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: syncope major surgical or invasive procedure: defibrillator placement history of present illness: ms. is a 64 year old female with cad, depression, chf, and chronic pain who presented to today after syncope x 2. patient reports that her legs "gave out" while she was in the kitchen last night and that she hit her head on the kitchen counter but did not remember wheter she had loc. she elected to not seek medical attention last night but did have slight bleeding and pain at her left occiput where she hit her head. this morning she drove her husband to work, then stopped at a coffee shop. she described feeling light headed and nauseous and subsequently lost consciousness in the car while it was parked. ems was called by passerbys and the patient was taken to osh ed ambulance . initial vital signs at osh ed were 97.9 77 123/70 18 98% on ra. repeat vital signs at osh ed revelaed bp as low as 94/53 with hr of 72 for which she received 2l of ns iv. serum toxicology screen and ammonia levels were negative. ct head and neck imaging were reassuring and her head laceration was stapled. following admission to , the decision was made to transfer her to for consideration of icd placement. . on arrival to the floor, the patient is comfortable and without additional complaints. . review of systems on review of systems, she denies 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 denies recent fevers, chills or rigors. s/he denies exertional buttock or calf pain. all of the other review of systems were negative. . 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: dyslipidemia, hypertension 2. cardiac history: cad with nstemi , stemi -pci: bms to lad -ischemic cardiomyopathy with lvef of 20-25% on osh tte 3. other past medical history: copd gerd migraine headaches osteroarthritis chronic lower back pain depression social history: patient is married, lives with husband. family stress due to death of her son from heroin overdose. also has daughter w/ current substance abuse problems. a 60 pack year history and currently smokes about one pack per day, but has plans to quit. . family history: mother had chf, died from at age 80. father died from lung cancer. physical exam: admission physical exam: vs: 98.2 70 105/52 18 95% on ra general: alert, oriented, no acute distress heent: 4 cm laceration with 5 staples on left occiput. sclera anicteric, dry mucus membranes, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: soft heart sounds, regular rate and rhythm, normal s1 + s2, holosystolic murmur best heard over mitral area. abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical exam: pertinent results: admission labs: 03:23am blood wbc-7.0 rbc-3.93* hgb-13.1 hct-39.2 mcv-100* mch-33.3* mchc-33.4 rdw-14.6 plt ct-240 03:23am blood neuts-77.0* lymphs-15.5* monos-3.0 eos-4.1* baso-0.4 03:23am blood pt-11.0 ptt-31.5 inr(pt)-0.9 03:23am blood plt ct-240 03:23am blood glucose-75 urean-11 creat-0.5 na-141 k-3.4 cl-109* hco3-21* angap-14 03:23am blood alt-14 ast-21 ck(cpk)-78 alkphos-59 totbili-0.4 03:23am blood ck-mb-4 ctropnt-<0.01 06:02am blood ck-mb-4 ctropnt-<0.01 03:23am blood albumin-3.3* calcium-8.3* phos-2.4* mg-2.1 03:23am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg discharge labs 05:43am blood wbc-11.5* rbc-4.05* hgb-13.4 hct-40.5 mcv-100* mch-33.2* mchc-33.2 rdw-15.1 plt ct-481* 05:43am blood pt-13.1 ptt-91.4* inr(pt)-1.1 05:43am blood glucose-131* urean-10 creat-0.4 na-138 k-3.8 cl-98 hco3-30 angap-14 05:43am blood alt-354* ast-232* alkphos-154* totbili-0.7 05:43am blood albumin-3.5 calcium-8.8 phos-2.9 mg-2.4 12:30pm blood hbsag-negative hbsab-positive igm hbc-negative igm hav-negative 12:30pm blood hcv ab-negative 04:33am blood type-art temp-36.4 rates-/27 tidal v-500 peep-5 fio2-40 po2-110* pco2-44 ph-7.50* caltco2-36* base xs-10 intubat-intubated vent-spontaneou 06:39am blood lactate-1.3 04:33am blood freeca-1.12 pertinent studies echocardiogram the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. there is moderate regional left ventricular systolic dysfunction with mid to distal septal, anterior and apical akinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . ct chest/abd/pelvis: impression: 1. multiple bilateral pulmonary emboli. evidence of pulmonary arterial hypertension and concern for right ventricular strain. 2. small residual right pneumothorax with chest tube in place. 3. more consolidative changes in the right lower lobe. early developing pneumonia is not excluded. 4. enlarged liver with mottled enhancement pattern and periportal edema suggestive of congestive hepatopathy. perihepatic and pelvic ascites. 