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: dyspnea major surgical or invasive procedure: thransthoracic echocardiogram transesophageal echocardiogram tunnelled dialysis catheter placed picc line placed renal biopsy right heart catheterization history of present illness: ms. is a 62 yo f w/ h/o dm2, living unrelated kidney transplant , pvd s/p several toe amputations, cad s/p cabg, dchf, htn, hyperlipidemia, obesity, osa, current tobacco abuse, presumed copd with home o2 requirement, a fib s/p ablation, h/o dvt on coumadin who was admitted to osh with sob. o2 sat in ed 89% unclear if this was on any o2. she also had leg swelling, no cp or cough. cxr on admission showed moderate chf, bnp 8500. . review of osh records show that she was admitted there from for sob, chf treated with lasix gtt. during this admission, she also had a flutter and an ablation. admission for ams thought proteus uti treated with ertapenem and arf to high 1's from baseline 1.2. admission for ams e coli uti treated with bactrim, arf, hyponatremia, chf diuresed on lasix gtt, noted r pleural effusion. . of note the records of this 10 day hospitalization at the osh are remarkable for lack of completeness. cr there trended nadired at 1.7 on -2 and then slowly rose to 2.3 on when pt was transferred. of note, admission wt there was 130.3 kg and weights there seem to have varied wildly but trended to 124.6 on . she was also treated with a 10 day course of ceftriaxone and bactrim ending for presumably uti. pt was on bumex for 1 day ending . was also on lasix gtt from admission until . pt recieved 1 dose metolazone . of note, the pt states she has had 5 admissions this year with 1 at where a stent was placed about 1 mo ago. states most admissions for fluid overload and 4 with uti. . pulm c/s at states pt was on ativan for agitation; pt confirms high anxiety treated with this medication. pt had been afebrile for entire hospital course up to that time, o2 sats were 94% on 5l o2, wbc 6, hct 27.9, plt 168k. she was noted to be excessively sleepy that day while talking to the consultant. they recommended continued diuresis and stated she had lost significant weight on lasix gtt. inpt sleep study was ordered at that time (records could not be located at this time at osh) and she was placed on empiric bipap with o2. ct chest was also recommended (although records of this could not be found o/n). renal was consulted on admission as was cardiology. she was ruled out for an mi. of note, in cards consultation, she stated she had a stent 1 mo ago but cards could not find records of this (likely b/c per pt this was at ). . on arrival to the floor, pt states she is depressed, scared and afraid to go to sleep. states she often needs ativan for her anxiety in house. she denies any pain. she states she was put on bipap at osh but woke up in a panic with a sore throat from this. also c/o epistaxis at osh. does c/o sob. pt states she does not recall all events from the osh as she is often delerius in the hospital. c/o morning nausea and headache at osh. c/o constipation. . ros: denies fever, chills, cough, chest pain, abdominal pain, vomiting, diarrhea, brbpr, melena, dysuria, hematuria. past medical history: esrd s/p living unrelated renal transplant dm c/b retinopathy and neuropathy htn cad s/p cabg diastolic heart failure w/ nl ef per osh records a fib s/p ablation hyperlipidemia pvd h/o chronic le ulcerations s/p several toe amputations and debridements - h/o pseudomonas and vre. s/p bl le revascularization osa- scheduled to start bipap as an outpt hypothyroidism current smoker presumed copd on home o2 (pt apparently unable to complete outpt pfts at osh) obesity h/o dvt on coumadin anxiety depression tia urinary incontinence . social history: smokes 10 cigarettes per day, denies heavy alcohol use, denies other drug use. lives with husband, does not work family history: father died of bulbar palsy, mother died of mi but per chart had als. brothers with dm physical exam: vitals - t:98.4 bp:116/53 hr:66 rr:20 02 sat: 99% on 3l nc general: obese, anxious f in nad heent: perrl, ncat, sclera anicteric. cardiac: regular, 3/6 systolic murmur heard best at rusb lung: decr bs on left base with bronchial bs in whole of left lung. r side with crackles way up lung field abdomen: obese, + bs, soft, non-tender incl over renal transplant site at rlq. ext: stage 1 decub l heel, stage 1 sacral decub. 1+ pe bilat, 1+ dp bilat neuro: pt not oriented to date. knows month and year as well as hospital. oriented to person. cn 2-12 grossly intact. appropriate throughout conversation. pertinent results: 09:40pm pt-29.3* ptt-38.1* inr(pt)-2.9* 09:40pm plt count-207 09:40pm wbc-6.0 rbc-3.13* hgb-9.2* hct-29.2* mcv-93 mch-29.4 mchc-31.5 rdw-17.1* 09:40pm calcium-8.8 phosphate-4.4 magnesium-2.9* 09:40pm estgfr-using this 09:40pm glucose-213* urea n-64* creat-2.6*# sodium-138 potassium-3.8 chloride-92* total co2-35* anion gap-15 09:58pm urine rbc-0 wbc->50 bacteria-few yeast-none epi- trans epi- 09:58pm urine blood-neg nitrite-neg protein-75 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-mod 09:58pm urine color-straw appear-hazy sp -1.014 09:58pm urine osmolal-352 09:58pm urine hours-random urea n-404 creat-96 sodium-12 potassium-66 tot prot-40 prot/crea-0.4 creatinine 2.6 -> 4.4 urine culture (final ): yeast. ~3000/ml. urine culture (final ): yeast. 