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: penicillins / codeine / morphine attending: chief complaint: hypotension s/p surgical asd closure major surgical or invasive procedure: asd repair history of present illness: ms. is a 74 yo f with h/o af, ipf (on 4l home o2), cardiomyopathy with ef 35%, and diabetes who was admitted today for asd closure with dr. . plan was for her to be admitted to the np service post-procedure, repeat echo tomorrow am and discharge home. asd closure was successful, but during the procedure patient became bradycardic to 40s and hypotensive to 70s systolic. received 500cc ivf with little improvement. she was then was started on dopamine and neosynephrine gtt (now weaned to only dopamine), and bolused with atropine 0.5mg iv x2. in the pacu she was given another 1l ivf with little hemodynamic improvement. of note, midazolam, fentanyl, rocuronium and etomidate were used for sedation and paralysis during the case. patient is now being admitted to the ccu for pressors and monitoring overnight. . during asd closure, patient was noted to have left to right shunting at the level of the left brachiocephalic artery. she was also found to have right to left shunting at the level of the right atrium, causing hypoxemia (see below for blood oximetry data). filling pressures were found to be wnl: ramean 9, rvedp 8, pap 54/24, pcwp 11. ratio of pulmonary blood flow to systemic blood flow (qp/qs) was 1.4. asd was successfully closed. given her h/o ipf and right heart failure, selective catheter placement in each of the 4 pulmonary arteries was performed and angiography demonstrated no stenosis. plan is for patient to start asa and warfarin anticoagulation and f/u with dr. in 1 month. . patient has h/o cardiomyopathy with ef 35% and ipf diagnosed in . over the past 6 months she has become progressively more short of breath, now becoming extremely dyspneic on minimal exertion (e.g. walking to bathroom). she is on 2-4l o2 per nc at home, normally satting in high 70s to low 80s on room air and low 90s on 4l o2. . on arrival to the ccu, patient is hemodynamically stable (sbp 110s, hr 60s), satting 88-93% on 4l. she is awake and responding to questions. denies pain, dyspnea, chest pain, palpitations, nausea, leg pain. past medical history: 1. atrial fibrillation, currently rate controlled with toprol-xl and warfarin for thromboembolic prophylaxis. 2. interstitial pulmonary fibrosis on 2l (4 liters with exertion) home o2 initiated spring of only at night and requiring oxygen around the clock at present. 3. hospitalization last year for decompensated heart failure. 4. cardiomyopathy, most recent lvef of 35% in addition to rv dysfunction and severe tr on a recent echo. nyha iii-iv. 5. secundum asd noted on recent echocardiogram with left-to-right shunting. 6. diabetes. 7. chronic right hip pain due to hip fracture requiring the use of a crutch for ambulation. 8. tonsillectomy social history: patient worked previously as a nurse. she never smoked cigarettes. family history: mother - dm, liver cancer, died at 70. father - hypertension, stroke, died at 70. no family history of cardiac disease. physical exam: admission physical exam: general: elderly asian f in nad. aaox3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 8 cm. positive kussmaul sign. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular. +rv heave. split s1, loud s2. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. fine inspiratory crackles throughout both lung fields. no wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: cool, no c/c/e. no femoral bruits. skin: right groin bandage c/d/i, no hematoma. no stasis dermatitis, ulcers, scars, or xanthomas. neuro: aaox3, cnii-xii grossly intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. pulses: dp/pt 1+ bilaterally . discharge physical exam: unchanged. pertinent results: labs on admission: 04:15pm blood wbc-6.0 rbc-3.84* hgb-9.2* hct-31.1* mcv-81* mch-24.0* mchc-29.6* rdw-17.0* plt ct-370 07:26am blood pt-21.3* inr(pt)-2.0* 04:15pm blood glucose-104* urean-15 creat-0.6 na-138 k-3.5 cl-100 hco3-31 angap-11 04:15pm blood alt-11 ast-18 ld(ldh)-207 alkphos-60 totbili-0.4 04:15pm blood calcium-8.6 phos-4.6* mg-1.6 03:46am blood digoxin-0.8* iron studies: 06:00am blood caltibc-382 ferritn-17 trf-294 tte : pre-device deployment: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). a patent foramen ovale is present. a right-to-left shunt across the interatrial septum is seen at rest. overall left ventricular systolic function is mildly depressed (lvef= 45-50 %). the right ventricular free wall is hypertrophied. the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. severe tricuspid regurgitation is seen. dr. was notified in person of the results at time of procedure. tte : the left atrium is mildly dilated. the right atrium is moderately dilated. a septal occluder device is seen across the interatrial septum. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no ventricular septal defect. the right ventricular free wall is hypertrophied. the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: primary reason for hospitalization: ms. is a 74 yo f with h/o af, secundum asd, ipf (on 4l home o2), cardiomyopathy with ef 35%, and diabetes who was admitted today for asd closure, procedure c/b bradycardia and hypotension. . #.hypoxemia: ms. was satting 88-93% on 4l o2 per nc on arrival to ccu. with her end stage ipf, she reports home o2 sats of high 70s-low 80s on room air, and 90-94% on her usual 4l. cxr inconsistent with fluid overload. worsening of pah may also be contributing to worsening hypoxemia/dyspnea. on the floor, she would desaturate to the 70s on 4l nc with ambulation. with preoxygenation with 100% nrb prior to and with ambulation, these desaturations were avoided. per most recent pulm notes, her pulmonary and overall functional status has significantly worsened over the past 6 months, now with dyspnea on minimal exertion and requiring 4l home o2 at all times. unfortunately there is no effective therapy for ipf. baseline cxr showed interval worsening of ipf. ms. outpatient pulmonary provider . recommended diuresis, and ms. was 2l negative length of stay with 20mg po daily furosemide. unfortunately, diuresis did not appear to cause a improvement in dyspnea, and her spo2 would still decrease to the low 90s on 4l nc with minimal ambulation. in addition, her blood pressure dropped to the high 70s after diuresis with pt reporting subjective fatigue, prompting discontinuation of all standing lasix. on per pulm recs patient underwent inhaled no trial with serial targeted echos assessing tricuspid regurgitation jet before/after no. after receiving no, her pulmonary hypertension improved moderately, with decrease in pulmonary artery systolic pressure from 37-79mmhg to 39-54mm hg. she did not report subjective improvement in symptoms with no (trial performed at rest), and her o2 sats were 97-100% throughout. she will be followed up as outpatient with pulmonology, where she may be candidate for either pulmonary vasodilator (sildenafil) or inhaled prostacyclin therapy. on discharge she is satting between 90-100% on 4l nc, also requiring pre-oxygenation with 8l by high-flow facemask prior to exertion (e.g. chair to bed) in order to prevent dropping her o2 sats. per her request, she is discharged to home rather than pulmonary rehab. . #.bradycardia, hypotension: patient became bradycardic and hypotensive during asd closure, requiring both neosynephrine and dopamine and atropine and ivf. she was weaned off dopamine over the next day with stable bps and hr. most likely etiology was slow clearance of sedative/paralytic anesthesia during the case, as well as possible oversuppression of heart rate with home digoxin and beta blocker. patient was hypotensive to high 70s-low 80s multiple times throughout ccu stay, so her home medications were tapered down: metoprolol was stopped, and lasix was also stopped as she remained euvolemic without diuretics . her home digoxin was not changed, with goal of improving rate control without sacrificing blood pressure, and she was continued on 0.125mg daily . #.s/p secundum asd closure: procedure was successful, with repeat echo showing well-seated septal occluder device. patient also noted to have right-to-left interatrial shunting (eisenmenger syndrome) as well as severe (3+) tr during procedure, secondary to her chronically elevated right heart pressures (which themselves are likely secondary to pulmonary hypertension from ipf as well as earlier left-to-right shunting across asd). she became bradycardic and hypotensive in the or, which required dopamine drip which was maintained for 24 hours. she was hemodynamically stable and off of pressors 24 hours following the procedure and did not have a pressor requirement at any later time this admission. repeat tte on showed improved lvef (55%), but also worsening rv pressure overload and worsening tr (4+). another tte on demonstrated small left-to-right shunt across the septal occluder device, and slight improvement in pulmonary pressures. home warfarin and asa were continued for anticoagulation following the procedure. home digoxin and metoprolol were also continued. . #.anemia: ms. became anemic to hct 26.8 this admission with mcv 80; hct 31 on arrival and drifting down since then. her baseline hct is 37. worsening microcytic anemia does suggest likely iron deficiency, and iron studies were consistent. stools guaiac negative. iron supplementation was initiated, with slow improvement in her hct. she would likely benefit from outpatient colonoscopy to rule out occult malignancy if her life expectancy improves from the current poor (<6 month) prognosis. . #.afib: ms. was well rate-controlled on metoprolol and digoxin and is on home warfarin for thromboembolic prophylaxis. given bradycardia, her metoprolol was decreased from 50 to 25mg po daily, and she remained under good rate control. she is also on home digoxin. warfarin dose was also decreased from 3mg to 2mg po daily as her inr was supratherapeutic. . #.cardiomyopathy: patient has h/o nyha class iii-iv cardiomyopathy with echo from showing lvef 35%, rv dysfunction and severe tr. echo post-procedure showed lvef 45-50%. etiology of her heart failure could be ipf causing pulmonary hypertension and increased right heart afterload, as well as chronically increased right heart filling pressures asd. in addition, her left-to-right brachiocephalic trunk may have further increased right heart preload, further exacerbating right overload. right heart failure likely then led to left heart failure. after an initial