5. splenic infarct. 6. generalized anasarca. . leni : impression: 1. occlusive thrombus within the left profunda femoris vein which extends into the common femoral vein where there is partial, non-occlusive thrombus. 2. no right lower extremity dvt. . cxr : impression: 1. further withdrawal of the endotracheal tube, clinical correlation is recommended. 2. improvement of right basilar atelectasis and left basilar pleural effusion, atelectasis, and consolidation. 3. stable right apical pneumothorax. . ruq us: : impression: 1. no evidence for cholecystitis. 2. thickened gallbladder wall, bilateral pleural effusions, trace perihepatic ascites, hepatomegaly and dilated hepatic veins/ivc compatible with fluid overload and congestive failure, with the patient's pain perhaps relating to congestive hepatopathy. . ruq us: : preliminary read: no cholecystitis, cbd not dilated, gall bladder edema present but improved in comparison to prior. . microbiology: sputum culture: streptococcus pneumoniae - sensitive to penicillin and cdiff: negative urine culture: yeast 10,000-100,000 organisms/ml. , , , , , , blood cultures: no growth to date ebv igg positive and igm negative cmv igg negative and igm negative brief hospital course: 64 year old woman with cad, copd, chronic systolic heart failure with ef 20-25%, depression and chronic pain who was transferred from an outside hospital with recurrent syncope and need for icd placement. . acute care: # shock: on admission to the ccu, pt was hypotensive to the 80s systolic and was given norepinephrine and phenylephrine as well as 4l ns to maintain maps above 60. her hemodynamics were consistent with a mixed picture of cardiogenic and septic shock. an iabp was placed on for pressure support, then removed on . the patient was also supported with pressors, norepinephrine and phenylephrine, from until . she was empirically treated for a pulmonary embolism with a heparin drip, although this was initially discontinued after ct-a was negative and she developed melena. pt was treated with ceftriaxone for a streptococcus pneumoniae pneumonia, however because she remained febrile and unstable, was re-broadened to vanc/cefepime. she was extubated on , but remained delerious. on , she had tachypnea to rr 40-50's, and was re-intubated. because her cardiac issues had become secondary to medical ones, she was transferred to the micu. in the micu, she was given continued on cefepime for 7 days ( to ) to treat s.pneumonia (sensitive to penicillin). she received a ct torso which showed new bilateral pulmonary emboli, rll consolidation, splenic infarct, and signs of congestive hepatopathy. lower extremity dopplers showed left femoral deep venous thrombosis. she was started on heparin drip and transitioned to lovenox on . echocardiogram showed depressed lvef 25-30% with worsening severe mitral regurgitation. she temporarily required pressors for blood pressure support while in the micu. she was aggressively diuresed with a lasix drip (10+ liters of fluid were removed) and was successfully extubated on . on day of discharge she is still 5.9l positive for length of stay and thus will continue on lasix drip upon discharge to ltac. . # respiratory failure: patient was coded on the floor on for respiratory distress and hypoxemia requiring intubation. respiratory failure was initially thought to be secondary to pulmonary edema; however chest x-ray was more consistent with lobar pneumonia. she was eventually extubated on , but extubation was complicated by agitation. the patient responded well to haloperidol for agitation but developed long qtc so this was discontinued. on , she had tachypnea to rr40-50's, pao2 72, but work of breathing too much and was thus re-intubated and transferred to micu service. please see above for micu events. we think failure of intubation initially was multifactorial, but likely due to persistent pneumonia, new pulmonary embolism and most importantly, significant pulmonary edema due to mitral regurgitation. with diuresis, her respiratory status and mr have appeared to improve dramatically. we anticipate even further improvement with continued diuresis and management of her copd. . # systolic congestive heart failure: patient has known severe systolic dysfunction with most recent lvef of 20-25% from osh tte in . her ef on echocardiogram done here was 30%. given stemi > 30 days ago (in ) and lvef < 30% patient meets madit2 criteria for icd placement, however icd placement was postponed until medical stability was achieved and