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: heparin agents attending: chief complaint: loss of consciousness major surgical or invasive procedure: cardiac catheterization, intubation/extubation history of present illness: 60 yo m with pmh of cad, dm, htn with h/o prior mi. h/o chf with refusal of prior echo. has reportedly been out of several medications for approximately one month. this morning, he awoke and his caregiver helped him to the bathroom. he started to walk back when he developed a severe cough and returned to the bathroom. he sat on the toilet, becoming acutely sob and diaphoretic. per his caregiver, he was mumbling, head tipped back and eyes looking at ceiling. she was concerned for seizure (with h/o seizure) but he did respond to her the whole time. ems was called. they could not get pulse oximetry, and he was unresponsive so he was intubated in the field. . in the ed, initial vitals were 120, 160/90 with o2 saturation in the 30s. given 40mg iv lasix x2. cxr per ed read was concerning for ards vs chf. femoral line placed and given vanc/zosyn for possible pna. ekg while in ed, sedation and bp problem. was hypertensive upon arrival with sbps up to the 200s. started on nitro gtt that was titrated up to maximum of 2.98 mcg/kg/min and fentanyl with versed boluses for sedation, though he was still fighting the ventilator. given 10mg vecuronium at 8am due to ventilation issues. femoral line placed, not sterile. still struggling on ventilator, started on propofol. his pressure then dropped rapidly to 80/60s. stopped both nitro gtt and propofol. he was noted to have rising troponin but had no ischemic changes on ecg, thought to be a possible nstemi. because of a possible heparin allergy, the ed was ordering argatroban prior to transfer. he was not given plavix as he had no po access. he did not get cta for possible pe because of his creatinine of 1.7. ct head with prior cva, no acute hemorrhage. medications at time of transfer were 5 versed / 100 fentanyl bolus with gtts, asa 600mg pr, low dose nitro gtt, argatroban to be started upon arrival in the ccu. he continued to have dysynchronised breathing but o2 sat was 96% on 100 fio2 with peep of 10 and rr 30 x vt 450. . per discussion with caregiver and daughter upon arrival to the floor, patient had been well and in his regular state of health until the acute decompensation this morning. no recent cough, fevers, chills, difficulty breathing, chest pain, abdominal pain, diaphoresis or unusual sob. caregiver relates today's episode is similar to one that occurred in when he had a cva and mi and was treated at . no sick contacts or recent illness. had stopped all medications besides imdur, metoprolol and asa in the past month due to not seeing his pcp for over year. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac risk factors: has diabetes, dyslipidemia and severe hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: s/p stent in distal lad -pacing/icd: none 3. other past medical history: coronary artery disease # s/p mult mis - prior care at , has refused stress and cath. ekg shows previous inferior infarction. # congestive heart failure - exacerbation , refused all workup including echo. # hypertension - poorly controlled; on toprol, lisinopril, indur and amlodipine prior to reportedly stopping one month prior # insulin dependent diabetes mellitus - followed at but missed appointments. last a1c 8.8% # hyperlipidemia - recently not taking atorvastatin # chronic renal failure - baseline creatinine about 1.6. presumably from diabetes and htn. # stroke - s/p r sided cva in ' with expressive aphasia, now wheelchair bound # psych - on zyprexa, has been unable and unwilling to work with any mental health professionals per his doctor in b+w # violence - spoke with pcp at +w. pt. kicked out of practice there as he was violent toward the staff. # tobacco abuse # h/o alcohol abuse - now abstinent, prior dts and seizure during withdrawal. social history: he lives with his wife in , ma. he is disabled secondary to stroke. able to walk short distances at home with walker. also has electronic wheelchair. -tobacco history: prior long, heavy smoking history. decreased to cigarettes a day approximately 6-8 years ago when had cva / mi. -etoh: prior long history, quit approximately 6-8 years prior when had cva / mi -illicit drugs: none family history: noncontributory. physical exam: vs: t=98.4 bp=121/76 hr=95 rr=32 on vent o2 sat=94% on vent with rr 32, tidal volume 450ccs, peep 10 and fio2 of 100%. general: wdwn, lying intubated, grimace to sternal rub. heent: ncat. sclera anicteric. perrl. conjunctiva