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: sulfa (sulfonamide antibiotics) / cipro / vancomycin attending: chief complaint: syncope, hypoxia major surgical or invasive procedure: right central venous line placement for dialysis history of present illness: 60f with a h/o iddm, cad s/p cabg (lima -> lad, svg to ), s/p stemi () w/ occlusion of vein graft, s/p stents to lad and (), schf (ef ~35% 2/12), s/p aicd, pvd s/p r toe amputations and l bka p/w syncope. rehab uses a lift to move her and she feels like she can't breathe every time they use it. while she was being moved in today, she passed out, was given o2 and felt better but was sent in to ed. . labs were wnl, aicd not interrogated as no shock delivered. cxr showed anasarca and fluid. pt was recently hospitalized for an episode of unresponsiveness, work up essentially negative at that time, thought to be possibly due to sedating medications and discharged with increased dose of torsemide for her chf. however, note from , pt has not responded to 40 mg of torsemide, so increased to 40 am/20 pm torsemide and did receive 1 dose of metolazone on . wt on was 273#, pt states her wt is 230# back in late . lisinopril was started and then stopped due to increase in creatinine. called hospitalist here as they feel that the patient requires higher level of care and iv diuresis and the initial plan had been for admission to floor and discharged to advanced care. . while in , pt refused treatment and became more hypoxic. her initial vitals in ed showed her satting 96 on 4l nc but eventually came down to 88% on 4l and pt refused to take iv diuretics till coming upstairs. floor refusing to take her bc of hypoxia. pt also refusing foley but did finally receive iv torsemide in ed. transfer vitals were: 72 130/77 16 95% on 7l venti mask. . on arrival to the icu, patient appears comfortable, satting high 90s on 4l nc. pt states that her shortness of breath is stable, endorses orthopnea and interval improvement in her swelling, denies chest pain, pnd, cough, fever/chills or abdominal pain. . review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough/wheezing. denies chest pain, palpitations. nausea, vomiting, diarrhea, constipation, abdominal pain. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: past medical history (per record): cardiovascular risk factors: + htn + hl + dm # cad: stemi in with occlusion of vein graft interventions: cabg: with lima -> lad and vein graft to , 25 % at the time percutaneous coronary interventions: - stents in left anterior descending and # systolic chf - ischemic cardiomyopathy, severely reduced lv function. echo in with ef 25 - 30% # pacing/icd: right-sided aicd in place () for primary prevention given ef # iddm, eye and renal manifestations, last hba1c 9.3% () # asthma # pvd # s/p left bka # s/p right 1st toe amputation # h/o left intraductal breast cancer - s/p left mastectomy in /, now question of right-sided breast cancer, which is just being followed # s/p cholecytectomy social history: hospitalized at and/or rehab since . otherwise lives in , having left her own home in 6 mos ago. wheelchair-bound. son is hcp, daughter also involved; a third son lives in . -tobacco history: none -etoh: rarely -illicit drugs: denies, but used marijuana in the past family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission exam general: alert, no acute distress, nc in place. heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp difficult to appreciate given body habitus lungs: clear to auscultation in upper lung fields, +scattered wheezes, crackles at the bases up to mid lung bilaterally cv: faint heart sounds, rrr, normal s1/s2, no murmurs, rubs, gallops abdomen: obese abdomen, soft, non-tender, bowel sounds present, no rebound tenderness or guarding. pitting dependent edema up to mid axillary line. gu: no foley ext: s/p r great toe amputation and l bka. dp palpable on r foot (marked). right foot with black eschar on medial and lateral aspect of his right foot, also has debrided area on right side, clean red base with some white-ish fibrous material along the edges. pitting edema in dependent area all the up to sacrum/back. . cardiology service admission exam (transferred from medicine ) vs: 97.6 144/78 67 18 95/4l (88/ra) wt 125.3 kg gen: somnolent, minimally-verbal, nods occasionally in response to questions, grossly volume overloaded heent: mmm, oropharynx clear, eomi, perrl neck: supple, jvp to ear cv: rrr nl s1 s2 +2/6 sem lungs: breathing unlabored, poor