10,000-100,000 organisms/ml.. urine culture (final ): no growth. 4:56 pm pleural fluid gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (preliminary): no growth. 9:18 am pleural fluid gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (preliminary): no growth. pleural analysis wbc rbc polys lymphs monos eos baso meso macro other 09:18 45* * 7* 67* 21* 4* 1* 1 16:56 83* * 32* 19* 36* 4* 3* 3* 2* reactive mesothelial cell reviewed by on mesothelial cell,refer to cytology report reviewed by ,md on pleural chemistry totprot glucose ld(ldh) albumin cholest 09:18 2.3 151 83 12 16:56 2.6 166 100 1.7 21 ph 12:41 7.471 09:33 7.451 both pleural fluid analyses consistent with transudative effusions brief hospital course: ms. is a 62 yo f w/ h/o dm2, living unrelated kidney transplant , pvd s/p several toe amputations, cad s/p cabg, dchf, htn, hyperlipidemia, obesity, osa, current tobacco abuse, presumed copd with home o2 requirement, a fib s/p ablation, h/o dvt on coumadin who was admitted to osh with sob now being transferred for persistent dyspnea, arf. . # dyspnea/hypoxia- despite 10kg wt loss on lasix gtt at osh, pt remained fluid overloaded on exam; however, review of records showed discrepancy of weights at time of presentation at osh, so question degree of volume loss. no note made in osh records of thoracentesis of these in the past. patient was hypoxic to 68% on room air following transfer, improving with supplemental oxygen. suspect dyspnea is multi-factorial, and effusions, decreased vital capacity with elevated frc (? component of obstruction given tobacco abuse), and perhaps exacerbated by osa. no e/o infection. inr initially therapeutic, low suspicion for thromboembolic disease. suspect hypoxia v/q mismatch in setting of volume overload. plain films showed moderate sized effusions, right > left, and patient underwent bilateral thoracentesis, with subsequent recurrence of pleural effusions. aggressive diuresis with metolazone and furosemide, then diuril with furosemide, with 1 to 1.5 liters of urine output daily. tte showed diastolic dysfunction, notable mr, providing likely etiology of effusions in setting of diastolic left heart dysfunction. pleural fluid cytology negative for malignant cells, and fluid was transudative. cardiac enzymes were negative. optimized hemodynamics with good bp and hr control. cardiology was consulted and recommended a right heart catheterization, which was performed and showed elevated wedge and pulmonary artery pressures. patient was subsequently transferred to the ccu. while in the ccu, patient was diuresed initially with metolazone and lasix and subsequently with bumex and metolazone. she was diuresed with a goal of diastolic pap 15-20. her pleural fluid was re-tapped on for comfort. a repeat chest ct was done that showed pleural effusions, air trapping. diuresis was continued but with very little improvement in her pap and wedge. it was suspected that mitral regurgitation contributes to her shortness of breath. patient was electively intubated for to evaluate degree of mr. showed mild mr. ultimately, , patient was started on hemodialysis. pt was electively intubated for on , she was on mask ventilation beforehand and would not have tolerated procedure without intubation due to impaired oxygenation. she was difficult to wean off intubation immediately after the procedure. she was changed to pressure support only on but was not awake enough to attempt extubation. sedation was progressively decreased until she was successfully extubated on . after extubation, pt failed a swallowing assessment and had a ng tube placed to provide feedings and medications. she pulled out her ngt during episode of delirium/sundowning s/p extubation but was able to resume po 3 days later. her sob has been improving until day of discharge and she has adequate oxygen saturations (high 90s). . # arf with h/o type ii dm, esrd s/p renal transplant - pt with cr nadir 1.7 at osh trended to above 4 during her course. suspect vascular congestion, volume overload contributing to poor renal perfusion and suggestion of intravascular volume depletion based on urine lytes. pt just completed 10d course of bactrim and ceftriaxone at osh. ultrasound read suggests rejection, no e/o hydronephrosis. initial biopsy result not consistent with acute rejection, more consistent with chronic allograft nephropathy. tacrolimus was converted to sirolimus. a temporary hd line was placed and