were pink. no xanthalesma. neck: thick, intubated, difficult to appreciate jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. distant heart sounds. tachycardic, regular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: central rhochi, diffuse crackles worst lower down on anterior exam. no wheezes or rhonchi. abdomen: soft, slightly distended. no hsm. no abdominal bruits. extremities: no femoral bruits. skin: small, dry 2cm ulcer on right big toe. pulses: right: carotid 2+ femoral 2+ radial 2+ dopplerable dp and pt : carotid 2+ femoral 2+ radial 2+ dopplerable dp and pt pertinent results: on admission: laboratory data: 132 96 14 -----------< 356 5.6 17 1.7 . wbc 18.3 hct 47.9 plt 506 . ck 146 -> 354 -> 475 ck-mb 36-> 51->59 ->17 ->12 trop 0.51->0.77->2.31->3.69->4.46 bnp 3793 . alt 19 ast 45 tbili 0.4 lipase 54 lactate 9.6->2.0 . tox screen negative . 10:39 abg 7.26/52/54/25 13:00 vbg 7/30/30/51/26 . ua: negative except glucose 1000 . ct head w/o contrast : 1. no acute intracranial hemorrhage or major vascular territory infarction. 2. extensive multifocal cystic encephalomalacia, related to chronic infarcts in the left more than right frontoparietal and occipital lobes and right cerebellar hemisphere, with associated ex vacuo dilatation of the left lateral and fourth ventricle, respectively. the overall pattern is suggestive of previous embolic infarction. 3. chronic microvascular and lacunar infarction. 4. fluid in the nasal cavity with air-fluid levels in the bilateral sphenoid sinuses may be relate to intubation and supine positioning; clinical correlation recommended. . cxr : et tube is approximately 4.5 cm above the carina. there is diffuse bilateral interstitial and airspace opacities. the heart size is top normal. the costophrenic angles are excluded on this study. there is no evidence of pneumothorax. the osseous structures are grossly unremarkable. cxr : the patient was extubated in the meantime interval with removal of the ng tube tip. the cardiomediastinal silhouette is stable. there is improvement in the left lower lobe retrocardiac opacity consistent with resolution of atelectasis. there is also improvement in the right basal opacity most likely due to decrease in right pleural effusion. still bibasal opacities are present consistent with atelectasis versus resolving pulmonary edema and should be followed closely for documentation of complete resolution. . echo : the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is severely depressed (lvef= 20 %) with global hypokinesis and regional akinesis of the inferior and infero-lateral walls. the apex is scarred and dyskinetic. there is no ventricular septal defect. rv with mild global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. . cardiac catheterization : selective coronary angiography in this right dominant system demonstrated triple vessel disease. the lmca had no angiographically apparent disease. the lad was diffusely diseased proximally and in the mid segment and was 100% occluded distally prior to a stent in the distal lad. there was an 80% stenosis of the origin of the 1st diagonal branch. the distal lcx had a 70% stenosis prior to the termination. om1 was occluded with right to left collaterals. om2 was 100% occluded and showed staining which could represent an acute occlusion. the rca was <50% occluded throughout the vessel. the mid pda was 100% occluded. 2. resting hemodynamics limited to central aortic pressure revealed a pressure of 123/78mmhg. brief hospital course: 59 m with htn, hyperlipidemia, cm, cad, chf, cri, h/o stroke and psychiatric issues presents in respiratory distress. hospital course by problem is as follows: . # coronaries: patient with history of multiple prior infarctions and rising troponins after diaphoresis and loss of consciousness, but without ecg changes of ischemia, most consistent with nstemi. he went for cardiac catheterization and was found to have diffuse three vessel disease with apparent acute occlusion of his distal second obtuse marginal. the lesion was not suitable for intervention and the patient was managed medically with bivalirudin (heparin allergy), aspirin and plavix load. he was evaluated by cardiothoracic surgery who felt that he did not have appropriate distal sites for bypass. he was previously prescribed aspirin, toprol-xl, lipitor, imdur and lisinopril, though he was only taking asa, imdur and toprol in the last months not having seen his pcp for over year. he was restarted on aspirin, metoprolol, imdur and lisinopril for blood pressure control and high dose atorvastatin for post-mi lipid control. his metoprolol was also increased