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: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath, dyspnea on exertion major surgical or invasive procedure: none history of present illness: in brief, pt is an 86 y/o with a pmh of afib on coumadin, chf ef 45%, htn, recently diagnosed copd who presented with several weeks of sob and doe. she was admitted to the micu and underwent tte which showed critical as, with valve area 0.5 cm2 and mean gradient 78 and peak gradient 129. she is being transferred to ccu for further care. . with regards to the patient's doe, it has been worsening over the last few weeks. previously, the patient was able to walk around the mall without much difficulty. her breathing has been even worse over the last few days, to the point that she gets short of breath even at rest. on the day of admission she was seen to be very sob by her daughter and was brought to her pcps office where her amb sat was 86% on ra and she was sent to ed. . past medical history: # htn # chf # copd: recently diagnosed by dr. at # stable goiter # afib on coumadin # ? aortic stenosis # gerd # osteoporosis # basal cell under left eye # s/p resection of childhood tumor "behind heart" social history: lives at . smoking: quit 40 years ago, but had 10 pack year priot to that family history: nc physical exam: t 36.7 hr 92 bp 110/77 rr 18 sao2 94% on ra general appearance: well nourished eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: large goiter on r cardiovascular: holosystolic murmur with loss of s2 consistent with severe as, no delayed upstrokes peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (breath sounds: crackles : at bases) abdominal: soft, non-tender, bowel sounds present extremities: right: 2+, left: 2+ skin: not assessed neurologic: attentive, follows simple commands, responds to: not assessed, movement: not assessed, tone: not assessed pertinent results: : wbc: 5.5 3.18* hgb: 9.9* hct: 30.3* 96 31.2 32.6 15.6* plt: 232 inr 1.8 gluc: 96 bun: 29* creat:1.0 na:144 k:4.2 cl:101 bicarb: 36* agap:11 . cxr mild chf. right paratracheal density/mass. left basal pneumonia. no change since the examination done one hour earlier. ct scan of chest suggested. echo the left atrium is elongated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with septal/inferior hypokinesis. tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. . cxr compared to the film from two days previous there continues to be cardiomegaly. there is increased pulmonary vascular re-distribution and increased bilateral effusions left greater than right suggesting worsening chf. the prominence in the right paratracheal region is again seen and it is unclear if this is due to tortuous vessel versus a mass in this region. the opacity in the retrocardiac region has also increased and it is unclear if this is due to pulmonary edema or an infectious infiltrate. pleural calcifications are again noted. . impression: worsening chf. . cus impression: bilateral 1-39% ica stenosis with blunted common carotid waveforms consistent with aortic stenosis. antegrade vertebral flow. right thyroid cyst as described above. . ct chest impression: 1. the thyroid is markedly enlarged, with multiple masses. the thyroid gland extends into the superior mediastinum, resulting in mass effect on the great vessels, particularly the right brachiocephalic artery, left common carotid and subclavian arteries, and brachiocephalic veins. the origin and course of the left common carotid artery cannot be delineated on this study. the right brachiocephalic vein is sandwiched between the first rib and goiter, with multiple collateral vessels seen in the upper neck. furthermore, at least one of the thyroid nodules in the right superior mediastinum contains multiple thin flecks of calcium, concerning for neoplasm. multiple enlarged mediastinal nodes are also seen. further evaluation is recommended, to evaluate for the possibility of a thyroid cancer. 2. cardiomegaly, coronary artery calcifications, aortic valve and mitral valve calcifications, and aortic atherosclerosis. 3. small-to-moderate bilateral pleural effusions. 4. mosaic attenuation in the lungs, possibly related to airtrapping. 5. l1 compression fracture. . spirometry spirometry 1:20 pm pre drug post drug actual pred %pred actual %pred %chg fvc 0.74 2.10 35 0.78 37 +6 fev1 0.56 1.34 41 0.65 48 +16 mmf 0.44 1.63 27 0.78 48 +78 fev1/fvc 76 64 118 83 130 +10 lung volumes 1:20 pm pre drug post drug actual pred %pred actual %pred tlc 1.76 3.93 45 frc 1.03 2.41 43 rv 1.05 1.83 58 vc 0.71 2.10 34 ic 0.73 1.52 48 erv -0.03 0.58 -4 rv/tlc 60 47 128 he mix time 3.00 dlco 1:20 pm actual pred %pred dsb 4.65 14.98 31 va(sb) 1.52 3.93 39 hb 10.20 dsb(hb) 5.25 14.98 35 dl/va 3.46 3.81 91 . cardiac cath comments: 1. selective coronary angiography of this right dominant system did not reveal flow limiting coronary artery disease. the lmca was normal. the lad had mild disease. the lcx was small without disease. the mid-rca had a 40% stenosis. 