructions: provider: , md phone: date/time: 10:30 provider: , m.d. date/time: 12:20 procedure: venous catheterization, not elsewhere classified diagnoses: congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified other persistent mental disorders due to conditions classified elsewhere other specified cardiac dysrhythmias benign neoplasm of cerebral meninges old myocardial infarction personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits hypoxemia acute diastolic heart failure other malaise and fatigue other pulmonary embolism and infarction delirium due to conditions classified elsewhere disorder of bone and cartilage, unspecified other nonspecific abnormal serum enzyme levels anorexia other postablative hypothyroidism urge incontinence 

Answer: The patient is high likely exposed to