to 400mg daily, which he tolerated well. . # dyspnea: most likely due to flash pulmonary edema caused by diastolic dysfunction in the setting of myocardial ischemia. myocardia ischemia was either due to acute coronary thrombus or hypertensive urgency; pt has had prior multiple admissions for pulmonary edema in the setting of hypertensive urgency due to medication non-compliance. pneumonia seemed unlikely with the rapid onset of symptoms and lack of cough or fever, although he had a wbc of 18. wbc did trend down steadily to 12.7 prior to discharge. his cxr was most consistent with acute pulmonary edema. patient was placed on a lasix drip up to a maximum of 10mg/hr. he was negative 1.5l overnight in the ccu the first night and his fluid overload improved with blood pressure control. he had improved drastically by hospital day two and was -4.5l by the end of his hospital stay. pt was extubated without any complications on and was saturating at 98% on room air by the time of discharge. . # respiratory failure: patient arrived in hypoxemic respiratory failure, almost certainly due to acute pulmonary edema in the setting of acutely worsened chronic congestive heart failure. his initial abg's showed acidosis (ph 7.03) and hypoxemia (po2 59). there was no evidence of massive pe or infection to explain the large a-a gradient. initially started on ards protocol which was later discontinued not meeting criteria (pa)2/fio2) and clinical picture. pt tolerated pressure support and eventual extubation on . pt continued to have good peripheral perfusion until time of discharge. . # loss of consciousness: unclear etiology for his loc. most likely hypoperfusion due to ischemic heart failure due to acute thrombus and hypertensive urgency. seizure seemed unlikely as patient was speaking throughout. the non-contrast head ct did not show an acute process and he did not have the quick recovery expected for a vagal episode (although he was intubated). two days after admission, patient was weaned off sedatives and extubated. he gradually returned to his baseline mental status and did not have any further loss of consciousness. . # pump: found to have an ef of 20%, mild lv dilation, global hypokinesis and regional akinesis on echocardiogram. his bnp of 3793 was actually lower than on previous admissions, suggesting that he may not have acutely elevated atrial pressures. overall, his presentation was concerning for ischemic worsening of already poor systolic function. pt was diuresed succesfully throughout his day, putting out 4.5l through the duration of his length of stay. . # rhythm: pt was in sinus tachycardia initially. pt was continued on metoprolol while in the ccu for prevention of post-mi arrhythmias. his betablocker was titrated up to 400mg daily on , which he tolerated well. pt will be continued on this upon discharge home. . # dm. followed by , with poor compliance, although patient was apparently still taking his insulin at home. pt was given bs checks qachs with humalog sliding scale in the ccu. hba1c was 9.9 on . . # hypertension. pt initially on nitro infusion in ed for management of hypertensive emergency. pt was normotensive by the time of arrival to ccu. pt has difficult to control hypertension at baseline. metoprolol was restarted after cardiac cath, home imdur was continued. lisinopril and amlodipine were restarted as well on friday, . . # hyperlipidemia: unclear level of control, was not taking high-dose statin prior to admission. pt was restarted on atorvastatin 80mg qdaily as lipid panel showed: chol 197 tg 120 hdl 33 ldl 140 . # respiratory acidosis: due to hypoventilation in the setting of respiratory failure which improved with ventilation. final abg prior to extubation was: 7.45/160/42 . # anion gap metabolic acidsosis. pt had lactic acidosis on admission which resolved in ccu and was monitored closely. . # elevated troponin: most likely due to nstemi and acute plaque rupture. repeat cardiac enzyme while in the ccu trended down. ck 17 --> 12, mb 5.6 --> 4.4 . # leukocytosis: patient was afebrile throughout his ccu stay and did not report any recent sick contacts per family. leukocytosis may have been a stress response to nstemi, and trended down with time. no antibiotics were given and blood cultures ngtd x2, although pending upon discharge. . # thrombocytosis: likely reactive. was trended with reassuring improvement. . # hyponatremia: most likely fluid overload given flash pulmonary edema, poor lasix compliance and le edema. pt was diuresed as above with good effect. pt resumed home dose of lasix. . # cri: cr near baseline of 1.6, 1.7 on admission. have