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: olanzapine attending: chief complaint: chest pain --> bradycardia major surgical or invasive procedure: intubation and extubation central line placement and removal history of present illness: 76 yo man with dm, htn, hl, (possibly chf, cad) who presented to osh today after several days of worsening cp and apparently self titrating up of his home medical regimen (see below: digoxin, bb, amlodipine) who was found to be bradycardic to 20s (? bp) and was electively intubated (difficult intubation) and was externally paced. while at osh, he received 1mg of atropine, digibind (1 vial), calcium gluconate (10g), glucagon (4mg). he was also started on dopamine and propofol. transferred to for further evaluation. . on arrival to osh his bp was 100/40 and in ventricular escape. with rate in 20s. his bp trended upward to 229/112 prior to transfer to . in the , attempt to place an internal pacer (now at r atrium vs. vent. wall) was made, however there was no capture. he required continued external pacing throughout as apparently w/o this he had no intrinsic rhythm. he received 4 vials of dibibond, 4mg glucagon, 2mg of calcium gluconate. the patient spontaneously converted to slow afib with lbbb. . unable to obtain ros given intubation. past medical history: 1. cardiac risk factors: + diabetes, +dyslipidemia, +hypertension 2. cardiac history: - cabg: none - percutaneous coronary interventions: none - pacing/icd: none 3. other past medical history: - atrial fibrillation, likely permanent - managed with metoprolol and digoxin, previously anticoagulated. - ckd, likely cr 1.4 baseline. social history: - tobacco history: quit smoking 15 years ago - etoh: noted in notes that he drinks 2-3 beers/daily - illicit drugs: none noted in osh records family history: noncontributory. physical exam: on admission: general: sedated, intubated heent: ncat. sclera anicteric. perrl, although small. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 7cm. cardiac: pmi located in 5th intercostal space, midclavicular line. , normal s1, s2. ii/vi hsm at apex. no thrills, lifts. no s3 or s4. lungs: ctab, no crackles, wheezes or rhonchi. abdomen: soft, distended. hypoactive bs. no rebound or guarding. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 1+ pt 1+ left: dp 1+ pt dopplerable on discharge: ____________ pertinent results: on admission: 06:00am blood wbc-9.7 rbc-3.76* hgb-12.1* hct-36.7* mcv-97 mch-32.1* mchc-33.0 rdw-14.3 plt ct-203 06:00am blood neuts-78.0* lymphs-18.4 monos-2.8 eos-0.3 baso-0.4 06:00am blood pt-16.4* ptt-31.5 inr(pt)-1.4* 06:00am blood fibrino-416* 06:00am blood urean-53* creat-2.9* na-139 k-6.3* cl-109* hco3-22 angap-14 06:00am blood alt-27 ast-38 alkphos-42 totbili-0.6 10:30am blood ld(ldh)-314* 06:00am blood lipase-72* 06:00am blood albumin-3.8 calcium-8.9 phos-4.2 mg-2.3 10:30am blood %hba1c-6.1* eag-128* 10:30am blood tsh-1.1 10:30am blood digoxin-6.8* 06:00am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 07:49am blood type-art fio2-100 po2-107* pco2-60* ph-7.16* caltco2-23 base xs--8 aado2-553 req o2-91 intubat-intubated creatinine 06:00am blood creat-2.9* 06:07pm blood creat-2.7* 04:09am blood creat-3.0* 02:49pm blood creat-2.4* 04:57am blood creat-1.7* 02:23pm blood creat-1.9* 07:16am blood creat-1.8* microbiology: joint fluid: wbc-135 rbc-195* polys-15 lymphs-5 monos-9 mesothe-11* macro-60 gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. sputum cx: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and chains. respiratory culture (final ): moderate growth commensal respiratory flora. haemophilus species not influenzae. heavy growth. beta-lactamse negative: presumptively sensitive to ampicillin. haemophilus species not influenzae. moderate growth. 2nd morphology. beta-lactamse negative: presumptively sensitive to ampicillin. stool: clostridium difficile. feces positive for c. difficile toxin by eia. imaging: tte (on admission): the left atrium is mildly 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. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. tee: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no intracardiac shunt seen at rest (with agitated saline). no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. no thoracic aortic dissection is seen. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. impression: no spontaneous echo contrast or thrombus in the atria/ atrial appendages. no intracardiac shunt. no thoracic aortic dissection. normal global -ventricular systolic function. mild to moderate mitral regurgitation. ekg: atrial fibrillation. left bundle-branch block. since the previous tracing of no significant change. ct head: impression: 1. no evidence of hemorrhage or recent infarction. 2. moderate-to-severe small vessel ischemic changes. ct chest/abd/pelvis: impression: 1. bibasilar consolidative opacities, likely atelectasis. superimposed pneumonia however is not excluded and may account for the enlarged subcarinal lymph nodes. small focus of hyperdense material at the right base could suggest aspiration. 2. cbd dilation without intrahepatic duct dilation. no definite mass or stone. a non-emergent mrcp could be used to further evaluate. probable gallbladder sludge. changes from initial wet read were discussed via phone with dr. at 9:20pm on . 