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: cozaar / ace inhibitors / morphine attending: chief complaint: scrotal swelling major surgical or invasive procedure: none history of present illness: hpi: 80 yo m with h/o dm, cad (s/p cabg in , ), infarct related cardiomyopathy (ef 20-25%), s/p biv icd, prostate cancer s/p b/l orchiectomy and turp, of bladder stones and radiotherapy , who p/w gradually increasing scrotal pain and swelling as well as decreased uop. he states that this urinary stream gradually became weaker in the last 3 days and then nothing came out yesterday. his scrotum also became acutely enlarged to the point where he could not walk. he also noticed increased bilateral leg swelling, and that his "whole body is leaking fluid". he has gained 12 pounds in the last 2 days. he admits to eating tv dinners every 2-3 days for years, but noticed a decreased appetite when his edema started. he states he has been taking all his meds faithfully. last night, he felt sob at rest and required his home o2 which he hasn't needed in a while. he also had concomitant chest pressure that was relieved with 3 tabs of nitro (typically happens 3x/month). denies f/c/n/v, cough, orthopnea, palpitations, syncope, h/a, dizziness. . of note, pt was admitted in for scrotal swelling and renal failure chf exacerbation that responded to po torsemide but not iv lasix. . in ed, initial vs 97.4 80 101/60 20 98%. because scrotal exam was concerning for necrotizing fasciits, pt received vanc/clinda. scrotal us was obtained and urology c/s felt no contributing gaseous process. cxr showed cardiomegaly without pulmonary edema or pleural effusions. foley was also placed and pt then admitted to cardiology for management of likely chf exacerbation. . on arrival to the floor, vs 97.3 67 98/67 18 99%ra. pt feels well without cp or sob. foley put out 350cc. past medical history: cardiac history: hyperlipidemia, hypertension, diabetes mellitus * cabg: (svg-distal lad, distal lcx, distal rca), re-do in * percutaneous coronary interventions: none * pacing/icd: biventricular icd (placed in ) . past medical & surgical history 1. paroxysmal atrial fibrillation 2. infarct-related cardiomyopathy with significant coronary disease, (ef 20-25%, left ventricular systolic dysfunction with akinesis of the inferior septum, inferior wall, and inferolateral wall) 3. coronary artery disease 4. ventricular tachycardia storm status-post biventricular icd placement in ( generator replacement in )s/p vt ablation /. atrial tachycardia status-post ablation (, ), atrial flutter status-post ablation, and avnrt status-post slow pathway modification 6. prior history of stroke post-cabg in ; another stroke () - mild residual visual disturbance and unsteady gait 7. prostate cancer s/p turp 8. diet-controlled diabetes mellitus 9. chronic renal insufficiency (baseline 2.0-2.3) 10. h/o nephrolithiasis 11. intermittent vertigo history 12. mild insomnia (sleeps 2-3 hours nightly) 13. s/p tonsillectomy (at age 40 years) 14. s/p mastoidectomy social history: patient lives at home alone in , ma. patient is independent in his adls. has a cane for walking but only uses it occasionally. retired nurse. or used illicits. usually has 1 glass of wine with dinner but none in past 8 months. family history: patient is adopted. unaware of biological family history. physical exam: admission physical examination: vs: 97.3 67 98/67 18 99%ra uop 350cc general: a&ox3, lying in bed, appears deconditioned, nad heent: nc/at. sclera anicteric, eomi. dry, cracked lips. neck: supple with jvp of 8 cm. no carotid bruits appreciated. cv: rrr, nl s1, s2, no s3, iii/vi systolic murmur @llsb without radiation to axilla pulm: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. gu: scrotum markedly erythematous and edematous (2+). no ttp. b/l inguinal folds with fine scales and well-demarcated bright red patches. extr: 2+ b/l le edema to the knees. overlying skin is hyperkeratotic, scaly with red-purple-brown hyperpigmentation. neuro: a&ox3, mild dysarthria. . discharge physical examination: vs: 98.5 98.1 130/89 69 20 199% ra fbs 136 wt: 81.6kg, from 82.2kg i/o 24h: 1000/1700 general: a&ox3, lying in bed, appears deconditioned, nad heent: sclera anicteric. mm dry neck: jvp at ~6cm on right cv: rrr, nl s1, s2, no s3, ii/vi systolic murmur @llsb without radiation to axilla pulm: resp were unlabored, no accessory muscle use. inspiratory crackles at bases b/l. some mild wheezes as well in bases. coughing. abd: soft, nt, nd, +bs. no hsm or ttp. ecchymosis on mid abdomen gu: scrotal skin much less taut, rugae more