ultrafiltration was started. first day 4l were taken off. pt continued to receive rapamycin and her levels were monitored daily. pt was continued on dialysis in the ccu because of rising cr levels and electrolyte imbalances. renal team was following pt and thought that she may require permanent hd though kidney may recover some function in the future. a permanent tunneled cath was placed and she was continued on hd with plans to continue as outpt. at the time of d/c, she was producing urine but incontinent. she will aslo follow with transplant nephrology. . # chf- likely cause of sob - see above. pt currently not eligible for acei/ for medical optimization given renal issues. continued metoprolol, simvastatin, hydralazine, and isosorbide dinitrite with diuresis as above. her sob has improved since hd and fluid removal, but she continues to have some peripheral edema. cxr immediately prior to discharge showed resolved pulmonary effusions and is much improved from last study. pt was started on ipratropium nebs as she reports hx of copd but does not use nebs at home. we monitored closely her i+os and daily weights. overall, she is improved from admission. . # pt trending hct down over last several days at osh from 32 to 29 here. pt with high risk for bleeding on anticoagulation but also getting phlebotomized. inr normalized following discontinuation of warfarin in setting of renal biopsy. her coumadin was restarted for a fib on tele . inr was monitored and stable. pt was started on epogen infusions with hd to improve anemia. . # osa- empirically started on bipap at osh prior to transfer. patient likely has component of osa given body habitus. mild hypercarbia on abgs. monitored on continuous pulse oximetry overnight, with one desat to 88% overnight, no indication for positive airway pressure as inpatient, plan for outpatient evaluation. pt is s/p intubation and extubation for , she was successfully extubated. . # pt had fairly steady blood sugar measurements during admission. she was restarted on glargine at 10u and titrate up to her home dose of 50u. finger sticks were measured qid. . # pt's bp was controlled throughout admission on amlodipine 10mg qd and metoprolol tartrate 75mg . . # anxiety- cont duloxetine and sw consulted. pt became depressed after learning that she may need permanent hd. duloxetine was changed to venlaxafine because of hd. lyrica was added, which she was taking at home. . # h/o a fib- on warfarin; had ablation earlier this year for a flutter. warfarin and were discontinued in setting of renal biopsy and continued to be held for procedures (thoracocentesis). pt had an episode of a fib on and coumadin was restarted at 5mg, inr closely monitored. dose later increased to 10mg, which is her home dose. . #uti - pt had cloudy urine in foley on , culture was positive for enterococcus on 6.27. pt was started on ampicillin (despite unclear documentation of previous allergy bc cultures were sensitive to amp) but had severe nausea as reaction. she was switched to vanco 1g daily, dosed with her hd. trough levels came back low (7) after 3 days of vanco so her total daily dose of 1.25g - she should receive 1g with hd and 250mg ( of 500mg tablet) after hd. vanco trough levels should be measured before hd at outpt center. medications on admission: atorvastatin 20 mg tablet qpm bupropion hcl 100 mg tablet 1.5 tablet(s) by mouth twice a day duloxetine 60 mg capsule, delayed release(e.c.) 1.5 capsule(s) by mouth furosemide 40 mg tablet 2 tablet(s) by mouth once a day insulin glargine 100 unit/ml solution 50 q am insulin lispro 100 unit/ml solution per sliding scale lisinopril 20 mg tablet 1 tablet(s) by mouth once a day metoprolol tartrate 50 mg tablet 1 tablet(s) by mouth twice a day mycophenolate mofetil 500 mg tablet 1 tablet(s) by mouth twice a day omeprazole 20 mg capsule, pregabalin 75 mg capsule 1 capsule(s) by mouth once a day risperidone 0.5 mg tablet 1 tablet(s) by mouth once a day sulfamethoxazole-trimethoprim 400 mg-80 mg tablet 1 tablet(s) by mouth once a day tacrolimus 1 mg capsule 1 capsule(s) by mouth twice a day warfarin 10 mg tablet 1 tablet(s) by mouth once a day aspirin 325 mg tablet, delayed release (e.c.) 1 tablet(s) by mouth once a day multivitamin tablet 1 tablet(s) by mouth once a day (otc) . medications on transfer: .albuterol neb q 4 hrs prn .ascorbic acid 500mg .aspirin 325 daily .amlodipine 10mg daily .duloxetine 60mg daily .hydralazine 50mg po tid .insulin glargine 20u qhs .humalog insulin ss 4 times daily .lactulose 20gm .metoprolol tartrate 75mg .cellcept 500mg .nystatin topical tid .pregabalin 75mg .ranitidine 150mg daily .simvastatin 20mg qhs .bactrim ds mwf .tacrolimus 1mg q 12 hrs .coumadin doses daily ranging from 5mg to 10mg .zinc 220mg daily discontinued inpatient meds incl bumetanide, docusate, clonidine, mvi, risperdal discharge medications: 1. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 5. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po daily (daily) as needed for constipation. 6. metoprolol tartrate 25 mg tablet sig: three (3) tablet po bid (2 times a day): hold sbp <100, hr < 55. 7. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po bid (2 times a day). 8. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for fungal rash. 9. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 10. simvastatin 20 mg tablet sig: one (1) tablet po at bedtime. 11. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po days (mo,we,fr). 12. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 13. multivitamin tablet sig: one (1) tablet po daily (daily). 14. sirolimus 1 mg tablet sig: 1.5 tablets po daily (daily). 15. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 16. heparin (porcine) 1,000 unit/ml solution sig: 4,000-11,000 units injection prn (as needed) as needed for line flush. 17. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 18. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 19. warfarin 10 mg tablet sig: one (1) tablet po once a day. 20. ipratropium bromide 0.02 % solution sig: one (1) vial inhalation q6h (every 6 hours) as needed for sob. 21. venlafaxine 37.5 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 22. lorazepam 0.5 mg tablet sig: 1-2 tablets po tid (3 times a day) as needed for anxiety. 23. nicotine 7 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily): stop after 2 weeks. 24. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 25. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 26. vancomycin 1000 mg iv hd protocol 27. lorazepam 0.5-1 mg iv q12h:prn nausea hold for somnolence 28. pregabalin 75 mg capsule sig: one (1) capsule po daily (daily): please give after dialysis on dialysis days. . 29. vancomycin 500 mg recon soln sig: intravenous once a day for 2 days: please give 250mg after dialysis sessions where pt receives 1g. total daily dose should be 1.25g. please check vanco trough levels before hd. discharge disposition: extended care facility: - discharge diagnosis: primary: acute on chronic diastolic congestive heart failure end stage renal disease . secondary: coronary artery disease hypertension chronic obstructive pulmonary disease mild mitral regurgitation urinary tract infection 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 were admitted to the hospital because of your shortness of breath. we treated you with intravenous medications to get rid of the fluid in your lungs. we also drained some of the fluid in your lungs. we believe that your shortness of breath was from heart failure. your kidney transplant is failing and we had to place a tunnelled catheter and resume dialysis. please talk to your kidney doctors about whether they think your kidneys will recover. we have made the following changes to your medications: 1. start vancomycin for enterococcus in your urine. your last day will be for total of 7 day course. 2. stop taking isordil, chlorthiazide, furosemide, hydralazine duloxitine, and albuterol nebs. 3. start taking vitamin c, zinc and mvi for wound healing. 4. start senna, colace and lactulose as needed for constipation 5. start miconazole powder for your rash 6. start sevelamer to lower your phosphate 7. start tylenol for your pain 8. change cymbalta to vanlafaxine for your depression. 9. start vancomycin for a urinary tract infection 10. start lorazepam as needed for anxiety 11. decrease your glargine to 10 units in the morning 12. start humalog sliding scale before meals. .... weigh yourself every morning, notify provider if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. followup instructions: urology: department: surgical specialties when: at 1:30 pm with: , md building: campus: east best parking: garage . primary care: provider: , md phone: date/time: 4:30 , , phone: fax: . : department: hemodialysis when: saturday at 12:00 pm department: medical specialties when: tuesday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: cardiology . cardiology: name: dr. when: thursday at 11:15 am location: medical address: , , , phone: md, procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart insertion of endotracheal tube hemodialysis venous catheterization for renal dialysis thoracentesis thoracentesis closed [percutaneous] [needle] biopsy of kidney right heart cardiac catheterization diagnoses: obstructive sleep apnea (adult)(pediatric) tobacco use disorder mitral valve disorders unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified chronic airway obstruction, not elsewhere classified atrial fibrillation acute on chronic diastolic heart failure coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status other and unspecified hyperlipidemia morbid obesity long-term (current) use of anticoagulants personal history of venous thrombosis and embolism complications of transplanted kidney 

Answer: The patient is high likely exposed to