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: egg / morphine sulfate / propofol analogues attending: chief complaint: dyspnea major surgical or invasive procedure: 1. cardiac catheterization 2. cardiac stenting of left main coronary artery and right coronary artery 3. tunneled hemodialysis line placement history of present illness: mrs. is a 76 year old woman with cad (s/p bms to mid lad in ), schf (ef 40%), pvd s/p r axillobifemoral bypass with graft which the fem-fem is now occluded, carotid endarterectomy x 2 on the left last in , s/p sma pci, copd (on 2l nc), pes on coumadin who presents intubated/sedated from in setting of acute pulmonary edema, respiratory failure, oliguric , and critical left main disease. . patient was transferred from hospital. she had recently been discharged after treatment of pneumonia (unknown antibiotic course), and while at home in days after discharge, developed progressive dyspnea and possible fever. she denied sputum production or cough. bnp on admission was 1000, up from 600 during previous admission for pneumonia. she was started on zpack, ceftriaxone, and levofloxacin for pneumonia/copd exacerbation, and given iv lasix 20mg tid for pulmonary edema. she does not take lasix as an outpatient. she was noted to have a cr of 1.4 on admission, which rose to 4.8 with diuresis. lasix was discontinued and renal consult was obtained, who recommended stopping lasix, giving ivf for pre-renal azotemia, and changing levofloxacin to ampicillin. she was also found to have an enterococcus uti and started on unasyn. id and heme/onc consultations were obtained for leukocytosis 19 with left shift. both agreed that leukocytosis was likely reactive, but to treat pneumonia and uti, and to follow-up with outpatient records. patient does have chronic leukocytosis and thrombocytosis noted during prior admission to as well. per heme/onc consultation at that time, pattern appeared less likely to be mds, more likely to be reactive, possibly related to iron deficiency as well. patient was initiated on hd 4 days prior to transfer, received third run of hd today, during which she developed acute left-sided chest pain, , not radiating. she developed severe respiratory distress, was intubated, had then noted to have new inferiorlateral st depressions on her ekg (i and avl and v6) then goes to cath lab where they find 90% lm, 70% rca, but no interventions were performed. she was transferred to the ccu for further management. . unable to obtain ros as patient is intubated. past medical history: cad s/p pci to lad () chf l cea r axillobifemoral bypass with graft mult foot/ankle surgeries htn copd on home o2 (2l nightly, occasionally during the day) s/p nephrectomy incarcerated umbilical hernia s/p repair acute cholecystitis s/p cholecystostomy drainage asthma pe x 2 on coumadin ckd ischemic colitis, chronic s/p celiac and sma stents bladder cancer: recent treatment history at , she's had 3 procedures in the past couple years including chemical bath of the bladder. last 2 checks were clear. urologist is . social history: patient lives alone in an apartment building. she has one son that lives in another town. sister who used to live in the same building passed away. only goes grocery shopping once per month at times runs out of milk and bread. hx of tobacco 80 pack years no etoh, no drug use family history: father mi @ 60, mother ad, sister dm2. no hx of dvts, pes. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: physical examination on admission: vs: t98.4 bp= 111/59 hr=91 rr=20 o2 sat= 98(intubated) general: intubated, sedated, but arousable and can answer yes/no to questions heent: ncat. sclera anicteric. perrl. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: intubated, anterior lung exam revealed no crackles, wheezes or rhonchi. abdomen: normoactive bowel sounds, soft, ntnd. extremities: cold, clamy, faintly palpable dp and pt pulses b/l neuro: sedated but arousable, able to squeeze with both hands and move both feet to command . physical exam on discharge: 97.9 89 139/46 20 98% on 2l general: awake, in nad, aox2 heent: ncat. sclera anicteric. perrl. cardiac: rrr, normal s1, s2. grad ejection systolic murmur, loudest in rusb. no thrills, lifts. no s3 or s4. lungs: anterior lung exam revealed some crackles in bases, but no wheezes or rhonchi. abdomen: normoactive bowel sounds, soft, ntnd. extremities: faintly palpable dp and pt pulses b/l neuro: patient aox2, but still appears very weak. no gross deficits pertinent results: labs on admission: 10:00pm blood wbc-37.7*# rbc-4.37 hgb-12.1 hct-36.3 mcv-83 mch-27.7# mchc-33.3 rdw-19.3* plt ct-1013* 10:00pm blood neuts-76* bands-6* lymphs-2* monos-6 eos-2 baso-0 atyps-0 