visibly defined. size much decreased. penis no longer buried. no ttp. b/l inguinal folds much less red and scaly. extr: trace b/l le edema, much improved since admission. overlying skin is hyperkeratotic, scaly with red-purple-brown hyperpigmentation pertinent results: cbc: wbc-7.8# rbc-4.04* hgb-11.4* hct-33.3* mcv-83 mch-28.2 mchc-34.1 rdw-16.0* plt ct-100* neuts-73.5* lymphs-19.8 monos-5.6 eos-0.7 baso-0.4 04:08am blood wbc-6.3 rbc-3.59* hgb-9.9* hct-30.4* mcv-85 mch-27.6 mchc-32.6 rdw-16.9* plt ct-137* . chemistry: glucose-136* urean-95* creat-4.7*# na-133 k-4.4 cl-93* hco3-27 04:08am blood glucose-134* urean-96* creat-3.1* na-135 k-3.5 cl-89* hco3-34* angap-16 04:08am blood calcium-9.1 phos-4.0 mg-2.3 . cardiac enzymes: 12:40pm ck-mb-7 ctropt-0.09* probnp-* 07:00pm ck-mb-7 ctropt-0.09* 05:55am ck-mb-6 ctropt-0.08* . liver tests: alt-34 ast-43* ck(cpk)-239 alkphos-96 totbili-0.5 lipase-22 albumin-3.2* . other: lactate-1.8 %hba1c-7.7* ck(cpk)-214 05:55am blood triglyc-69 hdl-40 chol/hd-2.7 ldlcalc-54 ldlmeas-54 . scrotal us findings: the patient is status post bilateral orchiectomies. there is marked enlargement of the scrotum with striking widespread edema including areas of ill-defined fluid, although there is no dominant or discrete fluid collection. no definite foci of gas are visualized. impression: marked edema and ill-defined fluid, which could be of infectious etiology or due to a form of third spacing in the appropriate setting, without definite foci of gas or discrete collection. . cxr findings: the patient is status post coronary artery bypass graft surgery. a biv pacemaker/icd device with three leads appears unchanged. the heart is moderately enlarged. the cardiac, mediastinal and hilar contours appear unchanged. the lungs appear clear. there are no pleural effusions or pneumothorax. mild degenerative changes are similar along the thoracic spine. impression: no evidence of acute disease. . renal us findings: the kidneys are normal in size with the right kidney measuring 10.0 cm and the left kidney measuring 9.1 cm. within the left interpolar region, there is a 9 mm simple cyst. no suspicious renal mass is seen. there is no hydronephrosis or evidence of renal calculi. the bladder is collapsed and suboptimally evaluated. impression: small left renal simple cyst. otherwise, unremarkable renal ultrasound with no hydronephrosis. no son evidence of renal stone, although ct is more sensitive. . tte the left atrium is elongated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is at least 15 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (lvef= 25 %) with akinesis to dyskinesis of the inferior and infero-lateral segments (basal infero-lateral aneurysm) and hypokinesis of the remaining segments (the lateral wall contracts best). lv dysynchrony is present). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. compared with the prior study (images reviewed) of , no change. . ruq u/s: the liver shows no focal or textual abnormalities. portal vein is patent showing hepatopetal flow. a gallstone is seen in a collapsed gallbladder, grossly unchanged from prior ct examination. there is no intra-or extra-hepatic biliary duct dilatation. the cbd measures 0.3 cm. trace amount of fluid is seen around the liver. the pancreas is unremarkable, note is made that the pancreas tail is obscured by bowel gas. the spleen measures 12.7 cm and is unremarkable. no fluid is seen in the right and left lower abdominal quadrant. impression: 1. trace amount of fluid around the liver. 2. cholelithiasis in a collapsed gallbladder. 3. normal echotexture of the liver with no intra- or extra-hepatic biliary duct dilatation. cxr: as compared to the previous radiograph, there is unchanged evidence of a perihilar increase in density of the lung parenchyma, right more than left. the distribution of these changes, notably combine to the cardiomegaly of the patient, are more consistent with pulmonary edema than with pneumonia. there is no evidence of pleural effusions. normal appearance of the hilar and mediastinal contours. right central venous access line and left port-a-cath in situ. brief hospital course: a/p: 80 yo m with h/o dm, cad s/p cabg in , ), chf with ef 20-25% s/p biv icd, h/o prostate cancer and nephrolithiasis, who p/w scrotal and le edema suggestive of chf exacerbation. . # chf exacerbation: likely precipitated primarily by biv pacing being shut off, and also by dietary indiscretion. in , his lv lead was turned off as it was thought to be abutting a scar, and he was in vt storm at that time. he now presents with evidence of