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: no known allergies / adverse drug reactions attending: chief complaint: chest pain major surgical or invasive procedure: cystoscopy procedure: bladder neck contracture was able to be dilated up to 25-french. calcifications, using the cystoscope knocked the calcification off into the bladder. then using stone crushers through a 20-french cystoscope, the stones were crushed into small pieces. these were then ellik evacuated free. mechanical ventilation history of present illness: mr. is a 77m with a history of known proximal descending aortic arch penetrating ulcer (found in medically treated) also with history of cad s/p cabg, who intially presented to hospital on with 9/10 chest pain radiating to the back x 1 day. cta at this time showed worsening ulcer and he was transferred to for surgical intervention. on arrival to ed, ekg showed new lbbb and cardiology thought this was chronic ischemic cardiac disease. while on vascular surgical service hypertension was attempted to be controlled with labetolol drip and iv labetalol pushes with goal bp<120. he was then found to have acute renal failure which was thought most likely secondary to contrast infuced nephropathy from cta. aggressive ivfs for treatment of cin caused respiratory distress and pulmonary edema. tte showed lvef40% stable, moderate mr, moderate to severe tr. patient was transferred to the unit where he was intubated for a short term and started on a lasix drip. while in the micu, patient was agressively diuresed with lasix drip while understanding kidneys needed protection. hypertension was difficult to control requiring nicardipine drip to maintain sbps <120. nicardipine has since been discontinued on tuesday (day before transfer) and oral regimen of amlodipine 10mg, imdur 90mg daily, carvedilol 25 and hydralazine 50mg po tid have been able to maintain bp at goal. renal function improved slightly to 2.4 (baseline of 1) and lasix drip discontinued >24 hours ago. patient has now been autodiuresing -500 today without medical diuresis. of note, also patient received 4 transfusions during admission x2, and 10/18/12m. no clear source of bleeding and patient was guiac negative. on arrival to the floor, patient overall appears well though with pain in his legs which is a chronic issue. he is upset that pain is not being adequately treated and he is only receiving half his normal home dose. he is breathing comfortably on 4l nc. past medical history: - proximal descending aortic arch ulcer diagnosed on cta done for chest pain (managed medically by cards/pmd) - htn - hld - cad s/p cabgx3 (), stent () - b/l lower extremity calf pain of unknown etiology (abis wnl ) - ckd (baseline cr: 1.1) - history of prostate ca s/p brachytherapy () - bph - history of nephrolithiasis s/p lithotripsy - bladder calculus - history of pud () - - history of gib (hemorrhoids, no bleeding source on c-scope ) - chronic anemia (baseline hct: 24-32) psh: - cabgx3 lima-lad, svg-om, svg-d1 () - lcx stent () - open cystolithotomy () social history: patient was born in poland, lived there for 20 years then moved to and lived there for 6 years. currently retired. has 2 daughters, in and port, and one son. currently living with his wife. his wife recently had a hip surgery, now recovering at rehab facility. patient is a former smoker, used to smoke about 4 cigarettes/day for 10-15 years but quit 30-40 years ago. no history of alcohol or drug abuse. primarily polish-speaking. independent in adls at baseline. family history: heart disease on father's side of the family. no history of sudden cardiac death. no family history of colon cancer or other cancers. no reported history of kidney disease in family. father: cad mother: anemia physical exam: exam on trasnfer from cvicu: vitals: 98.6, 127/43, 63, 14, 97% 6l nc general: alert, oriented, no acute distress interactive and moving around. occassionally appears uncomfortable. heent: sclera anicteric, mmm, oropharynx clear w/ dentures, eomi, perrl neck: supple, jvp elevated to 11cm, no lad cv: regular rate and rhythm, normal s1/s2, +s3, no murmurs, rubs lungs: rales 2/3 up lungs posteriorly, no wheezes or rales abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis, trace edema bilaterally neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred discharge exam: vitals- t 98.5 bp 147/69 hr 62 rr 18 o2 96% ra, maintained when ambulating general: wdwn 77 yo male in nad. oriented x3. mood, affect appropriate. heent: ncat. neck: supple with flat jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. soft diastolic murmur heard best at lsb. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. no crackles abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ neuro: no focal deficits pertinent results: admission labs: 01:25pm blood wbc-3.1* rbc-2.76* hgb-8.2* hct-24.5* mcv-89 mch-29.6 mchc-33.4 rdw-16.8* plt ct-235# 01:25pm blood neuts-59.4 lymphs-33.9 monos-6.2 eos-0.4 baso-0.1 01:25pm blood hypochr-1+ anisocy-1+ poiklo-2+ macrocy-normal microcy-1+ polychr-normal ovalocy-2+ tear dr1+ ellipto-2+ 01:25pm blood pt-12.8* ptt-36.9* inr(pt)-1.2* 01:25pm blood glucose-110* urean-13 creat-1.1 na-143 k-4.2 cl-105 hco3-25 angap-17 10:43pm blood ck(cpk)-25* 01:25pm blood ck-mb-2 01:25pm blood ctropnt-<0.01 10:43pm blood ck-mb-2 ctropnt-<0.01 08:00pm blood ck-mb-2 ctropnt-<0.01 probnp-6913* 01:25pm blood calcium-9.0 phos-3.0 mg-1.7 12:50pm urine color-straw appear-clear sp -1.028 12:50pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg 10:01am urine rbc-101* wbc-37* bacteri-few yeast-none epi-0 transe-<1 bnp: 08:00pm probnp-6913* 08:10am blood wbc-8.3 rbc-3.65* hgb-10.9* hct-31.1* mcv-85 mch-29.9 mchc-35.1* rdw-16.5* plt ct-227 04:29am blood glucose-125* urean-45* creat-3.0* na-137 k-4.4 cl-93* hco3-34* angap-14 06:10am blood glucose-95 urean-36* creat-1.9* na-134 k-4.1 cl-93* hco3-39* angap-6* 08:10am blood glucose-117* urean-32* creat-1.7* na-137 k-4.3 cl-93* hco3-33* angap-15 08:40am blood glucose-125* urean-40* creat-1.7* na-137 k-3.8 cl-92* hco3-33* angap-16 08:40am blood calcium-9.4 phos-4.0 mg-2.1 08:08pm blood pep-no specifi micro: all negative blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient mrsa screen mrsa screen-final inpatient urine urine culture-final inpatient mrsa screen mrsa screen-final inpatient mrsa screen mrsa screen-final inpatient blood culture blood culture, routine-final emergency blood culture blood culture, routine-final emergency urine urine culture-final emergency imaging: carotid us: less than 40% stenosis of the bilateral extracranial internal carotid arteries. ct torso: 1. increase in size of previously seen thoracic aortic ulceration. 2. multiple smaller ulcerations of the descending thoracic aorta and abdominal aorta. 3. stenosis of the celiac artery origin and the bilateral renal artery origins. 4. small bilateral pleural effusions. 5. air within the bladder, recommend clinical correlation. echo: the left atrium is moderately dilated. the left atrium is elongated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is mildly depressed (lvef= 40 %) secondary to mild global hypokinesis. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular cavity is mildly dilated there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 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. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is moderate-severe pulmonary artery systolic hypertension. the main pulmonary artery is dilated. there is an anterior space which most likely represents a prominent fat pad. impression: moderately dilated left ventricular cavity with mild global systolic dysfunction. moderate mitral regurgitation. moderate-severe tricuspid regurgitation with moderate-severe pulmonary artery systolic hypertension. mri chest w&w/o contras 1. stable size and appearance of distal aortic arch penetrating ulcer. 2. new, moderate bilateral pleural effusions with simple fluid. 3. supra-renal 3.2cm aortic aneurysm with small dissection is unchanged. cxr: in comparison with study of , there are lower lung volumes in this patient who has undergone a prior cabg procedure. continued cardiomegaly with increased pulmonary vascular congestion, the appearance of which may be enhanced by the low lung volumes. mild bibasilar atelectasis persists. ekg: sinus or ectopic atrial rhythm. left bundle-branch block. since the previous tracing of the rate is now faster. q-t interval is shorter. otherwise, probably no change. brief hospital course: mr. is a 77m with a history of known proximal descending aortic arch penetrating ulcer (found in , treated medically with antihypertensives), cad s/p cabg, who was transferred to initally for surgical intervention however course was complicated by hypoxia, and decompensated chf. # hypoxemic respiratory failure/acute congestive heart failure: most likely secondary to pulmonary edema acute chf, but also suspect a component of atelectesis decreased tidal volume from constipation, and decreased respiratory drive from frequent opiod use for chest pain. no evidence of pna