metas-7* myelos-1* 10:00pm blood hypochr-normal anisocy-2+ poiklo-2+ macrocy-1+ microcy-1+ polychr-1+ ovalocy-2+ burr-occasional tear dr 10:00pm blood pt-15.0* ptt-105.8* inr(pt)-1.4* 10:00pm blood glucose-135* urean-19 creat-2.6*# na-142 k-5.0 cl-102 hco3-24 angap-21* 10:00pm blood ld(ldh)-671* ck(cpk)-235* totbili-0.5 10:00pm blood calcium-8.9 phos-6.6*# mg-2.0 10:00pm blood hapto-305* . cardiac enzymes: 10:00pm blood ck-mb-24* mb indx-10.2* ctropnt-0.55* 02:04am blood ck-mb-23* mb indx-9.6* ctropnt-1.00* 04:16pm blood ck-mb-11* mb indx-5.2 ctropnt-1.18* . lactates: 10:37pm blood lactate-2.7* 04:33pm blood lactate-1.0 . tte : the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. lv systolic function appears moderately-to-severely depressed (ejection fraction 30 percent) secondary to akinesis of the septum and hypokinesis of the anterior free wall, inferior free wall, and lateral wall. contractile function of the posterior wall appears preserved. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid regurgitation jet is eccentric and may be underestimated. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. . renal ultrasound : impression: no hydronephrosis. no change from a ct in . . cardiac cath comments: 1. successful pci of the lmca with a 3.0x15mm promus des, post-dilated to 4.0mm. 2. successful pci to the rca with a 3.0x23mm promus des, post-dilated to 3.5mm. 3. terumo band to the right radial artery. 4. no complications. . final diagnosis: 1. two vessel coronary artery disease. 2. successful pci to the lmca and rca with promus des. 3. patient to remain on aspirin and clopidogrel indefinitely, without interruption. 4. no complications. . ct head impression: 1. left occipital lobe loss of -white differentiation could be related an acute on chronic infarct. an mr may be obtained for further evaluation. 2. left maxillary sinus fluid. . mri head impression: 1. chronic infarction identified in the left parietooccipital region with extensive area of encephalomalacia, associated chronic microvascular ischemic disease is present. 2. punctate areas of restricted diffusion are noted in the subcortical white matter on the right frontal lobe, left frontal convexity and right prefrontal region, likely consistent with small thromboembolic ischemic changes. 3. there is narrowing of the left internal carotid siphon and distal vascular branches, likely consistent with atherosclerotic disease as described above. 4. mucosal thickening is noted on the left maxillary sinus with air-fluid levels, possibly consistent with ongoing inflammatory process. . interventional impression: successful exchange of a temporary hemodialysis catheter for a 23 cm tunneled hemodialysis catheter. the catheter tip is in the right atrium. the line is ready to use. . cxr : findings: in comparison with the study of , the monitoring and support devices are essentially unchanged. continued opacification at the left base with blunting of the costophrenic angle, consistent with atelectasis and small effusion. less prominent changes are seen on the right. . carotid ultrasound impression: right ica 70-79% stenosis. cannot rule out more severe stenosis due to calcification. consider cta if clinically indicated. left ica no stenosis. on discharge: 140 98 50 ----------------< 106 4.8 30 4.2 ca: 8.8 mg: 2.6 p: 7.4 &#8710; wbc-17.4 hb-8.7 hct-25.7 plt-540 pt: 26.1 ptt: 150 inr: 2.5 brief hospital course: primary reason for hospitalization: mrs. is a 76 year old woman with cad (s/p bms to mid lad in ), schf (ef 40%), pvd s/p r axillobifemoral bypass with graft which the fem-fem is now occluded, carotid endarterectomy x 2 on the left last in , s/p sma pci, copd (on 2l nc), pes on coumadin who presents intubated/sedated from osh in setting of acute pulmonary edema, respiratory failure, oliguric , and critical left main disease. . active diagnoses: # cad: cardiac cath showed 90% lm, 70% rca lesion, no intervention was performed initially. initial ekg at osh showed severe ste in i and , depressions in lateral leads. repeat ekg on transfer looked improved although still with ste in i and . patient still endorses chest pain when asked. patient was initially on a heparin gtt and nitro gtt. ct surgery consultation believed patient was too high risk to take for cabg, due to multiple comorbidities. thus, patient was taken to cardiac cath and des were placed in left main and rca. she was continued on coreg 3.125 mg , captopril 6.25 mg tid, plavix 75 mg daily, atorvastatin 80 mg daily, aspirin 325 mg daily. she is to not stop aspirin or plavix without speaking to her cardiologist. . # respiratory distress. patient was initially intubated at osh for respiratory distress, thought to be