3. left adrenal nodule, indeterminate for an adenoma. if clinically warranted, recommend dedicated adrenal cross sectional imaging. abdominal u/s: impression: dilated common bile duct measuring 1.9 cm proximally, tapering down to 0.8 cm but not completely visualized along its entire length. no cause for dilation identified. further evaluation with an mrcp is recommended. brief hospital course: 76 yo man with dm, htn, hl, ?chf who presented to osh with complete heart block needing transcutaneous pacing possibly secondary to b-blocker or digoxin toxicity, intubated with hypoxemic respiratory failure with pna/parapneumonic effusion and extubated on . hospital course complicated by poor rate control with atrial fibrillation, acute on chronic renal failure, non-typeable haemophilus pneumonia, c. difficile diarrhea, and resolving toxic-metabolic encephalopathy with labile blood pressures. # complete heart block ?????? he arrived in complete heart block, potentially secondary to digitalis and beta-blocker toxicity, s/p glucagon and repeated administrations of digibind. there was increased concern for b-blocker toxicity given his initial hypoglycemia and hyperkalemia, both of which seem to have resolved. his digoxin and metoprolol were held and his baseline heart rate of atrial fibrillation with left bundle branch block with heart rates 80s-110s returned. we started a low-dose b-blocker (lower than home dose) with good control of hr, without deficits in blood pressure. # acute hypoxemic respiratory failure with severe hypoxemia pneumonia with ?parapneumonic effusions: pao2/fio2 ratio was initially 185, so it was presumed that he developed ards. on review of his echocardiogram, his lvef was preserved and his rv was normal, without evidence of strain. tee with bubble study was negative for shunt. given his etoh history, it is possible the patient could have aspirated. the patient did have a retrocardiac opacity and bibasilar atelectasis as well as bilateral pleural effusions. he continued to have copious secretions and a worsening leukocytosis, for which he was started on broad-spectrum antibiotics. ?vap vs. aspiration pna. his sputum showed gpcs and gnrs on gram stain, but only non-typeable haemophilus grew out in culture. he was quite difficult to extubate, secondary to agitation and hypertension, but was eventually extubated on . he was kept npo due to inability for the speech and swallow service to clear him secondary to delirium. once he was cleared, he resumed a normal diet. his vancomycin (- ) and pip/tazo ( ?????? ) was narrowed to ceftriaxone to cover these gpcs and haemophilus for a total 8-day antibiotic course, ending on . # hypertension: he developed hypertensive urgency with systolic bps reaching >200s, felt to be secondary to volume overload and known essential hypertension. multiple anti-hypertensive agents were tried, but only a nitroglycerin gtt with prn iv hydralazine, and uptitrated doses of captopril tid were able to keep his blood pressure under control. given persistent htn despite multiple agents, we also considered secondary causes of hypertension such as renovascular or endocrine disease, but these were not evident. he was weaned off a nitro gtt and he was started back on the majority of his home anti-hypertensives: amlodipine, captopril tid (instead of lisinopril), and labetalol (instead of metoprolol). if his blood pressure continues to be difficult to control, we would recommend an outpatient work-up for secondary causes of hypertension. on the floor his catpropril was changed to lisinopril and his labetalol was uptitrated. his home imdur was added back and his hydralazine was changed to dosing. # atrial fibrillation: patient in afib with lbbb, at baseline, anticoagulated with coumadin. while he was being treated with antibiotics, we adjusted his coumadin dosing as needed. he was rate controlled with increasing doses of metoprolol, which was eventually changed over to labetalol for both blood pressures and rate control. digoxin was discontinued and should not be restarted as an outpatient. # c. diff: patient noted to be c. diff positive, likely in the setting of recent hospitalization and antibiotic use. abdominal exam without peritoneal signs, but patient did eventually develop an ileus. tube feeding had been started given the patient's relatively long period of intubation, but was held. an aggressive bowel regimen caused copious stool output, prompting placement of a flexiseal. he was initially started on po vancomycin and iv metronidazole for severe c. diff (elevated creatinine, leukocytosis, and fevers). iv metronidazole was discontinued when his leukocytosis and creatinine began to resolve. he should be continued on po vancomycin for 14 days after completing his pna antibiotics ( ?????? for 14-day course - see below). # toxic-metabolic encephalopathy: patient with underlying infection, s/p extubation, unfamiliar environment with confusion and agitation likely consistent with delirium. he was given seroquel 25 mg prn and standing qhs for agitation. he is also quite hard of hearing, so reorientation was difficult, but his delirium mostly resolved prior to transfer from the icu and seemed to resolve on the floor. # acute on chronic renal failure with hyperkalemia ?????? the