significant right-sided heart failure on admission with scrotal and le edema, but clear lungs and high o2 sats. given his borderline hypotension, lasix gtt was started and uptitrated to 20 mg/hr. however, the rate of diuresis continued to be suboptimal at -700cc/day. he was then transferred to ccu to initiate milrinone gtt. he tolerated this well, and with a combination of lasix 30mg/hr and milrinone, was making ~1000-1500cc/day, though given intakes was not really diuresing. renal decided that he would benefit from dialysis. a temporary hd line was placed, and he received 2 ultrafiltration sessions, with about 3l fluid removed per session. he then appeared to be euvolemic to slightly volume up. it was decided that his goal was slightly volume up, given pre-load , lasix/milrinone and ultrafiltration sessions were stopped on . given he is now on anti-arrythmics (mexilitine and quinidine), his lv lead was restarted. previously, he has had great benefit from receiving biv pacing, so did not want to give up on this therapy for him per attending. he continued to make 1100-1700cc/day urine, and his creatinine continued to trend down. he developed a cough and cxr showed slightly worsening pulmonary edema, so his home dose of torsemide was restarted on , and he tolerated this well. . # oliguric acute on chronic kidney failure: he presented close to anuric, though to be pre-renal etiology from chf causing decreased rbf. cr was markedly elevated from baseline of 1.7-2.0 in , to 4.9 on admission. therapy for chf (above) resulted in continual improvement in renal function. he received 2 sessions of ultrafiltration, but did not get hd, given renal did not think he needed it and they didn't want to cloud the picture in terms of his diuresis. by discharge, he was making 1700cc urine per day, and creatinine was down to 3.0 . # urinary retention: foley was placed via cystoscopy on admission, difficult in part buried penis. removed on as thought to be unnecessary. on he had urinary retention, with 750cc residual after a small urination. his bladder was distended and painful. urology replaced the foley, and he should f/u with urology (dr ) in 2 weeks (appnt made for him) . # hypokalemia: pt has had issues with hypokalemia, k+ 3.1 lowest. worse when he was receiving active diuresis. he has required near daily k+ repletion. at rehab, his k+ should be checked regularly, so that he gets appropriate repletion. also, he has a metabolic alkalosis frmo diuresis. as this resolves, k+ will shift out of his cells and potentially create hyperkalemia, so that should be watched as well. . # scrotal swelling: fluid retention chf exacerbation. urology evaluated scrotum in the ed and felt there was no infectious etiology. he received a scrotal u/s (per report section), which was reassuring that infection was unlikely. edema improved dramatically during admission, as was back to baseline upon discharge . # cad s/p cabg: ekg showed no new ischemic changes, and cardiac enzymes normal. he was ruled out for mi. home aspirin 81 mg, isordil, metoprolol and atorvastatin were continued. . # rhythm/?afib: pt is a/v paced, has biv pacemaker for chronic dchf, not on coumadin at home. anticoagulated with asa325 daily. maintained on home mexilitine, quinidine, and metoprolol. his biv was reactivated, per above. . # cough: developed non-productive cough, no fever or leukocytosis. cxr from (pa/la) suggests pulmonary edema more than pneumonia. he is not on an acei. minimal relief with saline nebs, ipratropium nebs, and tessalon pearls. cough may be pulm edema and perhaps will improve when that is cleared. started on guaifenesin w/ codeine as well, which is providing symptomatic relief. . # dm: a1c 7.7%. sugars well controlled with home lantus and sliding scale. . # hld: good lipid profile, continued atorvastatin. . # intertrigo: had a groin rash scrotal edema. successfully treated with topical miconozole powder. . # anemia: has baseline anemia with hct in low-mid 30s, worsening during this admission, labs suggestive anemia of chronic disease and likely contribution from ckd. . # coagulopathy/thrombocytopenia: inr 1.2-1.5, albumin 3.2 suggests diminished synthetic function of liver. lfts normal on admission. ruq u/s w/o liver abnormalities. hepatitis serologies also negative. labs do not suggest consumptive process. likely congestive hepatopathy. . # ij clot: discovered upon placing hd line. not be good candidate for anti-coagulation beyond what he is already on, so no changes made. . # hypona: na+ ranging 131-135. likely hypervolemic hyponatremia from chf exacerbation. expected to