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: cough and difficulty breathing major surgical or invasive procedure: none history of present illness: 79f with history of hypertension, osteoporosis and 3+ mitral valve regurgitation who presented to today with 1 week of productive cough at home (husband sick with similar illness), no fevers but lots of green sputum. one week ago the patient went to her pcp for her yearly physical and was completely well. at today and was found to be hypoxic to 84% on ra and cxr showed a left sided pleural effusion. she was also noted to be tachycardic with an irregular rhythm and ekg showed afib (no prior history) so the patient was instructed to go to the ed. in the ed, initial vs were: 98.9 80 128/79 20 94% 6l. then tachy into 150s, ekg showed afib w/ rvr. labs notable wbc of 9 but 32% bands, sodium 130, creatinine of 1.9 and lactate 3.4. u/a was negative. patient was given ceftriaxone and azithromycin and 2.7l ivf. after the fluids, the patient became more hypoxic to 85% and appeared to flash. gave 20 iv lasix, 20 iv dilt, then on a dilt drip, on bipap. rr came down from 44 to 28-32. bipap . patient is full code. on arrival to the micu, patient reports she feels somewhat better. she was taken off of bipap and put on a nrb but became more tachypneic so was put back on bipap. bedside ultrasound showed small pleural fluid on the left side. past medical history: osteoporosis mitral valve prolapse with 3+ mr. moderate secondary pulmonary hypertension. s/p tah for leiomyoma . cyst on back removed in . s/p tonsillectomy. episode of shingles. breast fibroadenoma left, . social history: she is a retired professor of writing at , . she does not smoke. moderate alcohol consumption, no more than two glasses of wine. lives with her husband. 20 pack years smoking history. quit smoking 40 years ago. family history: father died of congestive heart failure in his 70's. mother died of congestive heart failure at age 88. she is married with three stepchildren and four grandchildren. physical exam: physical exam on arrival on the medicine floor: vitals: t: 97.3 bp: 117/58 p: 96 r: 18 o2: 94% 4l nc general: elderly woman sitting upright in hospital bed, pleasant, alert, oriented, and breathing comfortably with nc. occasional coughing. heent: perrl, eomi, sclera anicteric, mucus membranes moist, oropharynx clear without erythema or exudates neck: supple, no lad or thyromegaly appreciated lungs: coarse breath sounds throughout without appreciable wheezes. fair air movement. cv: irregular rhythm, normal s1 + s2, ii/vi holosystolic murmur best heard at the apex. abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly appreciated ext: cool, 2+ dorsalis pedis pulses bilaterally, no clubbing, cyanosis or edema physical exam on discharge: vitals: t: 98.6 bp: 110/70 p: 82 r: 20 o2: 94% general: elderly woman sitting upright in her chair, pleasant, talkative, and breathing comfortably on room air heent: perrl, eomi, mucus membranes moist neck: supple lungs: crackles heard at the left lower throughout. left greater than right crackles at the bases, withhout appreciable wheezes. cv: irregular rhythm, normal s1 + s2, harsh ii/vi holosystolic murmur best heard at the apex. abdomen: soft, non-tender, non-distended ext: warm and well-perfused, no clubbing, cyanosis or edema pertinent results: labs on admission: 06:58pm blood wbc-9.4# rbc-4.09* hgb-13.0 hct-38.4 mcv-94 mch-31.8 mchc-33.9 rdw-12.0 plt ct-488* 03:57am blood wbc-17.0*# rbc-3.73* hgb-11.9* hct-35.3* mcv-95 mch-31.9 mchc-33.6 rdw-12.1 plt ct-464* 06:58pm blood neuts-50 bands-32* lymphs-10* monos-7 eos-0 baso-0 atyps-1* metas-0 myelos-0 04:34am blood neuts-65 bands-16* lymphs-10* monos-8 eos-0 baso-0 atyps-0 metas-1* myelos-0 03:57am blood neuts-81* bands-3 lymphs-6* monos-7 eos-2 baso-0 atyps-0 metas-1* myelos-0 06:58pm blood glucose-170* urean-53* creat-1.9*# na-130* k-5.1 cl-93* hco3-24 angap-18 04:34am blood glucose-127* urean-43* creat-1.2* na-133 k-4.0 cl-100 hco3-22 angap-15 03:57am blood glucose-120* urean-26* creat-0.7 na-137 k-3.8 cl-103 hco3-25 angap-13 06:58pm blood ck-mb-4 probnp-9794* 06:58pm blood ctropnt-0.04* 04:34am blood ck-mb-6 ctropnt-0.02* 06:58pm blood osmolal-289 06:58pm blood tsh-0.69 07:05pm blood lactate-3.4* urine culture (final ): <10,000 organisms/ml. legionella urinary antigen negative for legionella serogroup 1 antigen. labs on discharge: wbc 15.6, hb 10.1, hct 30.1, plt 1011 pmn 86.6, lymphs 9.5, monos 2.8, eos 0.9, baso 0.2 na 138/k 4.5, cl 105/hco3 26, bun 17/cr 0.6, glu 101 ca 8.4, mg 1.9, p 3.8 pt 18.0, inr 1.6 dig 0.8 relevant imaging: cxr (on admission): left lower lobe atelectasis and left pleural effusion; given the possible history of smoking, an obstructive neoplasm at the left hilum causing left lower lobe atelectasis and effusion cannot be excluded on this radiograph and is best further evaluated with a chest ct. cxr (on discharge): there is background copd with diffuse parenchymal scarring. the cardiomediastinal silhouette is enlarged, though partially obscured on the left by a moderate-sized pleural effusion and underlying collapse and/or consolidation. there is also a small right pleural effusion, with underlying collapse and/or consolidation. doubt chf. compared with , 15:38, the left-sided effusion is larger. otherwise, i doubt significant change. patchy opacities throughout both lungs may represent parenchymal scarring due to background copd, but the possibility of a superimposed patchy interstitial process cannot be entirely excluded. (the appearance is similar to a film dated , at which time it was thought to represent extensive multifocal pneumonia.) ct chest w&w/o contrast: 1. no evidence of pulmonary embolism. 