initial hyperkalemia was likely caused by beta-blocker toxicity although it can also be seen with digitalis toxicity. he has underlying ckd (stage iii per note) likely worsened in setting of reduced perfusion and diuresis. cr 2.9 on admission. his baseline nephropathy is likely secondary to htn and dm, but this acute kidney injury may have been secondary to hypovolemia vs. atn for hypotension secondary to bradycardia. # normocytic anemia - his admission hct 36.7 trended down to 28, without active signs/symptoms of acute blood loss. while it stabilized now in high 20s, iron studies were unrevealing. we did not uncover a cause of this anemia, though his initial hematocrits may have been due to hemoconcentration. # right knee effusion: his right knee was noted to be quite enlarged with a large effusion. there was no evidence of crystals or septic arthritis on joint aspiration. per family, he has had swelling in the past, possibly related to underlying oa. joint aspirate had no growth on culture. there was not any further erythema or warmth throughout the hospitalization # dm ii: he is on glipizide at home and his hba1c was 6.1 on admission, indicating good control. he was maintained on ssi while in house. # hyperlipidemia: he was continued on simvastatin. # code: full code # contact: daughter (hcp) medications on admission: - lisinopril 10mg daily - asa 81mg daily - digoxin 125mcg daily - glipizide 5mg daily - simvastatin 40mg daily - warfarin 5mg daily - furosemide 40mg daily - metoprolol tartrate 200mg - spironolactone 25mg daily - imdur 60mg daily - ativan 1mg daily - ? amlodipine 5mg daily (per osh records, but no medication bottle) discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 3. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 4. isosorbide mononitrate 60 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 5. glipizide 5 mg tablet sig: one (1) tablet po once a day. 6. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 10 days. disp:*40 capsule(s)* refills:*0* 7. warfarin 3 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. outpatient lab work please check the inr on and fax to dr. . fax: 9. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily): please start this medication after your bp has been checked at your appointment this friday, . 10. amlodipine 5 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: discharge diagnosis: primary: digoxin toxicity heamophilus pneumonia clostridium difficle diarrhea hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital due to a slow heart rate due to one of your medications (dignoxin). due to your instability with the slow heart rate, you were intubated (a breathing tube was placed) this medication was stopped and your heart rate was treated and improved. you were also found to have a pnuemonia and were treated with an antibiotic with improvement. additionally you developed diarrhea caused by a bacteria called clostridium difficile. you will need to complete an antibiotic course for this infection. you blood pressure was also very elevated and multiple medication changes were made. medication changes: restart lisinopril 10 mg daily after your follow-up appointment friday stop spironolactone stop digoxin stop ativan decrease metoprolol to 100 mg twice daily start vancomycin 125 mg every 6 hours until the last dose on change warfarin to 3mg daily otherwise continue your outpatient medications as prescribed. followup instructions: primary care doctor practitioner name: , md address: 237a route 6, , phone: fax: friday 1:15 pm you will need to have your inr checked within the next 72hours because the level was slightly lower today after you received a slightly higher dose of your coumadin yesterday. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances insertion of temporary transvenous pacemaker system arthrocentesis diagnoses: hyperpotassemia other iatrogenic hypotension anemia, unspecified coronary atherosclerosis of native coronary artery congestive heart failure, unspecified toxic encephalopathy acute kidney failure, unspecified unspecified septicemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation personal history of tobacco use other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) acute respiratory failure atrioventricular block, complete pneumonitis due to inhalation of food or vomitus intestinal infection due to clostridium difficile other left bundle branch block long-term (current) use of anticoagulants paralytic ileus calculus of gallbladder without mention of cholecystitis, without mention of obstruction ventilator associated pneumonia delirium due to conditions classified elsewhere diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled chronic diastolic heart failure mixed acid-base balance disorder other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms poisoning by other antihypertensive agents effusion of joint, lower leg osteoarthrosis, localized, not specified whether primary or secondary, lower leg poisoning by other and unspecified agents primarily affecting the cardiovascular system accidental poisoning by agents primarily affecting cardiovascular system poisoning by cardiotonic glycosides and drugs of similar action unspecified crystal arthropathy, lower leg 

Answer: The patient is high likely exposed to