improve with ongoing diuresis. pt is asymptomatic . # goals of care: palliative care saw pt, who has been aware of his declining functional status. he lives independently and is not interested in health aids. he is dni, but ok to resuscitate. ======================== transitional issues # potassium should be checked and repleted regularly at rehab # f/u with urology in 2 weeks to f/u urinary retention # please contact (patient's primary cardiologist) as soon as possible after arrival as he would like to remain informed of mr. progress. he can be reached at medications on admission: 1. aspirin 325 mg tablet, delayed release (e.c.) po qd 2. atorvastatin 20 mg po qd 3. metoprolol succinate xr 100 mg tablet po qd 4. isosorbide dinitrate 20 mg po tid 5. torsemide 60 mg tablet po qd 6. metolazone 2.5 mg po on sundays 8. quinidine gluconate xr 324 mg po tid 9. mexiletine 150 mg po q8h 10. insulin glargine 100 unit/ml soln 14 units sc qhs 11. miconazole nitrate 2% powder top prn rash 12. cholecalciferol (vitamin d3) 2,000 unit po qd 13. folic acid 0.5 mg po qd 14. ascorbic acid 1,000 mg po qd 15. senna 8.6 mg po bid 16. docusate sodium 100 mg po bid discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po once a day. 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. tablet extended release 24 hr(s) 4. isosorbide dinitrate 20 mg tablet sig: one (1) tablet po q8h (every 8 hours). 5. torsemide 20 mg tablet sig: two (2) tablet po daily (daily). 6. quinidine gluconate 324 mg tablet extended release sig: one (1) tablet extended release po q12h (every 12 hours). 7. mexiletine 150 mg capsule sig: one (1) capsule po q8h (every 8 hours). 8. insulin glargine 100 unit/ml solution sig: fourteen (14) units subcutaneous at bedtime. 9. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 10. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 12. ascorbic acid 1,000 mg tablet sig: one (1) tablet po once a day. 13. senna 8.6 mg tablet sig: 1-2 tablets po daily (daily) as needed for constipation. 14. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain or fever. 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 16. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 17. tessalon perles 100 mg capsule sig: one (1) capsule po three times a day as needed for cough. discharge disposition: extended care facility: - discharge diagnosis: primary: congestive heart failure, acute on chronic kidney failure, hyponatremia secondary: coronary artery disease, anemia, hypertension, hyperlidpidema 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: dear mr , it was a pleasure taking care of you at . you were admitted because you stopped urinating and had scrotal edema. this was found to be secondary to heart and kidney failure. you were treated with medications, and your heart and kidneys are making a recovery, though are still sick. weigh yourself every morning, and call your doctor if weight goes up more than 3 lbs. the following changes have been made to your medications: ** decrease metoprolol succinate to 50mg once daily ** decrease torsemide to 40mg once daily ** change quinidine to twice daily (instead of 3x daily), while your kidney function recovers ** start nephrocaps ** start tessalon pearls for cough supression followup instructions: name: , md address: , , phone: *please call your cardiologist to book a follow up appointment for your hospitalization. you need to book an appointment within 2-3 weeks of discharge. if you have any questions or concerns please call the office. we are working on a follow up appointment in nephrology with dr. for your hospitalization within 2-3 weeks of discharge. the office will contact you at the facility with the appointment information. if you have not heard within 2 business days please contact the office at . department: surgical specialties when: tuesday at 9:30 am with: , m.d. building: campus: east best parking: garage department: cardiac services when: monday at 2:00 pm with: device clinic building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: hemodialysis venous catheterization for renal dialysis diagnoses: thrombocytopenia, unspecified anemia in chronic kidney disease end stage renal disease renal dialysis status congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified hyposmolality and/or hyponatremia personal history of malignant neoplasm of prostate coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease retention of urine, unspecified automatic implantable cardiac defibrillator in situ acute on chronic systolic heart failure 

Answer: The patient is high likely exposed to