and suspicion for pe not high at this time. jvp, rales, cxr and bnp consistent with fluid overload. additionally, prior to tranfer from surgery service, patient received aggressive ivfs and blood transfusions (6l positive currently) for acute kindey injury and contrast administration. patient briefly required ventilatory support. patient was managed on a lasix ggt, and began to autodiurese prior to transfer from icu. electrolytes were monitored frequently and repleted as needed. at time of transfer to the medical floor, patient was 3l positive for hospital stay still. supplemental o2 was weaned down to 4l nc satting 91-92% upon transfer. on the cardiology floor, pt. was started on torsemide 20mg po daily for 3 more days, and diuresed approximately 3l. his respiratory status greatly improved and by time of discharge his spo2 was 96% on ra while ambulating. # aortic ulcer: initial appearance on cta was concerning for enlargement of descending aortic arch ulcer and initial vascular surgery's initial plan was for urgent operative management. patient subsequently developed contrast-induced nephorpathy and congestive heart failure exacerbation as outlined above. at this point patient not medically stable for major vascular surgery. mri showed that aortic ulceration was actually stable in size and vascular surgery decided that it could be managed medically until his acute medical issues of acute congestive heart failure and acute kidney injury had resolved. goal bps for managment of aortic ulceration were set at sbps in the 120s. this was initially difficult to achieve in the icu, requiring multiple antihypertensive drips. upon transfer to cardiology floor, patient was stabilized on po regimen of amlodipine 10mg daily, carvedilol 25 mg po/ng , hydralazine to 75 mg po/ng tid, and isosorbide mononitrate (extended release) 90 mg po daily. with this regimen, patient's systolic bps were consistently in the 110s to low 120s. vascular surgery wanted to allow for patient's renal function to return toward baseline before operating, as the procedure would require a significant contrast load, so patient was discharged on this antihypertensive regimen with plan to follow-up with dr. of vascular surgery in 2 weeks for planning of surgical repair of aortic arch ulceration. #: patient developed acute kidney injury with cr peaking at 3.0 from a baseline of 1.2-1.5. was felt to be multifactorial with contrast induced nephropathy (patient received 2 contrast cts in a short period of time), atn (muddy brown casts seen on ua), and post-obstuctive nephropathy from bladder constriction causing bilateral kidney injury. additionally, patient was aggressively diuresed with evidence of contraction alkalosis and cr rise to 3.0. with break from lasix ggt, cr improved to 2.4. prior to transfer from the unit, patient began autodiuresing. on cardiology floor, urine output improved and cr trended down to 1.7 on discharge. # anemia: patient remained within baseline range (high 20s), however given cardiac issues, hct was trended closely and patient was transfused to a goal hct of >25. he was given 4 units pf prbcs prior to transfer from the vascular surgery service, where hct goal was >30. #cad: pt has known cad and is s/p cabg and pci in the mid-90s. ecg has shown ivcd to lbbb in the past, which is consistent with the current ecg. patient was started on aspirin 81mg daily and continued on home statin. blood pressures were managed as above. # bladder neck contracture: on , patient was taken by urology for cystoscopy and a bladder neck contracture was identified and dilated up to 25-french. calcifications, using the cystoscope knocked the calcification off into the bladder. then using stone crushers through a 20-french cystoscope, the stones were crushed into small pieces. these were then ellik evacuated free. a 20-french 3 way catheter was then placed into the bladder. foley remained in place over the course of the admission and patient was discharged with urology follow up in 1 week with dr. . medications on admission: home medications: - amlodipine 10 mg po daily - dilaudid 4 q6h prn - losartan 100 po daily - metoprolol tartrate 50 po bid - nitroglycerin 0.4 sl prn - omeprazole 20 mg po daily - pravastatin 80 mg po daily discharge medications: 1. amlodipine 10 mg po daily 2. hydromorphone (dilaudid) 4 mg po q6h:prn pain 3. omeprazole 20 mg po daily 4. aspirin 81 mg po daily rx *aspirin 81 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*3 5. atorvastatin 80 mg po daily rx *atorvastatin 80 