2. extensive multifocal pneumonia, worse in the left lower lobe. 3. bilateral nonhemorrhagic mild-to-moderate pleural effusions, predominantly subpulmonic. 4. bilateral reactive hilar adenopathy. 5. mild dilatation of the aortic root. : hyperdynamic left ventricular systolic function. moderate to severe anterior mitral valve leaflet prolapse with moderate mitral regurgitation. moderate tricuspid regurgitation. moderate pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , the left ventricular systolic function is now hyperdynamic (previously normal). the severity of mitral regurgitation and tricuspid regurgitation appear to have decreased somewhat, although the overall image quality is worse on the current study. the ascending aorta and descending thoracic aorta are now dilated. with saline: no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. brief hospital course: mrs. is a 79 year old previously healthy woman with a history of controlled hypertension and 3+ mitral valve regurgitation who was admitted to the hospital for multifocal pneumonia and new onset atrial fibrillation with rapid ventricular response to the 150s, requiring a stay in the medical intensive care unit before transfer to the medical floor. brief hospital course by problem: # multifocal pneumonia: the patient was admitted for hypoxic respiratory failure with o2sats 84% on room air. chest x-ray showed left lower lobe consolidation and effusion. she was given 3l of intravenous fluids in the ed, and her oxygenation acutely worsened, requiring bipap and transfer to the medical intensive care unit. repeat cxr was consistent with acute volume overload (see below). lung ultrasound was not concerning for empyema or parapneumonic effusion. ceftriaxone and azithromycin were started for community acquired pneumonia. legionella urinary antigen was negative. the patient had persistently elevated a-a gradients on hospital days , so a ct scan was done to rule out a pulmonary embolus. this was negative. given the patient's lack of improvement and ongoing leukocytosis with bandemia, her antibiotics were broadened to vancomycin, cefepime, and levofloxacin. she completed an 8 day course on . her respiratory status improved, and she was transferred to the medicine floor. persistent leukocytosis on prompted a repeat cxr, which showed continued bilateral pulmonary effusion (l>r). interventional pulmonology performed a thoracentesis for concern of a paraneumonic effusion. the pleural fluid was borderline exudative by light's criteria with negative cytologies and cultures. interventional pulmonology felt that there would be little benefit from further interventions. she continued to improve, and was weaned to room air. her ambulatory oxygen saturations were above 90% on room air. she was discharged to home with vna follow up for o2sat checks. # atrial fibrillation with rapid ventricular response: the patient has no prior history of atrial fibrillation. in the ed, the patient was found to be in afib with rvr to the 150s. she was immediately started on diltazem gtt and loaded with digoxin for rate control. she was transitioned to po diltiazem and continued on digoxin. her heart rate remained stable in the 90s-100s. echocardiography with bubble study did not show any changes to the mitral valve and was negative for intracardiac and extracardiac shunt. her tsh was within normal limits. the patient was started on coumadin for stroke prevention given a chads2 score of 2. (her insurance would not cover dabigitran). ultimately, her new onset atrial fibrillation with rvr was thought to be related to her multifocal pneumonia and mitral valvular disease. the patient should follow up with her cardiologist and undergo transesophageal as recommended by cardiology. # acute systolic congestive heart failure: in the setting of volume resuscitation, the patient's new atrial fibrillation with rvr and her underlying mitral valve regurgitation led to acute systolic congestive heart failure with flash pulmonary edema. her initial ekg showed st depressions that appeared to be rate related. acute coronary syndrome was unlikely as three sets of cardiac enzymes were within normal limits. she was diuresed with iv lasix, and her respiratory status improved. # acute kidney injury: the patient's creatinine on admission was 1.9 (baseline 0.5-0.6). the etiology was thought to be multifactorial, related both to intravascular volume depletion in the setting of acute systolic congestive heart failure and poor po intake given her illness. her creatinine improved with diuresis. her home lisinopril was held and not restarted on discharge given systolic blood pressures in the 90s-110s. when stable, lisinopril can be restarted as an outpatient. # persistent leukocytosis: the patient had persistent leukocytosis, prompting an additional workup for alternative infections. urine and blood cultures were repeatedly negative. cxr on prompted the thoracentesis described above. c. diff was negative x 3. ultimately, the persistent leukocytosis was attributed to a stress response. the patient's wbcs should be trended as an outpatient. # thrombocytosis: the patient's platelets continued to rise, reaching 1011 on the day of discharge. this was thought to be a reactive thrombocytosis given the patient's recent infection. her primary care physician, . , was contact about starting aspirin, and we elected not to start aspirin at this time given risk of bleeding wtih her new coumadin as