code status code be discussed. she is dnr, ok to intubate, therefore icd placement does not coincide with her current wishes. she is currently on lasix drip, and lisinopril was started on for afterload reduction. she will likely need to have lisinopril uptitrated and a beta blocker started. spironolactone is indicated and should be started once the lasix drip stops as long as her blood pressure tolerates. statin was held due to elevated lfts, but once liver function tests normalize, she should be re-started on statin. aspirin and plavix were continued. . # syncope: patient has a complicated pmh with several possible causes for her syncopal episode including arrhythmia from known ischemic disease, iatrogenic hypotension in the setting of severe systolic dysfunction with unknown complaince/dosing of home antihypertensive medications and overuse of sedating medications including percocet and gabapentin. additionally, discontinuation of provigil may have also contributed to her syncopal event. acs is less likely given the absence of her angial equivalent chest pain, ekg changes or cardiac enzyme abnormalities. it is unclear what causd her syncope. cyclobenzaprine was held and decreased her gabapentin to 400mg dosing. provigil was started. the patient was not orthostatic. as primary arrhythmia could not be ruled out as initial cause of syncope, patient will need to have an icd placed for secondary prevention. this is scheduled for 8am on . patient needs to monitored on telemetry at all times until icd placed. lovenox should be held the morning of device placement . # elevated lfts: seen by hepatology and consensus was that she has congestive hepatopathy. ruq us on was consistent with congestive hepatopathy and did not show evidence of biliary infection or dilitation. lfts did not trend down as expected with diuresis, therefore ruq us was repeated on which showed interval improvement in gall bladder edema and confirmed lack of presence of cholecystitis or cbd dilitation. we recommend repeating lfts in weeks when she follows up with her primary care physician. . # chronic pain: patient has known chronic pain with low back pain and arthritis managed with percocet and gabapentin. overuse of these medications may have contributed to her syncopal event. of note gabapentin was recently increased from 400mg to 800mg tid. osh documentation suggest that percocet was discontinued to hypotension. during her admission, gabapentin was continued at 400mg dosing. opiates were discontinued. . # depression: patient has a history of depression with suicide attempts. mood appears stable on admission. continued her home buproprion, fluoxitine, topamax. held quetiapine due to mental status not quite back to baseline prior to admission (suspect altered mental status likely due to prolongued affect of sedation used during intubation). . # gerd: developed melena when on heparin drip initially. she was started on iv ppi and transitioned to oral ppi. . # copd: appears stable from this standpoint. . code: full code emergency contact: () . summary of transition of care issues: - icd placement scheduled for at 8am, lovenox should be held the morning of procedure - monitor patient on telemetry until icd placement - pulmonology follow up for treatment of copd, will likely need to pfts - start beta blocker for goal hr 60-70 if blood pressure tolerates - uptitrate lisinopril if blood pressure tolerates - start statin if lfts normalize - repeat echocardiogram in 2 weeks - consider starting spironolactone if ef remains <40% on repeat echocardiogram - monitoring of lfts, if remains elevated will likely need referral to hepatology for further work up - wean lasix drip to lasix boluses once another 3-4l negative - needs pcp follow up to address chronic pain - pcp discussion of icd placement in future medications on admission: patient was unable to fully reconcile current medication list: xbupropion hcl 100 mg xsimvastatin 80 mg daily xaspirin 325 mg daily xxxgabapentin 800 mg tid xclopidogrel 75 mg daily xquetiapine 25-50mg qhs xranitidine hcl 150 mg xfluoxetine 60 mg daily xtopamax 100 mg xmultivitamin daily xfolic acid 1mg daily xthiamine 100mg daily xallegra . modafinil 100 mg (? not taking to cost) cyclobenzaprine 10 mg tid:prn pain (? not taking to dizziness) percocet 5-325 mg q4h:prn pain (? not taking to hypotension) metoprolol xl 12.5 mg (? not taking to hypotension) furosemide 20 mg daily (? not taking) hydrochlorothizide 25 mg daily (? not taking) discharge medications: 1. bupropion hcl 100 mg tablet sig: one (1) tablet po bid (2 times a day). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. topiramate 100 mg tablet sig: one (1) tablet po bid (2 times a day). 6. fluoxetine 20 mg capsule sig: three (3) capsule po daily (daily). 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 8. gabapentin 400 mg capsule sig: one (1) capsule po bid (2 times a day). 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 11. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 12. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain: do not exceed 2g per 24 hours. 13. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. ipratropium bromide 17 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. enoxaparin 100 mg/ml syringe sig: seventy five (75) mg subcutaneous once a day. 16. fluconazole 100 mg tablet sig: one (1) tablet po once a day for 3 days. 17. furosemide 10 mg/ml solution sig: 10mg/hr injection continuous infusion. 18. lisinopril 5 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary: chronic systolic heart failure coronary artery disease chronic obstructive pulmonary disease hypertension secondary: hyperlipidemia gastroesophageal reflux disease migraines chronic pain discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , you were admitted after being found unconscious in your parked car. it is unclear what caused you to lose consciousness, but it may have been related to your heart. you underwent placement of an icd (a defibrillator). you were intubated during which time you received antibiotics and medications to decrease the fluid in your lungs. you have significant heart valve disease (mitral regurgitation) and will need to follow up with cardiology upon leaving the hospital. you also developed a clot in your leg and lung for which you are now on medications to prevent future clots. you will also need to have an icd implanted in case a heart arrhythmia caused you to lose consciousness. you will have this device placed on tuesday at 8am. you should hold your dose of lovenox prior to the procedure. please note the following changes to your medications: - start lisinopril - start pantoprazole - start acetaminophen as needed for pain - start albuterol and ipratropium as needed for shortness of breath - start enoxaparin - start fluconazole for 3 days - decrease gabapentin to 400mg twice daily - stop ranitidine - stop seroquel please be sure to follow up with your physicians. please stop smoking. if you need assistance with quitting, please talk to your primary care doctor to discuss strategies. please weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. followup instructions: please make an appointment to see your primary care doctor within one week after leaving the rehabilitation facility. you have an appointment to have an icd placed on at 8am. department: ep when: tuesday at 8am where: 4, electrophysiology lab phone: ( please hold your lovenox the morning of the procedure department: medical specialties/pulmonary when: thursday at 1 pm (12:30 arrival) with: rn/dr. building: sc clinical ctr campus: east best parking: garage *please arrive by 12:30 for breathing tests. department: cardiac services when: friday at 9:00 am with: , m.d. building: campus: east best parking: garage md procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for 96 consecutive hours or more coronary arteriography using two catheters enteral infusion of concentrated nutritional substances implant of pulsation balloon right heart cardiac catheterization diagnoses: other chronic pain esophageal reflux mitral valve disorders congestive heart failure, unspecified unspecified essential hypertension unspecified septicemia severe sepsis chronic airway obstruction, not elsewhere classified depressive disorder, not elsewhere classified percutaneous transluminal coronary angioplasty status other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia acute respiratory failure iatrogenic pneumothorax alkalosis blood in stool septic shock old myocardial infarction pneumococcal pneumonia [streptococcus pneumoniae pneumonia] acute venous embolism and thrombosis of deep vessels of proximal lower extremity acute on chronic systolic heart failure syncope and collapse other pulmonary embolism and infarction migraine, unspecified, without mention of intractable migraine without mention of status migrainosus delirium due to conditions classified elsewhere lumbosacral spondylosis without myelopathy herpes zoster with other nervous system complications other diseases of spleen other specified disorders of gallbladder chronic passive congestion of liver 

Answer: The patient is high likely exposed to