secondary to pneumonia and pulmonary edema. patient was previously hospitalized a week prior to this current presentation for pneumonia (unclear course), discharged, and repeat cxr on admission looks like worsened pneumonia/chf. patient was diuresed at osh, but developed acute on chronic renal failure. renal consultation team thought was pre-renal azotemia, so patient was given ivf, and may have redeveloped pulmonary edema. at baseline, patient has severe copd on 2l oxygen at home. she was transferred intubated, sedated on cmv 400 x 14 50% fio2. fentanyl/versed was used for sedation, as patient is allergic to propofol. cvvh was later initiated for volume management. patient did well with risb and sbts, and was extubated once volume removal was achieved with dialysis. she remains on 2l nc on discharge, but oxygenates well on room air to 2l nc. . # altered mental status: as sedation was turned off to prepare patient for extubation, it was noted that she had prolonged ams and was not able to follow commands and did not have intact gag reflex. cvvh was continued to correct toxic-metabolic disturbances. ct head was obtained that showed question of ischemic injury in watershed zone between left mca/pca territories. a mri brain was obtained that showed no such infarction, but small areas of acute ischemia in the left frontal lobe. neurology consult was called, and these areas are believed to be too small to be the cause of ams. neurology recommended obtaining a carotid duplex for further evaluation of the acute ischemia. although patient had r ica stenosis, intervention was felt to be too high risk, and risks would likely outweigh benefits. her mental status slowly improved and she is near baseline per family on discharge. . # ckd: patient has solitary kidney, ckd stage iii. on admission to osh, cr was 1.4, but with diuresis had bumped to 4.8. was initially thought to be pre-renal, but after discontinuing lasix and giving ivf, did not show improvement in renal function, so likely atn. was initiated on hd at osh 4 days prior to transfer, had received 3 cycles at osh. osh work-up revealed that patient may have renal artery stenosis as evidenced by atrophic kidney (however, this could just be from ckd)and elevated renin and aldosterone. patient was maintaed on cvvh during this hospitalization. a temporary dialysis catheter was placed, and a tunneled line was then placed. ppd was confirmed negative. she will continue hemodialysis in rehab and outpatient setting. she is discharged on nephrocaps. epo should be initited with next session of dialysis. of note, renal recovery is possible for this patient and the need for hd should be continuously reassessed. . # uti: had enterococcus uti at osh and received 5 day course of unasyn prior to transfer. upon calling osh for speciation/sensitivity, it was found that enterococcus only sensitive to vancomycin, so patient has finished a 14 day course on . . # leukocytosis: patient had leukocytosis at osh up to 30. id and heme consults both thought could be reactive, secondary to infectious processes (pneumonia, uti). patient is also noted to have chronic leukocytosis and thrombocytosis, as noted in discharge summary in . at that time, heme/onc consultation also thought findings were reactive and not associated with hematologic malignancy. now, wbc 37.7 with 6% bands points to infectious etiology. as patient was treated for infection, leukocytosis trended down to 20s. bcr-abl pcr looking for cml was negative. hematology/oncology team felt that this could be a smoldering myeloproliferative disease with overlying component of infection. jak 2 returned positive, and there was a likely presumptive diagnosis of essential thrombocytosis vs other myeloproliferative disorders. . # thrombocytosis: patient has thrombocytosis to the millions. although this could be reactive, should assess other possible sources and hematologic disorder. jak2 mutation looking for myeloproliferative diseases was positive. platelet count trended down with treatment of infection, indicating a probably reactive etiology as well. plt count on discharge 540k. . # vasculopathy: patient is s/p r axillobifemoral bypass with graft which the fem-fem is now occluded, carotid endarterectomy x 2 on the left last in , s/p sma pci. she has been chronically anticoagulated on coumadin, but coumadin was held for hd line placement at osh. patient was later started on plavix and aspirin this admission and maintained on a heparin gtt. heparin gtt was discontinued when inr was 2.5. goal inr . . #. code status: full . transitional issues: # continue hd sessions at rehab and outpatient setting # speak and swallow consult # bladder scan daily, if >300cc, please straight cath medications on admission: clopidogrel 75 mg po daily tiotropium bromide 18 mcg capsule,1 inh daily fluticasone-salmeterol 250-50 mcg/dose disk 1 inh aspirin 325 mg tablet po daily coumadin 3 mg po daily diltiazem hcl sustained release 120 mg po daily clonidine 0.1 mg mg po tid nitroglycerin 0.3 mg sl prn chest pain metoprolol tartrate 100 mg po bid simvastatin 80mg po daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 7. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 8. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day): on days of hd, please give after hd. 9. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 10. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po q24h (every 24 hours): on days of hd, please give after hd. 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheezing. 13. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 14. isosorbide mononitrate 30 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 15. docusate sodium 100 mg tablet sig: one (1) tablet po twice a day. 16. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 17. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 18. epogen injection discharge disposition: extended care facility: - discharge diagnosis: primary: 1. acute coronary syndrome 2. end stage renal disease, on hemodialysis 3. essential thrombocytosis discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , . you were transferred to our cardiology icu as you were having a heart attack. while here, you had a stent placed in your left main coronary artery and right coronary artery on rca . there were no complications. you were on a beathing machine and mechanical ventilator, which you recovered from. . you required dialysis during your inpatient stay, and will need dialysis on discharge. you will be set up with a kidney doctor and appointment on discharge. please have your kidney doctor start epo with hemodialysis . you were noted to have a complicated urinary tract infection. you are receiving vancomycin therapy, which will be dosed per dialysis protocol. you have completed the entire course of antibiotics for this urinary tract infection. . you were also noted to have high white blood cell count and high platelet count, which is concerning for a myeloproliferative disorder. you also had a test that was positive for a jak2 mutation, which is often found in myeloproliferative disorders. you will have follow-up for this condition in hematology clinic. . you had several medication changes while here in the hospital. please take your medications as prescribed below. acetaminophen 1000 mg po/ng tid albuterol 0.083% neb soln 1 neb ih q6h:prn wheezing aspirin 325 mg po/ng daily atorvastatin 80 mg po/ng daily clopidogrel 75 mg po/ng daily captopril 6.25 mg po/ng tid carvedilol 3.125 mg po/ng citalopram 10 mg po/ng daily docusate sodium 100 mg po/ng ipratropium bromide neb 1 neb ih q6h isosorbide mononitrate (extended release) 30 mg po daily milk of magnesia 30 ml po/ng q6h:prn constipation nephrocaps 1 cap po daily nitroglycerin sl 0.3 mg sl prn chest pain ranitidine 150 mg po/ng q24h senna 1 tab po/ng warfarin 3 mg po/ng daily start epogen as prescribed by your kidney doctor. . weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: hemodialysis when: saturday at 7:30 am department: hematology/oncology when: thursday at 2:00 pm with: dr. building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: thursday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage md, procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more injection or infusion of platelet inhibitor left heart cardiac catheterization coronary arteriography using a single catheter enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis insertion of drug-eluting coronary artery stent(s) transposition of cranial and peripheral nerves insertion of two vascular stents excision of lingual thyroid percutaneous transluminal coronary angioplasty [ptca] procedure on two vessels intravascular imaging of coronary vessels diagnoses: subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified obstructive chronic bronchitis with (acute) exacerbation percutaneous transluminal coronary angioplasty status chronic kidney disease, stage iii (moderate) acute respiratory failure other complications due to other vascular device, implant, and graft long-term (current) use of anticoagulants streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] atherosclerosis of native arteries of the extremities, unspecified leukocytosis, unspecified acute on chronic combined systolic and diastolic heart failure personal history of pulmonary embolism essential thrombocythemia 

Answer: The patient is high likely exposed to