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: history of present illness: 76-year-old white male with a history of symptomatic bradycardia status post pacemaker, hypertension, hyperlipidemia, coronary artery disease, weakness over the last three to four weeks. the patient has a complicated cardiac history. he was hospitalized in for an acute thrombosis of the left anterior descending. the patient was seen earlier that week for an episode of near-syncope, was seen the following week in clinic by his primary care physician. in the clinic, he stated that since his pre-syncopal episode, he had felt fibrillation arrest and was resuscitated and brought to the coronary care unit. while in the coronary care unit, his enzymes were positive and, shortly afterwards, he was taken to the cardiac catheterization laboratory. the catheterization revealed near-total occlusion of his proximal left anterior descending and thrombus at the site of occlusion. the lesion was successfully stented with 0% residual stenosis. there were no other identifiable lesions in the left anterior descending. there was 50 to 60% stenosis of the obtuse marginal i. the right coronary artery showed minor irregularities in the proximal third. shortly after catheterization, the patient suffered from another episode of ventricular fibrillation, and then was successfully cardioverted, but then developed respiratory distress and was intubated for cardiogenic shock. echocardiogram at that time revealed an ejection fraction of 25% with anteroseptal and apical hypokinesis. he was intubated for over a month and required a tracheostomy. while intubated, his pacemaker was replaced with an icd model #7273. eventually, after a prolonged hospital coronary care unit stay, he was extubated and underwent intensive cardiac rehabilitation. since his coronary care unit admission, he has suffered from the following events: in , while in , he had an episode of ventricular fibrillation for which he was shocked. his defibrillator detection rate was reprogrammed from 188 to 167 beats per minute. he has lost 70 or 80 pounds, and continues to lose weight. he went from 247 to 170 pounds. his ace inhibitor was discontinued for suspected cough, and his beta blocker discontinued for asymptomatic hypotension. over the last three to four weeks, he has noted increased weakness. he has been playing golf fairly recently, but is no longer able to play. he becomes short of breath after walking a quarter of a mile, according to him. he denies any chest pain. he also has been having pain in his left shoulder, left upper chest, which was attributed to him lying in bed on that side. he notes that he has awakened in the middle of the night short of breath. he has also required a variable height of pillows on which to sleep. he denies any fevers or chills. he denies any nausea or vomiting. he has had problems with constipation. past medical history: 1. insulin-dependent diabetes mellitus, possibly type 2 diabetes. since his myocardial infarction, he reports that his glucose is on the low side, and he has not required any insulin. his fasting glucose has been around 120 to 130. last hemoglobin a1c was 6.16. 2. coronary artery disease as above 3. symptomatic bradycardia; pacemaker was placed in and was later replaced in , which was then replaced with a icd model #7273. 4. hypothyroidism, previously on synthroid, reason for discontinuing it is not known 5. hyperlipidemia, last profile in with ldl 93, hdl 53, triglycerides 135 6. gout 7. small bowel obstruction from previous hernia repairs 8. peripheral neuropathy 9. glaucoma 10. chronic renal insufficiency, baseline creatinine 1.3 social history: denies smoking. occasional ethanol. he lives in with his wife, visiting the area because granddaughter is graduating. he has 2 sons and 1 daughter, and 10 grandchildren. family history: father died at 51 from a myocardial infarction. medications: 1. coumadin, dose regularly adjusted for atrial fibrillation, receives 2.5 mg for five days, then 1.5 mg for two days, specifically on monday and wednesday 2. prilosec 20 mg by mouth once daily. he has been discontinued from many medications, including lanoxin, vasotec, atacand, synthroid, lasix, toprol xl, claritin and singulair. allergies: questionable tequin reaction. additionally, he was stopped also from amiodarone and lipitor because of elevated liver function tests but unclear which medication caused the reaction. physical examination: general: elderly gentleman with cardiac cachexia and obvious volume overload. dyspneic with speaking but able to complete sentences. heart rate 60, blood pressure 128/60, respiratory rate 20. head, eyes, ears, nose and throat: normocephalic, atraumatic, extraocular movements intact, pupils equal, round and reactive to light and accommodation, moist mucous membranes. neck supple without thyromegaly, jugular venous distention to angle of jaw. no lymphadenopathy. pulmonary: no wheezes or crackles appreciated. cardiac displace pmi s1, split s2, s3 and systolic murmur. abdomen: normal bowel sounds, soft, nontender, palpable liver edge. his abdomen was distended in the lower portions. he has a history of hernia. extremities: 2+ lower extremity pitting edema up to thighs and presacral edema. neurological: alert, awake, oriented x 3. laboratory data: white count 5.5, hematocrit 42.7, platelets 146, mcv 89, neutrophils 65.3, lymphocytes 25.4, monocytes .8, eosinophils .6, basophils .4. inr 1.4, ptt 31.2. cholesterol 141, triglycerides 72, ldl 88, hdl 39, tsh 43.7, free t4 1.3. sodium 140, potassium 4.5, chloride 101, bicarbonate 29, bun 20, creatinine 1.1, glucose 119. alt 10, ast 19, albumin 3.7, phosphate 3.8, alkaline phosphatase ________, total bilirubin 1.0, calcium 9.1. helicobacter pylori negative. urinalysis with trace blood, greater than 300 protein, 1.025 specific gravity, ph 5. troponin was less than .3. magnesium 1.9, phosphate 4.1, calcium 9.1. chest x-ray showed mild cardiomegaly with slight upper zone redistribution of the pulmonary vasculature, without evidence of interstitial or alveolar pulmonary edema. mild blunting of the left costophrenic angle and increased densities within both major fissures on the lateral view, indicating pleural thickening in these areas. small pleural effusions present. these findings were consistent with chronic congestive heart failure. there was demineralization of the osseous structures, but no evidence of compression fractures within the thoracic spine. dual lead defibrillator/cardiac pacer is seen with the generator overlying the left hemithorax. electrocardiogram shows paced rhythm with a left bundle branch block pattern. echocardiogram showed an ejection fraction of 15%. stress thallium showed moderate defect involving the anterior and septal walls. there was severe perfusion defect involving the cardiac apex. however, the test was stopped because of thallium pickup in the lungs. no exercise stress test was done. assessment and plan: 76-year-old white male with a history of coronary artery disease, symptomatic bradycardia status post pacemaker, ventricular fibrillation arrest, now comes with progressive deterioration of exercise tolerance and increase in dyspnea on exertion plus symptoms of paroxysmal nocturnal dyspnea, orthopnea, peripheral edema and was found to be in decompensated heart failure. he was admitted for treatment of his congestive heart failure. hospital course by system: 1. cardiac ischemia: the patient was felt to be in decompensated heart failure secondary to a discontinuation in his medications as well as possibly from an ischemic event. his troponin was negative, therefore he didn't have any event in the last week or so. he was not started on a beta blocker because he was in congestive heart failure. his cholesterol was thought to be in the desired range, so he was not started on any lipitor. he had a cardiac catheterization done on the fifth day of admission that showed right atrial pressure of 10, right ventricular pressure of 52/6, and the rest in the pump section. lvgram showed an ejection fraction of 18%, with left main being normal, the left anterior descending having 80% in-stent re-stenosis, 80% distal re-stenosis, 80% diagonal lesion at the ostium. the left circumflex showed mild disease. the right coronary artery showed mild disease. interventions were done, including the diagonal rotoblated and dilated with angioplasty with 20% residual. his left anterior descending had two interventions done. for the distal stenosis, a stent was placed. for the in-stent re-stenosis, angioplasty was done with subsequent brachytherapy. after his cardiac catheterization, he was continued on his aspirin and restarted on his plavix and integrilin. the beta blocker was started once he was thought to be in less overt congestive heart failure. the plavix was to be continued for 180 days, and the integrilin was to be continued for 18 hours. on the seventh day of admission, he was started on carvedilol 3.125 mg by mouth twice a day as he was thought to be near his dry weight. he was also started on an ace inhibitor early in the admission of captopril. when transferred to the unit, he was continued on his aspirin, and the plavix was discontinued briefly. the plavix was restarted on the third day in the coronary care unit. he was transferred out of the unit on . he was on aspirin and plavix, and he was continued on the beta blockade. his beta blocker was held initially in the setting of his hematoma, and has been continued. he will need follow up for continuation on his plavix for 180 days total. 2. pump: the patient was in overt congestive heart failure based on paroxysmal nocturnal dyspnea, chest x-ray, symptoms, ejection fraction on echocardiogram. the initial interventions were to give him furosemide 40 mg intravenously. he had been on furosemide in the past, and had been taking 20 mg by mouth once daily. it was thought that giving him 40 mg intravenously would definitely cause a response. he was also started on digoxin .125 mg by mouth once daily. he was also started on captopril 6.25 mg by mouth three times a day and it was uptitrated as tolerated. beta blocker would be started once he was compensated. his first day, he diuresed a large amount. his input was 474 and his output was 2605. consequently, further lasix was held, as more gentle diuresis was desired. the captopril was increased from 6.25 to 12.5 and then to 18.5. on the second day, captopril was increased to 25 mg by mouth three times a day. because he was going for cardiac catheterization, further active diuresis with lasix was held. he continued to diurese on the second day, with input of 600 and output of . on the third day, he was more even. his captopril was increased to 31.25 mg. he had his cardiac catheterization, which showed a pressure of 10, rv 52/6, pa 53/21, wedge pressure 29. left ventricular pressure