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: morphine / penicillins attending: chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with deployment of drug eluting stents in the rca history of present illness: 81 yo woman with h/o atrial fibrillation now s/p ablation, hypertension and rheumatic fever who was transferred to for cardiac catheterization. patient reports that on at 5:30 am, she walked to the bathroom and noted a burning chest pain in the upper chest with radiation to the jaw. she denies associated nausea, vomiting, dizziness, shortness of breath, or diaphoresis. she took an imdur with some improvement in symptoms, called ems and was taken to . on arrival to , she was noted to be in atrial fibrillation with ventricular rates to 140s. she spontaneously reverted to sinus rhythm. at , her initial troponin was negative but subsequent troponin i was 5.0. her inr was also noted to be elevated at 3.9. she was given aspirin and plavix and transferred to for catheterization once her inr normalized. of note, the patient had a myocardial perfusion study with spect in which showed apical ischemia that was medically managed. on arrival to the floor at , the patient was comfortable and chest pain free. she denied any shortness of breath at this time. review of systems on review of systems, she denied any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denied recent fevers, chills or rigors. she denied exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems was notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cad risk factors: dyslipidemia, hypertension 2. chronic kidney disease 3. hypothyroidism 4. atrial fibrillation, on coumadin 5. s/p hernia repair 6. s/p cholecystectomy 7. s/p l knee replacement social history: patient lives with her husband and her grown daughter. she has 9 children. -tobacco history: patient denies smoking -etoh: rare alcohol use -illicit drugs: none family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death, otherwise non-contributory. physical exam: admission exam general: elderly caucasian woman, alert and oriented x3. mood, affect appropriate. vs: t=96 bp=171/141 hr=68 rr=18 o2 sat=99% on ra heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 8 cm. cardiac: bradycardic. pmi located in 5th intercostal space, midclavicular line. normal s1, s2; 2/6 systolic ejection murmur heard best at rusb. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: 1+ pitting edema to the level of the mid shin. no femoral bruits. skin: mild stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 2+ left: carotid 2+ femoral 2+ dp 1+ pt 2+ discharge exam vs: t=97.8 bp=127/90-150/62 hr=53-75 rr=18 o2 sat=98% on room ra i/o 1250/1000 yesterday, 120/450 on day of discharge wt 104.6 kg from 103.2 kg yesterday neck: supple with non-elevated jvp cardiac: rrr, pmi located in 5th intercostal space, midclavicular line. normal s1, s2; 2/6 systolic ejection murmur heard best at rusb. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. extremities: 1+ pitting edema to the level of the mid shin. no femoral bruits. large hematoma of the right thigh; soft, dose not extend beyond previously marked borders. large hematoma of left arm; soft. multiple ecchymoses over bilateral upper extremities. pulses: right: femoral 2+ dp 1+ pt 2+ left: femoral 2+ dp 1+ pt 2+ pertinent results: cbc 06:30pm blood wbc-5.0 rbc-3.08* hgb-9.3* hct-27.8* mcv-90 mch-30.1 mchc-33.4 rdw-14.8 plt ct-237 08:09am blood wbc-4.9 rbc-2.37* hgb-6.8* hct-21.6* mcv-91 mch-28.9 mchc-31.6 rdw-15.1 plt ct-188 07:50am blood wbc-5.3 rbc-2.84* hgb-8.2* hct-24.5* mcv-86 mch-28.8 mchc-33.3 rdw-16.2* plt ct-201 coagulation at inr of 3.6 08:15pm blood pt-36.1* ptt-43.3* inr(pt)-3.6* 02:48am blood pt-39.3* ptt-150* inr(pt)-4.0* 07:05am blood pt-15.6* ptt-30.3 inr(pt)-1.4* 07:50am blood pt-13.4 ptt-27.0 inr(pt)-1.1 chemistry 06:30pm blood glucose-49* urean-47* creat-2.1* na-144 k-4.2 cl-114* hco3-19* angap-15 03:56am blood glucose-79 urean-53* creat-2.6* na-142 k-3.9 cl-115* hco3-17* angap-14 07:50am blood glucose-104* urean-53* creat-2.3* na-143 k-4.1 cl-111* hco3-20* angap-16 cardiac biomarkers at i of 5 06:30pm blood ck-mb-10 ctropnt-0.41* 10:20am blood ck-mb-6 ctropnt-0.51* 08:00pm blood ctropnt-0.62* 03:56am blood ck-mb-3 ctropnt-0.80* 01:10pm blood ck-mb-3 ctropnt-1.04* 07:05am blood ck-mb-2 ctropnt-0.98* misc 02:48am blood alt-13 ast-30 ld(ldh)-189 alkphos-44 totbili-0.2 08:49am blood caltibc-268 vitb12-626 folate-greater th ferritn-52 trf-206 urine 05:11pm urine color-straw appear-clear sp -1.006 05:11pm urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 05:11pm urine rbc-135* wbc-1 bacteri-few yeast-none epi-0 urine culture: mixed bacterial flora ( >= 3 colony types), consistent with skin and/or genital contamination. 