been poor forward flow given overall clinical picture of decompensated heart failure. pt was given mucomyst x2 and renally dosed medications to protect renal function post-cath. creatinine remained stable and was 1.8 upon discharge. . prophylaxis: -dvt ppx with bivalirudin ?heparin allergy -pain management with fentanyl gtt -bowel regimen with colace / senna . code: full (per daughter); however, on pt did express clear desire to be dnr only (intubate if needed). comm: partner and , at bedside. (daughter and of attorney) (caregiver) medications on admission: amlodipine 10 mg tablet 1 tablet(s) by mouth daily (stopped) atorvastatin 80 mg tablet 1 tablet(s) by mouth at bedtime (stopped) furosemide 20 mg tablet 3 tablet(s) by mouth twice a day (stopped) insulin lispro protam & lispro 100 unit/ml (75-25) suspension 60 units qam, 50 units qpm daily isosorbide mononitrate 30 mg tablet sustained release 24 hr 3 tablet(s) by mouth daily lisinopril 40 mg tablet 1 (one) tablet(s) by mouth once a day (stopped) metoprolol succinate 200 mg tablet sustained release 24 hr 1.5 (one and a half) tablet sustained release 24 hr(s) by mouth once a day zyprexa 2.5mg tablet one tablet by mouth at bedtime (stopped) aspirin 325 mg tablet, delayed release one tablet(s) by mouth once a day discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 3. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 4. olanzapine 2.5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 5. lisinopril 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* 6. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*1* 7. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* 8. furosemide 20 mg tablet sig: three (3) tablet po twice a day. disp:*180 tablet(s)* refills:*2* 9. metoprolol succinate 200 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po once a day. disp:*60 tablet sustained release 24 hr(s)* refills:*1* 10. insulin lispro protam & lispro 100 unit/ml (75-25) suspension sig: as directed units subcutaneous twice a day: 60 units qam, 50 units qpm daily . discharge disposition: home with service discharge diagnosis: primary: acute myocardial infarction, acute pulmonary edema, decompensated acute systolic congestive heart failure secondary: coronary artery disease, chronic kidney disease, chronic systolic congestive heart failure, history of stroke, diabetes mellitus (insulin dependent) discharge condition: improved. pt has been afebrile, saturating well w/o ventilation assistance, back to baseline per daughter. discharge instructions: you were admitted after having such terrible difficulty breathing that an ambulance was called to your house and you were intubated. you also had a heart attack (myocardial infarction) in this setting. you were evaluated with cardiac catheterization which revealed diffuse heart disease that would not respond well to surgery. you should take your medications every day to help avoid further damage to your heart. the only medication change is that your metoprolol (toprol xl) has been increased from 300 mg daily to 400 mg daily. you need to take this new increased dose for better blood pressure control and heart protection. please take all medications as prescribed. you have been given one month of your toprol xl at its new, increased daily dose. you need to see your new primary care physician, . , on to discuss your hospitalization and any other medications you may need. you have an appointment with her currently scheduled for 2:35 pm. seek medical advice if you develop fever, chills, difficulty breathing, chest pain, increased cough or sputum, nausea, difficulty urinating or any other symptom which is concerning to you. you should weigh yourself every morning and call dr. if your weight increases by >3 lbs in one day. you should also stick to a low sodium (2 grams daily) diet and avoid drinking too much fluids (<2 liters a day). daily weights and diet/drink changes can help preserve your heart function. followup instructions: please keep your appointment with your new primary care physician: : , md phone: building, , date/time: at 2:35pm md, procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified injection or infusion of platelet inhibitor left heart cardiac catheterization coronary arteriography using a single catheter angiocardiography of right heart structures diagnoses: acidosis subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified chronic kidney disease, unspecified other and unspecified hyperlipidemia acute respiratory failure long-term (current) use of insulin acute on chronic systolic heart failure 

Answer: The patient is high likely exposed to