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*3 6. carvedilol 25 mg po bid rx *carvedilol 25 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*3 7. hydralazine 50 mg po tid rx *hydralazine 50 mg 1 tablet(s) by mouth three times a day disp #*90 tablet refills:*3 8. isosorbide mononitrate (extended release) 90 mg po daily rx *isosorbide mononitrate 60 mg 1.5 tablet(s) by mouth daily disp #*45 tablet refills:*30 9. torsemide 20 mg po daily rx *torsemide 20 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*3 10. nitroglycerin sl 0.4 mg sl prn chest pain discharge disposition: home with service facility: homecare discharge diagnosis: aortic arch ulceration acute on chronic systolic congestive heart failure contrast induced nephropathy acute renal failure urethral calculus urinary obstruction discharge condition: mental status: clear, coherent ambulatory status: ambulates independently discharge instructions: dear mr. , it was a pleasure taking part in your care here at . you were admitted for severe chest pain. your initial ct scan looked like the ulceration of your aorta was expanding. repeat mri, which is a more sensitive test, showed that the ulceration was actually relatively stable. you developed kidney failure likely caused by a combination of the contrast from the cat scan and obstruction from a stone in your urethra. you were given fluids to help improve your kidney function. this resulted in worsening of your heart failure, ultimately requiring you to be on a breathing machine. with iv diuretics, your breathing improved significantly and you were able to come off the breathing machine. we continued to remove fluid using an oral diuretic and you no longer required extra oxygen. your chest pain resolved during the course of your hospitalization. you were evaluated by vascular surgery. given the results of your mri, which showed a stable ulcer, you do not require surgery during this hospitalization. instead your aortic ulceration was managed medically with strict blood pressure control. extra blood pressure medications were added to keep your blood pressure low to prevent worsening of your aortic ulcer. also, during your hospitalization you had a stone removed from your urethra and have had a foley catheter in place since then. you should follow-up with your urologist, dr. in 1 week for removal of the catheter. your kidney function has been steadily improving and your urine output has been good suggesting that your kidney function should return to normal. you will follow-up with the kidney doctors to ensure that your kidney function has returned to . the vascular surgery team has decided that it would be safest to send you home with strict blood pressure control and allow your kidneys and heart to recover from this hospitalization before performing the operation to repair your aorta. you will follow-up with dr. as an outpatient for further discussion of this surgery. again it was a pleasure taking part in your care and i wish you all the best in the future. followup instructions: department: vascular surgery when: at 10:30 am with: , md building: lm bldg () campus: west best parking: garage department: cardiac services when: thursday at 9:00 am with: , md building: campus: east best parking: garage department: west clinic when: at 2:30 pm with: , rn building: de building ( complex) campus: west best parking: garage department: when: pending with: , md building: (, ma) campus: off campus best parking: free parking on site **we are working on a follow up appointment with dr.. you will be called at home with the appointment. if you have not heard within 2 business days or have questions, please call the number above.** please follow-up with dr. of urology in 1 week for removal of foley catheter. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube other cystoscopy dilation of bladder neck transurethral clearance of bladder diagnoses: anemia in chronic kidney disease acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified thoracic aneurysm without mention of rupture hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified other and unspecified hyperlipidemia acute respiratory failure other left bundle branch block primary pulmonary hypertension bladder neck obstruction hypoxemia acute on chronic systolic heart failure other drugs and medicinal substances causing adverse effects in therapeutic use disorders of bilirubin excretion acute glomerulonephritis with unspecified pathological lesion in kidney other calculus in bladder 

Answer: The patient is high likely exposed to