well. her platelet counts will be followed as an outpatient. # hyponatremia: the patient was initially hyponatremic, which resolved on the second day of hospitalization. this was likely due to siadh in the setting of her pulmonary processes and/or intravascular volume depletion in the setting of her acute systolic congestive heart failure and poor po intake. # controlled hypertension: prior to admission, the patient took lisinopril for blood pressure control. this medication was held in the setting of her acute kidney injury and subsequent systolic blood pressures in the 90s-110s from the initiation of diltiazem. lisinopril was not started on discharge but may be restarted as an outpatient. # osteoporosis: restarted home calcium and vitamin d once she was taking pos. # deconditioning: due to her hospital stay, she felt "weak." she worked with physical therapy and was able to ambulate without assist with oxygen saturations above 90% on room air. transitions of care: - wbcs and platelets should be followed as an outpatient. - inr should be monitored for appropriate coumadin dosing. this has been arranged at the clinic. - lisinopril was not restarted given sbps 90s-110s. consider restarting as an outpatient. - pt should get scripts for 2.5 mg of coumadin as well at her follow up appointment for ease of dosing per the clinic. medications on admission: codeine-guaifenesin - 100 mg-10 mg/5 ml liquid - 1 tsp by mouth tid prn cough 6 oz. conjugated estrogens - 0.3 mg tablet - 1 tablet(s) by mouth once a day lisinopril - 20 mg tablet - 1 tablet(s) by mouth once a day calcium carbonate-vitamin d3 - 600 mg-400 unit tablet - 1 tablet(s) by mouth once a day discharge medications: 1. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 2. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 4. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. premarin 0.3 mg tablet sig: one (1) tablet po once a day. 6. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: multifocal pneumonia atrial fibrillation with rapid ventricular response mitral valve prolapse mitral regurgitation acute kidney injury secondary diagnoses: osteoporosis hypertension, controlled discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital because you had difficulty breathing. a chest x-ray was performed, which showed that you had pneumonia in multiple places in your lungs. this was later confirmed with a ct scan. you were initially taken to the medical intensive care unit and required special masks to help you breathe. you were also given a combination of antibiotics for an 8 day course, and your breathing improved over time. you were transferred from the intensive care unit to the medical floor, where you received additional physical therapy to help you improve your strength. your oxygen requirements have decreased since you have been in the hospital. you were able to walk without oxygen, and the oxygen levels in your blood remained appropriate. during your hospitalization, you were also found to have atrial fibrillation, an irregular heart beat pattern. your heart rate was initially very fast, so you were given medicines to slow your heart rate down. you will continue to take the digoxin and metoprolol as directed when you leave the hospital. you were also started on coumadin to make your blood less likely to clot and to decrease the risk of stroke related to clotting that can occur in people with atrial fibrillation. you will also continue to take coumadin as directed and have your blood drawn to make sure that your inr (a measure of anti-coagulation) is within the appropriate range. you had an of your heart while you were in the hospital. an is an ultra-sound picture of the way that your heart beats. it showed that you have mitral valve prolapse and mitral valve regurgitation. this means that the mitral valve in your heart does not close all the way, so some blood leaks through. please follow up with your cardiologist, dr. , as listed in the instructions below. when you initially came to the hospital, your creatinine was a little elevated. creatinine is a quantity that we can measure in the blood that helps us estimate your kidney function. your creatinine value normalized during your hospitalization and continued to remain normal throughout your hospital stay. instructions: stop the lisinopril that you took at home before you came to the hospital. your doctor may want to restart this as an outpatient. start taking metoprolol 50mg three times per day. start taking digoxin 125mcg every day. start taking coumadin 5mg every day. please go the the following appointments listed below, including this thursday in the post discharge clinic and monday with dr. . a nurse will come to your house for the next few days to make sure that the oxygen levels in your blood are appropriate. followup instructions: department: when: thursday 9:00 am phone: ( building: campus: east best parking: garage department: when: monday at 4:10 pm with: , m.d. building: campus: east best parking: garage provider: phone: date/time: 11:00 provider: , md phone: date/time: 9:20 procedure: thoracentesis diagnoses: pneumonia, organism unspecified mitral valve disorders unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified hyposmolality and/or hyponatremia atrial fibrillation other chronic pulmonary heart diseases paroxysmal ventricular tachycardia constipation, unspecified acute respiratory failure other disorders of bone and cartilage acute on chronic systolic heart failure leukocytosis, unspecified essential thrombocythemia 

Answer: The patient is high likely exposed to