of 135/13, area pressure of 136/75. he had constantly elevated right-sided and left-sided pressures. he had elevated left-sided pressure despite being on the diuresis. his weight had decreased to 155 by the fourth day of admission. he had come in at 172 pounds. the patient's blood pressure was 104 to 132 by the fourth day of admission. on the sixth day of admission, the patient had decreased blood pressure. the patient had an increased wedge pressure but decreased blood pressure. he initially received 250 ml of normal saline. he responded to it and did not have any respiratory complaints thereafter. his captopril was held at that time, as was his furosemide. however, because the patient was considered to have increased wedge pressure and he was not bleeding from his groin at that time, further fluids were held. it was thought that if his blood pressure were to further decrease, he may need inotropic support. however, it did not come to that. he had improved on review. he continued on lasix at the time of transition to by mouth. he was started at 40 once a day. he was receiving lasix after his cardiac catheterization. he was basically receiving 20 to 40 mg by mouth once daily. he continued to have mild diuresis. he had hypotension. the patient, on the , had blood pressures basically between 90 and 110. his carvedilol and lisinopril were continued. it was decided to change his captopril to lisinopril and stagger the doses between carvedilol and lisinopril. they were to be given in the morning and evening. his digoxin was continued. the patient was continued on some lasix. he is on 40 mg by mouth once daily. his blood pressure was low, between 90 and 100. he had increased creatinine on the 25th. his lasix was held at that time. lisinopril was continued. he had much weight loss, and it was thought that it was due to his diuresis. on the , the patient required a unit of blood. his hematocrit had decreased to 28.3. he required a total of two units before being transferred to the unit. he was still on lasix, but it was held because of increased creatinine. his creatinine returned back to 1, however, he had to be transferred to the unit on the , on the 12th day of his admission. in the unit, his lasix was held. his blood pressure medications were held at that time. his hematocrit was eventually stabilized and the medications were restarted gradually and gently. the diuretic were held, but his blood pressure medications were restarted on the 13th day of admission. on the 14th day of admission, he was still on his zestril and carvedilol, and he has been continued on this. he was continued on his carvedilol and lisinopril. at this point, the patient is near euvolemic state, and he is not on his lasix. he will need to be determined when to restart his lasix, probably at a low dose at 20 mg by mouth once daily. the patient responds fairly well to lasix. the patient is supposed to be evaluated for biventricular pacing, and was thought to be a good candidate for it. the patient has a history of atrial fibrillation. he also had a pacemaker placed previously, and a defibrillator. he, on the same day of admission, had nonsustained ventricular tachycardia. consequently, the ep service was called and consulted and pacemaker was interrogated. their initial recommendations were that the 20 beat run of nonsustained ventricular tachycardia could be tolerated, and the fact that his defibrillator did not go off was a good sign, and that it had to be more prolonged before it should go off. it was detected and charged appropriately and aborted shock appropriately. they were concerned about his atrial fibrillation, and they suggested cardioversion. they also had plans for assessing for biventricular pacing. ep service performed their ep study on the , the seventh day of admission. they further weighed in on the 23rd. they recommended anti-arrhythmics. they initially recommended amiodarone, but the patient had a history of elevated liver function tests. consequently, they recommended putting the patient on dofetilide. he was started on dofetilide. the concern with dofetilide was that it may prolong qt intervals, however, he did not suffer these effects. he had the ep study on the . the heparin was discontinued, he was continued on the dofetilide. he had several things done. the patient had an ablation done. he was also assessed for biventricular pacing and was felt to be a good candidate. he was also cardioverted. he had biventricular pacemaker mapping. he had a hematoma on the left side, and pressure was held, and it was considered stable. his blood pressure was stable at that time. over the next couple of days, the patient was hypotensive, with hematocrit decreased from 33 to 28.2. this was thought to be due to the hematoma, but it was stable. he was given two units of blood. he was considered to be in sinus rhythm. he was continued on dofetilide. however, he did not have any profound p waves. he was on heparin and coumadin after the procedure. his coumadin was given at 5 mg daily at bedtime. his heparin was at a goal of 60. after his hematoma expanded, he was stopped on the heparin and coumadin. heparin and coumadin were restarted on the 14th day of admission. his heparin was started on the 14th day of admission at a goal of around 60. the patient will have further ep workup in the next month. they are awaiting the biventricular pacer/defibrillator device to be approved by the fda. it is felt that the patient needs anticoagulation primarily because of his risk of stroke from his cardiomyopathy and his longstanding atrial fibrillation. 