07:20pm urine color-straw appear-clear sp -1.008 07:20pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 07:20pm urine rbc-89* wbc-3 bacteri-few yeast-none epi-1 ecg sinus bradycardia at 49 bpm. diffuse low voltage. consider prior inferior myocardial infarction. no previous tracing available for comparison. clinical correlation is suggested echocardiogram the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is top normal/borderline dilated. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened (?#). there is mild aortic valve stenosis (valve area 1.2-1.9cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild to moderate mitral regurgitation. mild aortic stenosis. small circumferential pericardial effusion. cardiac catheterization 1. selective coronary angiography demonstrated one vessel coronary artery disease. the lmca had a 20% stenosis. the mid-lad had a 30-40% stenosis, while the d1 also had a 30-40% lesion. the lcx has a 30% proximal narrowing; the av groove cx is a small caliber vessel. the rca had a 30% stenosis proximally. the distal rca was notable for an 80% ulcerated lesion. 2. resting hemodynamics revealed mildly elevated right-sided filling pressures with rvedp of 13 mmhg, and moderately elevated left-sided filling pressures with lvedp of 20 mmhg. there was severe systemic systolic hypertension with central aortic pressure of 167/70, mean 107 mmhg. there was no significant gradient noted on careful pullback from the aorta to the left ventricle. the cardiac index was preserved at 2.8 l/min/m2 (using an assumed o2 consumption). 3. successful pci of ulcerated distal rca stenosis requiring promus 3.5 x 15 mm drug eluting stent and additional overlapping proximal promus 3.5 x 8 mm stent. excellent result. 0% residual stenosis. timi 3 flow. no apparent dissection. brief hospital course: 81 yo woman with h/o atrial fibrillation on coumadin transferred from an outside hospital after she was found to have an elevated troponin in the setting of chest pain consistent with an nstemi. # cad/nstemi: patient was transferred from where she had found to have a troponin i elevated to 5. on admission to , she denied any further chest pain. initial troponin t was elevated at 0.41, with normal ck-mb and ekg suggestive of previous infarct. her home aspirin was increased to 325 mg. her home crestor was changed to atorvastatin 80 mg. she was additionally started on plavix and a heparin drip. beta-blockade was held in the setting of bradycardia, and ace-inhibitor was held due to renal function. troponin-t peaked at 1.04 on with ck-mb remaining normal. transthoracic echocardiogram of suboptimal image quality showed normal overall and regional biventricular systolic function (lvef >60%), mild symmetric left ventricular hypertrophy, mild-moderate mitral regurgitation, mild aortic stenosis, and a small pericardial effusion. catheterization was delayed in the setting of increased inr. she was given vitamin k 5 mg po, and inr fell to 1.5. on , she underwent right and left heart catheterization, which showed pcw and lvedp 20 mm hg (consistent with moderate left ventricular diastolic heart failure of uncertain duration) and an 80% ulcerated lesion in the distal rca. two drug eluting stents were placed with 0% residual stenosis. she was restarted on metoprolol 12.5 mg as her heart rate tolerated. at the time of discharge, she was prescribed on daily doses of asa 325 mg, metoprolol succinate 25 mg, plavix 75 mg and atorvastatin 80 mg. she remained chest pain free throughout her hospitalization and will follow-up with her pcp and primary cardiologist. # groin hematoma - after removal of the patient's femoral arterial sheath post-catheterization, a large hematoma formed. patient became hypotensive and bradycardic, consistent with a vasovagal reaction. a clamp was placed and hemostasis achieved. her hct fell from 27.8 to a nadir of 21.6, treated with transfusion of 1 unit packed red blood cells with appropriate increase in her hematocrit. she continued to have a large right thigh hematoma which was soft with no signs of extension and strong femoral and peripheral pulses. her hematocrit