2. resting hemodynamic measurement demonstrated moderately elevated left and right sided filling pressures with an lvedp of 25mmhg and rvedp 24mmhg. an accurate pcwp was not obtainable after several attempts. the mean pap was severely elevated at 62 mmhg. simulatenous pressure measurement in the lv and aorta demonstrated a mean 39mmhg gradient. the calculated fick cardiac index was preserved at 2.3 l/min/m2. 3. valvuloplasty was performed. we exchanged for a 8f sheath with a amplatzer super stiff wire in lv and advanced a 20mm tyshak 2 balloon. with rv pacing at a rate of 160 we performed 4 inflations manually with a 30cc syringe. the balloon would not fully inflate prior to being pushed into aorta but did improve from .5 to .64 and peak to peak gradient fell by 20mmhg. heparin was used for anticoagulation. 4. angioseal of the 8f rfa arteriotomy. final diagnosis: 1. coronary arteries are normal. 2. critical as 3. severely elevated left and right sided filling pressures. 4. severe pulmonary hypertension. brief hospital course: in the ed, initial vs were: t 97.3, p 95, bp 114/52, r 24, 94%ra o2 sat. ekg with st depression in v5-6 c/w strain pattern, and cxr c/w pulm edema and lll infiltrate. she was given nebs, levaquin and ctx. she became hypotensive intermittently to sbp 86/60 and got 250 ns b/c low bps. oxygen requirement increased to 97% on 4l nc. she did not get lasix given hypotension. she was admitted to the micu and reported feeling somewhat better. she denied any chest pain, chest pressure, palpitations, fever, chills, cough, sputum production, dysuria, or sick contacts (although does live in ). she noted progressive orthopnea and possible pnd. + le swelling. she is unsure of weight gain. # hypoxia: the primary cause for her hypoxia was likely pulmonary edema in the settting of critical as. pt has known critical as from osh records but per her primary cardiologist this has likely worsened. pt felt symptomatically improved after being diuresed with 20mg iv lasix but then dropped her sbps to 70-80s. she was clearly very preload dependant but also very sensitive to "fluid overload." there was initially concern for possible pna given lll infitrate on initial cxr, however she was afebrile and without leukocytosis. while in the micu, pt was started on a 5-day course of azithromycin. this was discontinued on transfer to the ccu due to lack of clinical signs/sx of pna. pft's were done which showed a restrictive pattern, not obstructive, please see pertinent results section for more details. given the high likelihood of the critical as contributing to pt's fluid overload and resultant shortness of breath, pt was evaluated for av repair, and decision was made to proceed with valvuloplasty (see above) in addition, given patient's pulmonary function tests, her outpatient copd medications were discontinued. pt was satting 82% on ra on discharge but 96% with 2l np. it is hoped that hypoxia will be improved with continued gentle diuresis. patient was discharged on 60 mg po daily of standing lasix and dose to be adjusted as needed by outpatient cardiologist. . # critical aortic stenosis: tte on revealed worsening of her critical as with a valve area of 0.5cm2. pt discussed options for treatment extensively with her family, primary cardiologist, and the team, and decision was made to proceed with valvoloplasty instead of aortic valve replacement given higher risks of morbidity and mortality with surgery and with the plan that if this failed to improve her symptoms she could still undergo avr in the future. valvuloplasty was performed with cardiac cath. cath showed 40% stenosis in rca. av area was increased from 0.5->0.65cm2. pt remained hemodyanamically stable post-procedure. pt will be following up further as outpt with dr. , her primary cardiologist. because of the critical aortic stenosis and preload dependence patient's outpatient ace inhibitor was discontinued. patient was restarted on outpatient lasix dose. patient should follow up with dr. on discharge to discuss furthur management. patient underwent pre-operative work-up including cardiac catherization, panorex etc, so should patient require surgery she will be able to get it in the future. . # goiter: pt has a large goiter on the right side of her neck which she reports as being stable over the past 55 years. thyroid function tests, including tsh, t3, t4, were all wnl. in the setting of possible avr surgery, goiter was further evaluated by ct, and was found to extend into the mediastinum. thoracics was consulted per request by ct surgery, and it was decided that pt could undergo future chest surgery if needed as the mass was not invading the aortic arch. endocrine was also consulted, and advised against fna/biopsy, as thyroid cancer is unlikely given chronicity of mass and normal tfts. concern was expressed over impingement on trachea by mass. as pt did not show any clinical signs of respiratory