air movement, no rales no wheeze abd: obese, tense edema but non-tender, +distant bs ext 3+ pitting edema of legs/thighs, 2+ pitting arms, equal bilaterally l bka r foot kerlix-wrapped + amputation 2nd digit (well-healing), no cyanosis neuro: aox2, somnolent, minimally verbal, able to move extremities on command, gait not assessed body habitus (& uses wheelchair at ) . discharge exam: vs tmax 98.6, bp 100-110s/50-70s, hr 70-80s, sats > 94% on ra exam unchanged except: mental status is appropriate response to questions and awake jvp 10 cm (mid-neck) . pertinent results: admission labs: 05:15pm blood wbc-7.9 rbc-3.72* hgb-9.5* hct-30.5* mcv-82 mch-25.4* mchc-31.0 rdw-21.8* plt ct-265 05:15pm blood neuts-78.7* lymphs-13.8* monos-5.4 eos-1.2 baso-0.9 05:15pm blood pt-16.1* ptt-39.5* inr(pt)-1.5* 05:15pm blood glucose-193* urean-86* creat-1.4* na-136 k-6.4* cl-99 hco3-27 angap-16 01:14am blood alt-35 ast-34 ld(ldh)-233 ck(cpk)-113 alkphos-133* totbili-0.9 01:14am blood ck-mb-5 ctropnt-0.25* 01:14am blood albumin-2.6* calcium-8.4 phos-3.8 mg-2.1 05:34pm blood lactate-2.4* k-4.7 . discharge labs: 06:29am blood wbc-7.9 rbc-3.37* hgb-8.4* hct-28.9* mcv-86 mch-25.0* mchc-29.1* rdw-21.2* plt ct-268 06:29am blood glucose-93 urean-62* creat-2.0* na-137 k-3.2* cl-91* hco3-35* angap-14 06:29am blood calcium-9.2 phos-4.7* mg-2.1 . micro blood cultures (, , ) - negative urine cultures (, ) - negative . studies . tte conclusions the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is moderate global left ventricular hypokinesis (lvef = 30-35%). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). moderate (2+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with moderate global systolic dysfunction. mild functional mitral regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , the findings are similar. . non-invasive duplex venous study of the right upper extremity clinical indication: morbid obesity and congestive heart failure with persistent right upper extremity edema. pulse doppler waveform analysis shows symmetric flow in the right and left subclavian veins. the right internal jugular vein is markedly dilated, measuring up to 1.6 cm in diameter and showing some effects of slow blood flow with swirling and somewhat sludgy flow. however, the ij is patent and is fully compressible. the axillary vein and both brachial veins are easily compressible and show normal wall-to-wall flow on color flow imaging. the cephalic and basilic veins are also compressible and fully patent, and picc line is seen within the basilic vein. conclusion: no evidence of dvt in the right upper extremity. note is made of a dilated and slow flowing internal jugular vein on the right side, possibly related to the patient's underlying congestive heart failure. . renal ultrasound findings: note is made that this is an extremely limited ultrasound due to the patient's body habitus. the right kidney is identified and measures 12.0 cm in length. no hydronephrosis is seen in the right kidney. a small shadowing non-obstructing stone is seen within the right renal collecting system measuring 5 mm. despite diligent effort, the left kidney could not be identified in the left flank or in the pelvis. ascites is seen in the pelvis. doppler examination: the doppler examination is entirely non-diagnostic. flow cannot be detected in the right kidney due to the technical limitations. the left kidney cannot be visualized. impression: 1. no hydronephrosis in the right kidney. small non-obstructing right renal stone. 2. no doppler examination could be performed as the visualization is extremely limited due to the patient's body habitus. 3. despite diligent effort, the left kidney could not be identified. 4. small amount of ascites seen in the pelvis . cxr single frontal view of the chest reason for exam: chf, improved oxygen requirement after aggressive diuresis. morbid obesity. comparison is made with prior study . moderate cardiomegaly is unchanged. pacer leads are in unchanged position, one in the right atrium, the second is probably in the right ventricle, though is in an unusual location more medial than expected. there is mild vascular congestion. bibasilar atelectases are larger on the left side. there is a small left pleural effusion. there is no pneumothorax. sternal wires are aligned. patient is status post cabg. right picc tip is in the lower svc. brief hospital course: ms. is a 60 year old female w/ history of severe systolic heart failure s/p cabg (), stemi (vein graft occlusion, lad/ stenting ) stents to lad and (), aicd placement, presents after hypoxic minimally-responsive episode at rehab, found to be grossly volume overloaded due to underdiuresis, improved after aggressive diuresis with lasix drip augmented with hemodialysis. . # hx syncope at rehab when pt was initially evaluated in the ed and icu, there was question about whether there was true syncope, especially since she was hypoxic. additionally, she was at level of somnolence/confusion, and the episode occurred in the setting of being moved via . noted recent admission for the same concern, during which time a work-up for arrhythmia, seizures, medication effect was without clear findings. aicd was interrogated w/o evidence of arrythmia. . # hypoxia on admission patient found to be hypoxic in ed to 88% on 4l nc. hypoxia thought to be due to ongoing volume overload and unresolved pulmonary edema, especially given her anarsarca, with some additional contribution from obesity hypoventilation and osa. no evidence of pneumonia on cxr. for chf management, see below. regarding etiology of likely worsening failure, concern was raised for chronic thromboembolic disease (svc syndrome given syncopal episode and upper extremity edema, or chronic pe burden). troponins were stably elevated and peaked at 0.28, thought to be due to renal failure. iv heparin started empirically when initial doppler us of extremities were difficult to definitely read as negative; patient subsequently had doppler us of all 4 extremities, reviewed carefully with radiology & read as negative--heparin discontinued. no v/q scan pursued given high likelihood false positive due to body habitus, cta not possible due to underlying renal disease. pt successfully weaned from oxygen after 15-20 kg volume removed by hd. . # acute on chronic systolic heart failure most recent echocardiogram 2 weeks prior to admission showed stable systolic function (lvef 35%). pt had been discharged on increased dose of torsemide & continued on digoxin and carvedilol. nonetheless, she was grossly volume overload on arrival to the cardiology service, after minimal response to torsemide in the icu and on medicine. transitioned to lasix drip, which successfully promoted diuresis of ~10 kg. hd started when worsening renal function and decreased uop limited further diuresis. hd effectively removed >15 kg additional body weight. pt felt better, was able to be weaned to ra. transitioned to torsemide at 200 mg qd with metolazone 5 mg and spironolactone 25 mg daily. tte performed after completion of hd, demonstrated unchanged, poor systolic function w/lvef 35%. family meeting held w/patient and son on to review pt's poor prognosis from a heart failure/renal failure perspective. she was seen by palliative care who felt that she would be able to get home hospice set up after pt/ rehab if she can rehab enough to not need 24 hour care. she was discharged on the following medications for heart failure: torsemide at 100 mg with metolazone 5 mg and spironolactone 25 mg daily, carvediolol 3.125 mg , aspirin 325 mg daily, clopidogrel 75 mg daily, atorvastatin 80 mg daily, digoxin 0.0625 mg daily. she will need to start an acei when her creatinine stablizes. while she is on aggressive diuresis, please check chemistry panel daily starting on and dose her potassium chloride daily to maintain a potassium greater than 3.5. when she appears euvolemic by exam and by her laboratory values (creatinine = 2.3, bun = 50, or bicarbonate = 40) then please decrease her torsemide to 100 mg once daily. . # acute-on-chronic kidney disease creatinine 1.4 on transfer, 2.0 on d/c date. only 1 kidney visualized on renal ultrasound, no hx nephrectomy so likely congenital. worsening creatinine likely secondary to diuresis, but this was necessary given overwhelming volume overload. ultimately patient required temporary hd as recommended by renal consult when her lasix diuresis waned & she developed somnolence/confusion/decreased appetite (considered possible symptomatic uremia vs med effect, see above). rij temporary hd line placed by hd. dialysis discontinued after when volume status and renal function improved. she was briefly treated with acetazolamide for low bicarbonate but this improved with improved creatinine clearance and she no longer needed the acetazolamide. she was continued on calcium acetate tablets 667 tid. . # intermittent somnolence & confusion: toxic medication effect waxing/ ms aox2 (name, hospital, not date) and increased somnolence from . no e/o infection (blood cultures, urine cultures and cxr all clear). some suspicion for symptomatic uremia but bun not particularly elevated. therefore, clearing w/hd sessions attributed to toxic med effect. thus, her venlafaxine was decreased to 112.5 mg daily and buproprion to 100 mg daily. . # peripheral vascular disease (pvd), stable foot ulcers pt with chronic pvd s/p l bka and r toe amputations and diabetic ulcers on r foot. patient had arterial non-invasive imaging during last hospitalization which demonstrated patent popliteal and pt arteries on the right with known moderate rle occlusive disease. ulcers appear stable and noninfected on exam. wound consult followed closely, requested vascular surgery evaluation - they felt ulcers were stable, not-infected-appearing. will need ongoing dressing changes/wound care per nursing recommendations (see page 1). she was discharged on aspirin 325 mg daily and clopidogrel 75 mg daily. # chronic low back pain patient takes qhs gabapentin chronically. this was discontinued in the setting of altered mental status (transitioned to tylenol). no complaints of back pain thereafter. gabapentin was not restarted at discharge. . # hx depression, anxiety, coping difficulty patient has been through long, difficult hospital -> rehab -> hospital course over the past 3 months. tearful, frustrated, and occasionally verbally abusive to nursing staff at time of transfer from medicine to cardiology. these symptoms resolved as a therapeutic relationship evolved. pt appeared to benefit from ongoing counseling by social work consult; refused psych evaluation. initially continued home medications (buproprion, venlafaxine xr) plus prn qhs ativan, which helped her mood by helping her sleep. these were dose-reduced when she later developed altered mental status. we note that the patient previously had a therapist at home in but has not seen anyone since first hospital admission in . . # diabetes mellitus, type 2 poorly controlled with complications, last a1c 7.6 (1/). bs maintained w/lantus + humalog ss. . transitional issues - needs follow-up appointment w/breast center, also for mammography and/or r breast ultrasound - needs psych/therapist after she gets to rehab - needs follow-up labs on and daily to check her potassium given multiple diuretics. also should check the creatinine given her acute on chronic heart failure. - needs close follow-up for diuresis, rehab shouldn't let her gain more than 3 lbs without calling cardiologist - may need to adjust doses of venlafaxine and buproprion once renal function improves, but recommend keeping gabapentin off given 2 admissions for "unresponsiveness" - still has picc for blood draws given ongoing diuresis with 3 agents. she should have this removed when her outpatient doctors think she not need frequent blood draws anymore or if it becomes painful or infected - she was not started on an ace-inhibitor because her creatinine was still elevated on discharge to 2, this should be added in the future with nephrology input - please check chemistry panel daily starting on and dose her potassium chloride daily to maintain a potassium greater than 3.5. - when she appears euvolemic by exam and by her laboratory values then please decrease her torsemide to 100 mg once daily. medications on admission: 1. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily prn as needed for constipation. 2. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for sob. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 7. atorvastatin 40 mg tablet sig: two (2) tablet po daily 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 9. digoxin 125 mcg tablet sig: one half tablet po daily 10. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp < 100 or hr < 50. 11. bupropion hcl 100 mg tablet extended release sig: one (1) tablet extended release po bid 12. venlafaxine 75 mg capsule, ext release 24 hr sig: four (4)capsule, ext release 24 hr po daily 13. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for abd pain, bloating. 14. gabapentin 300 mg capsule sig: one (1) capsule po qhs 15. torsemide 20 mg tablet sig: two (2) tablet po daily discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath/wheezing. 3. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). 4. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain (do not give for fever before alert ho). 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 6. bupropion hcl 100 mg tablet extended release sig: one (1) tablet extended release po qam (once a day (in the morning)). 