remained stable and was 24.5 at the time of discharge. # congestive heart failure: patient appeared euvolemic on physical examination on admission. she was noted to have an elevated bnp of 745 at , suggestive of congestive heart failure. tte demonstrated preserved biventricular systolic function. cardiac catheterization showed lvedp and pcw of 20 mm hg, consistent with isolated diastolic heart failure of uncertain duration. she was started on her home dose of furosemide 20 mg po with little response. she was given furosemide 20 mg iv once, and her oral dose was increased to 40 mg daily. the patient was not started on an ace-inhibitor due to her renal function (scr beginning at 2.1, rising to 2.6, consistent with stage acute kidney injury); she should follow-up with her primary cardiologist regarding starting an ace-i/ for secondary prevention in the setting of cad, tiny nstemi, chronic kidney disease, hypertension and left ventricular hypertrophy. the patient should follow-up with her primary cardiologist regarding the need for ongoing nitrates (since her flow-limiting cad was revascularized, and she was begun on beta-blockade). # atrial fibrillation: patient noted to be in atrial fibrillation on presentation to with ventricular rates to the 140s. she spontaneously converted to sinus with bradycardia. she was monitored on telemetry without any evidence of atrial fibrillation. she had a supratherapeutic inr on admission with an inr which peaked at 4.0. she was given vitamin k 5 mg po in preparation for cardiac catheterization. her inr was 1.4 at the time of the procedure. her coumadin was held in the peri-procedure period in the setting of a groin hematoma as above. her home dose of coumadin was restarted on hd 6. at the time of discharge her inr was 1.1. she will follow-up with her pcp regarding inr and titration of her coumadin dosing. # acute on chronic ckd: per report, patient has chronic renal insufficiency with baseline creatinine of 2.0. on admission, her creatinine was elevated to 2.1. her creatinine trended upward to a maximum of 2.6 prior to her coronary angiogram. elevation was attributed to volume depletion from diuresis and perhaps poor oral intake. she was given a total of 1.5 liters of bicarbonate in d5w with improvement in creatinine to a nadir of 2.1. post catheterization creatinine increased slightly but remained stable at 2.3. # uti: the patient was noted to have a urine culture with > 10,000 colonies of e. coli at . she received one dose of levofloxacin and was started on ciprofloxacin on admission from - . repeat ua/cx here on showed mixed bacteria consistent with skin contamination. antibiotics were discontinued as the patient was denying any further urinary symptoms. # hypertension: the patient was hypertensive on admission with sbps in to 180s requiring a nitroglycerin gtt. blood pressures improved, and the drip was discontinued. her furosemide dose was increased (see above). additionally she was started on metoprolol 12.5 mg for post-infarct secondary prevention. the patient was hypotensive during sheath pull in the setting of acute blood loss anemia as above which improved with administration of 1l ns. # dyslipidemia: patient's home crestor was changed to atorvastatin 80 mg daily. # rehabilitation- patient was evaluated by physical therapy during her admission. they felt she was significantly deconditioned and recommended cardiopulmonary rehabilitation. the patient declined placement at a rehabilitation facility but was provided with home physical therapy services on discharge. stable issues # hypothyroid: the patient was continued on her home levothyroxine transitional issues - patient will follow-up with pcp regarding inr and adjustment of her coumadin dosing. - patient will follow up with her cardiologist regarding diuretic therapy, continuing imdur, starting an ace-i/ - patient remained full code throughout this hospitalization medications on admission: - asa 81 mg daily - furosemide 20 mg daily - calcium with vitamin d - multivitamin - grapeseed extract - zolpidem 10 mg daily - warfarin 5 mg daily - omeprazole 20 mg - levothyroxine 50 mcg - isosorbide monitrate 60 mg daily - nitroglycerin 0.4 mg sl - rosuvastatin 5 mg daily discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 2. calcium with vitamin d 600 mg(1,500mg) -400 unit tablet sig: one (1) tablet po once a day. 3. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual prn as needed for chest pain: take every 5 minutes for a maximum of 3 doses . 