airway compromise, she closely monitored. pt also preferred not to pursue any surgical interventions for her goiter. she was monitored for signs of thyrotoxicosis after cath. pt continued to be hemodynamically stable and asymptomatic from the mass on day of discharge. she was advised to talk to her pcp if future symptoms associated with her neck mass arise. . # afib: pt home coumadin 2 mg daily, except sunday 3 mg. coumadin initially held in the setting of pericath/valvuloplasty. patient was not reversed with vit k. patient was started on low dose beta blocker. coumadin was held pre-operatively and discharged on previous coumadin regimen, with follow-up as outpt with her pcp/primary oncologist for dosing adjustment. patient was not adequately rate controlled however did not have room to increase her beta blocker given low heart rate. . # hypotension: pt was transiently hypotensive in ed and responded to a 500cc ns bolus. also hypotensive in the unit after diuresis with 20mg iv lasix. pt exquisitely sensitive to fluid shifts given her critical as. acei was held in the unit secondary hypotension and was not restarted in the setting of critical aortic stenosis. once hypotension resolved, was was restarted on low dose beta blocker for afib rate control . # hyperlipidemia: pt continued on her home lovastatin. . # gerd: pt continued on her home ranitidine. . # osteoporosis: pt continued on calcium, vitamin d and evista. medications on admission: # enalapril 10 mg am, 5 mg pm # lasix 20 mg 2x /week # ranitidine 150 # evista 60 daily # warfarin 2-3 mg daily # lovastatin 40 mg daily # os-cal 500 # tylenol 2 daily discharge medications: 1. raloxifene 60 mg tablet sig: one (1) tablet po daily (). 2. lovastatin 40 mg tablet sig: one (1) tablet po at bedtime. 3. calcium 600 + d(3) 600 mg(1,500mg) -200 unit tablet sig: one (1) tablet po twice a day. 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 5. acetaminophen 325 mg tablet sig: 1-2 tablets po four times a day as needed for fever or pain. 6. warfarin 2 mg tablet sig: one (1) tablet po once a day: every day except sunday. 7. warfarin 3 mg tablet sig: one (1) tablet po once a day: take sunday only. 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 9. aspirin 81 mg tablet sig: one (1) tablet po once a day. 10. outpatient lab work please check inr and chem-7 on thursday 26th 11. furosemide 20 mg tablet sig: one (3) tablet po daily (daily). discharge disposition: extended care facility: rehab ctr. of discharge diagnosis: primary: severe aortic stenosis (valve area 0.5cm2)status psot valvuloplasty with valve area improved to 0.65 acute systolic congestive heart failure . secondary: atrial fibrillation hypertension discharge condition: good, hemodynamically stable, shortness of breath improved inr 1.8 weight 81.4 kg good, hemodynamically stable, shortness of breath improved inr 1.8 weight 81.4 kg good, hemodynamically stable, shortness of breath improved inr 1.8 weight 81.4 kg discharge instructions: you were admitted for shortness of breath and dyspnea on exertion. you were evaluated by an echocardiogram, which showed a very narrow aortic valve, likely contributing to your symptoms. you were transferred to the ccu for closer blood pressure monitoring. you were seen by cardiothoracic surgery for valve repair but a valvuloplasty was performed instead as it was thought to be easier to tolerate. you were seen by endocrine and thoracic surgery who did not feel that your thyroid mass needed to be removed or was affecting other major organs. . new medicines: you were started on low dose metoprolol 12.5 mg twice daily to help your heart pump better your ace inhibitor was discontinued in the setting of severe aortic stenosis and marginal blood pressure please continue to take lasix 20mg daily. we stopped this briefly in the hospital. . if you experience any recurrent shortness of breath, dyspnea on exertion, or have chest pain, dizziness, fainting, or other if you have any questions or concerns about your medicines or discharge instructions. followup instructions: please follow-up with your cardiologist, dr. on at 1:45pm. please call the on tuesday at the office when you get home to schedule an earlier appt. procedure: combined right and left heart cardiac catheterization coronary arteriography using two catheters percutaneous balloon valvuloplasty diagnoses: abnormal coagulation profile anemia, unspecified esophageal reflux unspecified essential hypertension chronic airway obstruction, not elsewhere classified atrial fibrillation other chronic pulmonary heart diseases rheumatic heart failure (congestive) other and unspecified hyperlipidemia personal history of other malignant neoplasm of skin osteoporosis, unspecified mitral valve insufficiency and aortic valve stenosis anticoagulants causing adverse effects in therapeutic use diseases of tricuspid valve other specified hypotension goiter, unspecified 

Answer: The patient is high likely exposed to