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 8. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 9. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 10. digoxin 125 mcg tablet sig: tablet po daily (daily). 11. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 12. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 13. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for bloating/abdominal pain. 14. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching. 15. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 16. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 17. torsemide 100 mg tablet sig: one (1) tablet po bid (2 times a day). 18. venlafaxine 37.5 mg capsule, ext release 24 hr sig: three (3) capsule, ext release 24 hr po daily (daily). 19. insulin glargine 100 unit/ml solution sig: twenty (20) units subcutaneous at bedtime. 20. insulin aspart 100 unit/ml solution sig: as directed units subcutaneous three times a day: fbs: 71-150=0, 151-200=2, 201-250=4, 251-300=6, 301-350=8, 351-400=10, >400= md. 21. potassium chloride 20 meq tablet, er particles/crystals sig: two (2) tablet, er particles/crystals po once a day. 22. metolazone 5 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: discharge diagnosis: primary diagnosis acute on chronic systolic heart failure acute kidney injury . secondary diagnosis coronary artery disease peripheral vascular disease type 2 diabetes mellitus depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear ms. , . you were admitted to the hospital because you were having difficulty breathing. this is because you were having an exacerbation of your heart failure. you were treated with diuretics and your weight went down significantly because you had a lot of extra fluid on your body. also, your mental status was very sleepy so we adjusted the doses of your anti-depressant medications so that your mentation improved. . the following changes were made to your medications: decrease your digoxin to 0.0625 mg daily for heart failure increase your torsemide to 100 mg twice a day for heart failure decrease your venlafaxine xr (effexor) to 112.5 mg daily for depression decrease your buproproin (wellbutrin) to 100 mg daily for depression start calcium acetate 667 mg three times a day for your kidney disease start metolazone 5 mg by mouth twice a day for heart failure start spironolactone 25 mg daily for heart failure stop taking your gabapentin, this can make you somnolent . it is also very important that you weigh yourself every morning, md if weight goes up more than 3 lbs. . you should keep all of the follow-up appointments listed below and bring all your medications to each appointment so that your doctors to make sure they are the proper dosages. . it was a pleasure taking care of you in the hospital! followup instructions: cardiology wednesday at 10:30 am name: , location: -cardiology address: , , phone: name: dr location: -nephrology address: , , phone: appt: at 8:20am name: dr location: -vascular surgery address: , , phone: appt: at 9am procedure: hemodialysis venous catheterization for renal dialysis central venous catheter placement with guidance diagnoses: nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere other chronic pain anemia, unspecified congestive heart failure, unspecified acute kidney failure, unspecified coronary atherosclerosis of autologous vein bypass graft hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified asthma, unspecified type, unspecified other chronic pulmonary heart diseases personal history of malignant neoplasm of breast depressive disorder, not elsewhere classified other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) anxiety state, unspecified alkalosis long-term (current) use of insulin old myocardial infarction morbid obesity automatic implantable cardiac defibrillator in situ lump or mass in breast do not resuscitate status antidepressants causing adverse effects in therapeutic use lumbago acute on chronic systolic heart failure drug-induced delirium syncope and collapse below knee amputation status background diabetic retinopathy atherosclerosis of native arteries of the extremities with ulceration ulcer of heel and midfoot renal agenesis and dysgenesis diabetes with renal manifestations, type ii or unspecified type, uncontrolled diabetes with ophthalmic manifestations, type ii or unspecified type, uncontrolled obesity hypoventilation syndrome great toe amputation status 

Answer: The patient is high likely exposed to