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*0* 6. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 7. multivitamin tablet sig: one (1) tablet po daily (daily). 8. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime). 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 10. isosorbide mononitrate 60 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 11. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 12. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*60 tablet(s)* refills:*0* 13. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*60 tablet extended release 24 hr(s)* refills:*0* 14. grape seed extract 25 mg capsule sig: one (1) capsule po three times a day. discharge disposition: home with service facility: vna discharge diagnosis: non st elevation myocardial infarction coronary artery disease acute on chronic renal failure post-catheterization hematoma and acute blood loss anemia requiring transfusion transient hypotension consistent with vasovagal response hypertension urinary tract infection atrial fibrillation, with long term use of anticoagulants sinus bradycardia hyperlipidemia left ventricular diastolic heart failure of uncertain duration, likely chronic hypothyroidism mild to moderate mitral regurgitation mild aortic stenosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mrs. , it was a pleasure participating in your care while you were admitted to medical center. as you know you were admitted because you were having chest pain and were found to have a heart attack. you were transferred here to have a cardiac catheterization. the procedure could not happen right away because your inr was elevated. you were given medication to help bring your inr down. you underwent a catheterization which showed a blockage of one of the arteries in your heart. a stent was placed to open the blockage. after the procedure you had bleeding from the groin. you were sent to the icu for close and given a blood transfusion. the bleeding was controlled with pressure and you improved. you were started on several new medications for your heart. you will need to follow-up with your cardiologist regarding further changes to your medications, in paticular you should discuss with him the need to continue your imdur. your creatinine levels were initially elevated, indicating reduced kidney function. we believe this is due to your heart not getting blood to them well. you were given fluid and your kidney function improved. you should follow-up with your doctor regarding following your kidney function. your coumadin was held while you were admitted due to bleeding. this was restarted before your discharge. you should follow-up with your doctor of your inr and further changes in your coumadin dose. you were seen by physical therapy who felt you would benefit from physical therapy at home to help you to get stronger. the following changes were made to your medications 1. change crestor 5 mg to atorvastatin 80 mg daily 2. start metoprolol succinate 25 mg daily 3. start plavix 75 mg daily 4. increase aspirin to 325 mg daily 5. increase lasix to 40 mg daily 6. stop lisinopril because you kidney numbers are elevated. please discuss the appropriate time to restart this medication with your regular doctors. please take all other medications as instructed. please feel free to call with any questions or concerns. followup instructions: name: , address: ,, , phone: appt: at 1:45pm name: , md location: internal medicine associates address: , , , phone: appt: at 1:15pm md, msc 12-339 procedure: combined right and left heart cardiac catheterization coronary arteriography using two catheters 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 single vessel diagnoses: abnormal coagulation profile subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery urinary tract infection, site not specified congestive heart failure, unspecified acute posthemorrhagic anemia acute kidney failure, unspecified unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation hematoma complicating a procedure chronic kidney disease, unspecified other and unspecified hyperlipidemia cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure long-term (current) use of anticoagulants accidents occurring in residential institution knee joint replacement chronic diastolic heart failure other and unspecified escherichia coli [e. coli] 

Answer: The patient is high likely exposed to