3. vascular: after the patient had his ep study, he developed a left-sided hematoma. he was essentially stable for a few days. the patient had a controlled hematoma initially. however, on the 12th day of admission, the patient was walking around and then developed left flank pain. on examination, he had an expanding hematoma of the left groin. he had a hematocrit drop from the 30s to 28. he received two units. he had a bedside ultrasound which showed no pseudoaneurysm, but did show a large left hematoma. he was transferred to the unit for further observation. pressure was held initially for approximately two hours. the hematoma stabilized, but was large in the left anterior portion of his thigh. he was transferred to the unit for observation and had vascular surgery follow him. on the second day in the coronary care unit, the patient continued to be seen by vascular surgery. it was felt that he would benefit from surgical intervention. he went for operation, and was found to have a pseudoaneurysm of the profunda femoral artery. it was repaired, and the hematoma was evacuated. the patient did not have further interventions. the patient had anticoagulation initially held, but it was restarted once the hematocrits were stable. his hematocrit was stable in the coronary care unit. he did receive two units of blood prior to this large expanding hematoma. thereafter, he did require another two units. the goal was to keep him above 30. his hematoma is still present, but his hematocrit is stable, and the hematoma is thought to be stable. he had another unit transfused in the unit. it was decided that, because of his stroke risk, that he would need anticoagulation, and he was started on the 14th day of admission, however, it had to be done gently. 4. endocrine: the patient was on a regular insulin sliding scale and did not really require much. he is mainly diet controlled. 5. hematology: the patient had decrease in his hematocrit initially from 33 to 28.2 on the tenth day of admission. this was thought to be due to his left femoral hematoma from the initial ep study. he received one unit of blood, but his hematocrit did not bump. subsequently he received another unit. he did respond to that, and increased to 29.6 and then subsequently 31.3. however, when he suffered the expanding hematoma while walking on the 12th day of admission, his inr at that time was 1.4, and his ptt was 59. his anticoagulation was stopped at that time, but it was restarted on the 14th day of admission. he has continued on coumadin 5 mg by mouth daily at bedtime with a goal inr of 2 for the indication of atrial fibrillation and cardioversion. he had stable hematocrits in the coronary care unit, and at the time of discharge summary, he had a hematocrit of 31.7. 6. renal: the patient had a creatinine generally stable despite diuresis, however, on the ninth day of admission, it increased to 1.7. he had electrolytes done which showed a fena of less than 1% and a urea fairly low too. consequently he was thought to be dry, and his lasix was held at that time. he did receive some units of blood in that setting, and his creatinine did improve from 12.5 to 1.5. then the following day, it was 1.2. at the time of discharge summary, it was .7. the patient is still in the hospital awaiting his inr to be above 2. this is just a discharge summary up to . his medications at this time are as such: 1. heparin intravenous drip 2. warfarin 5 mg by mouth once daily at bedtime 3. aspirin 81 mg by mouth once daily 4. plavix 75 mg by mouth once daily 5. 60 mg by mouth twice a day 6. carvedilol 3.125 mg by mouth twice a day 7. lisinopril 10 mg by mouth daily at bedtime 8. magnesium oxide 400 mg by mouth three times a day 9. dofetilide 250 mcg by mouth twice a day 10. digoxin .0125 mg by mouth once daily 11. robitussin ac 12. regular insulin sliding scale 13. colace 14. dulcolax 15. protonix 40 mg by mouth once daily the patient is waiting his inr to be greater than 2. he will be discharged to home. he is to follow up with dr. and with the electrophysiologist for ventricular pacing/defibrillator placement next month. he should follow up with dr. at that time, or in two weeks. the patient lives in and was visiting his granddaughter's graduation prior to all of this happening. he will return to most likely, and then return in a month or so for the placement, or he will have the procedure done in the south. , m.d. dictated by: medquist36 d: 20:18 t: 03:30 job#: procedure: insertion of non-drug-eluting coronary artery stent(s) combined right and left heart cardiac catheterization coronary arteriography using two catheters angiocardiography of left heart structures injection or infusion of platelet inhibitor excision or destruction of other lesion or tissue of heart, endovascular approach other repair of aneurysm implantation or insertion of radioactive elements diagnoses: congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled atrial fibrillation accidental puncture or laceration during a procedure, not elsewhere classified other complications due to other cardiac device, implant, and graft ventricular fibrillation other and unspecified coagulation defects fitting and adjustment of automatic implantable cardiac defibrillator 

Answer: The patient is high likely exposed to