diuresis of 2l los, her standing lasix dose was decreased to 20mg daily po to keep her euvolemic, and then discontinued altogether as it was suspected to be contributing to her hypotension. . #.code status: per conversation with pt's outpatient pulmonologist , patient and her husband decided that she would like to be made dnr/dni. code status was updated in her medical record. patient refused inpatient pulmonary rehab despite urging by her inpatient team, and will therefore be discharged home with hospice (as well as continuation of all her current medical therapies). . # niddm: metformin was initially held, and ssi was started. metformin was restarted 3 days prior to discharge, but given low-normal blood sugars 90s-100s in the morning and likely short life expectancy, metformin was held upon discharge. . ==================== transitional issues: 1. needs colonoscopy to f/u iron deficiency anemia 2. patient needs to pre-oxygenate with 8l per facemask before any movement/ambulation. she is on 4l per nc at rest, satting 90-100%. 3. inhaled no improved -invasive tte studies, will need to consider inhaled prostacyclin therapy as an outpatient. 4. consider discontinuing beta blocker if appropriate rate control is achieved with digoxin as the beta blocker may be contributing to dyspnea. medications on admission: -digoxin 125 mcg po daily -warfarin 3.5mg po qhs (instructed to take 1mg on and resume usual dose on ) -furosemide 40mg po bid -metoprolol succinate 50mg po daily -metformin 1000mg po bid -oxygen: 2l/min continuously 2lpm cont via pulse dose, 4l/min with exertion via pulse dose. o2 sat 77% at rest. dx=515. please provide appropriate oxygen conserving device. -ergocalciferol (vitamin d2) 50,000 mg po qmonth -calcium carbonate (vitamin d3) 600mg ca (1500mg)-400 unit tab po daily discharge medications: 1. digoxin 125 mcg tablet sig: one (1) tablet po daily. disp:*30 tablet(s)* refills:*2* 2. warfarin 1 mg tablet sig: two (2) tablet po daily (daily). 3. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 5. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever, pain. 6. oxycodone 5 mg/5 ml solution sig: 4-16 mg po q1h prn as needed for pain. disp:*100 mg* refills:*0* 7. ativan 0.5 mg tablet sig: 1-2 tablets po every four (4) hours as needed for anxiety. disp:*20 tablet(s)* refills:*0* 8. haloperidol 1 mg tablet sig: one (1) tablet po q6h prn as needed for agitation. disp:*16 tablet(s)* refills:*0* discharge disposition: home with service facility: season's hospice discharge diagnosis: atrial fibrillation cardiomyopathy, ef 35% interstitail pulmonary fibrosis diabetes discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , you were admitted to the hospital following a catheterization and asd repair. following the procedure, your oxygen levels increased and you were found to have a low oxygen saturation with minimal activity. this improved a little with getting a little fluid off of you, and also improved with giving you oxygen by facemask before you exerted yourself. we felt you were a bit weak and would benefit from some rehabilitation from a pulmonary perspective. therefore, we transferred you to rehab where rehab with a focus on the lungs would take place. also while you were here we discovered that you had iron deficiency anemia. we started you on iron supplementation. we also found that your heart rates was rather low, therefore we decreased the doses of your metoprolol and digoxin which can both lower your heart rate. we made the following changes to your medications: 1. stop metoprolol 2. decrease warfarin (blood thinner) from 3.5mg daily to 2 mg daily 3. stop taking furosemide (lasix) 5. start ferrous sulfate 1 pill by mouth daily for iron-deficiency anemia 6. stop metformin as your blood sugars have been normal please take aspirin daily and continue coumadin and digoxin. weigh yourself every morning, and call your doctor if weight goes up more than 3 lbs. if you need to speak with dr. , you can reach him on his cell phone: . followup instructions: department: cardiac services when: wednesday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: medical specialties when: thursday at 3:30 pm with: drs. & building: sc clinical ctr campus: east best parking: garage department: pulmonary function lab when: thursday at 3:10 pm with: pulmonary function lab building: campus: east best parking: garage department: pft when: thursday at 3:30 pm md, procedure: pulmonary artery wedge monitoring arteriography of pulmonary arteries right heart cardiac catheterization phlebography of other specified sites using contrast material angiocardiography of venae cavae repair of atrial septal defect with prosthesis, closed technique diagnoses: other primary cardiomyopathies other iatrogenic hypotension anemia, unspecified congestive heart failure, unspecified cardiac complications, not elsewhere classified atrial fibrillation other chronic pulmonary heart diseases ventricular septal defect other specified cardiac dysrhythmias ostium secundum type atrial septal defect surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation do not resuscitate status acute on chronic systolic heart failure diseases of tricuspid valve other dependence on machines, supplemental oxygen idiopathic pulmonary fibrosis 

Answer: The patient is high likely exposed to