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: percocet / atorvastatin / alprazolam / oxytocin / demerol / codeine attending: chief complaint: epigastric pain and dyspnea major surgical or invasive procedure: cardioversion and transesophageal echocardiogram history of present illness: this is a 68 year-old female with a pmh history significant for cad (s/p cabg in ; lima-lad, svg-d1, svg-om1 and s/p multiple pcis with most recent cardiac catheterization in showing widely patent grafts), systolic chf (ef 20-25% in ), htn, hld, diabetes mellitus type 2, pvd who presented to with 1-week of abdominal pain associated with some dyspnea and chest discomfort. . the patient notes that she had the acute onset of progressive hypogastric discomfort that heightened to a in intensity and was dull and achy in character; exacerbated by movement and positional. she also associated this with some nausea, two episodes of vomiting this am (non-bilious, particulate, non-bloody) and some chest discomfort for the past week. the chest pain is a tightness that does not radiate, is a in intensity and is relieved with reclination and worsened when she roles to the right side. she denies fevers or chills, no diaphoresis but some mild palpitations. she denies headaches or vision changes. no lightheadedness or dizziness. she denies dysyuria or hematuria. she has no leg swelling or clot history. she denies sick contacts or uri symptoms recently. . at , where she received aspirin 162 mg po x 1, metoprolol tartrate 25 mg po, morphine 6 mg iv, zofran 4 mg iv, pantoprazole 40 mg iv and lovenox 70 mg sc x 1. her laboratory studies were remarkable for a wbc 8.9, hct 38.8, plt 182. sodium 132, potassium 3.9, creatinine 1.9 (baseline 1.1-1.4), normal lfts, inr 1.3 with lactate of 1.6 and a negative u/a. an ekg showed a.fib @ 113, lad/ni, twi in leads avl, i and twi in lateral leads (v5-6). a cxr showed a top-normal heart size, with no pleural effusion or consolidation. troponin-i was 0.12. bnp was 220. the atrial fibrillation was of unknown timing and thus cardioverted was deferred and rate control was employed. she subsequently became hypotensive and an urgent bedside 2d-echo showed an ef estimated at 10%. a right ij-cvc was placed. levophed gtt was started given her hypotension. she was transferred to for further management. . in the ed, initial vs 96.2 94 117/80 16 98%6l. exam was notable for mild epigastric tenderness, guaiac negative brown stool. laboratory studies demonstrated wbc 11.2, hct 41.9, inr 1.2. her bicarbonate was 21 (ag-metabolic acidosis of 14), creatinine of 2.2 and lactate of 2.1. repeat troponin was 0.04. repeat u/a was unremarkable. an ekg showed a.fib @ 98, twi in i, avl worse compared to prior. a cxr showed mild pulmonary edema. bedside 2d-echo showed no pericardial effusion and sub-optimal squeeze. fast was negative. a ct of the abdomen and pelvis was obtained showing right greater than left-sided pleural effusion, mild ascites with fat stranding centered around the omentum with concern for infarct, diverticulosis, normal appendix and a 2-mm non-obstructing left nephrolith. she received vancomycin 1 g x 1, flagyl 500 mg iv x 1, metoclopramide, zofran and morphine. cardiology and acs-surgery were consulted. she was admitted to the ccu for further management on levaphed gtt at 0.2. . on arrival to the ccu, she denies chest pain or trouble breathing. her abdominal pain is mild and improved. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. past medical history: * cardiac risk factors: dyslipidemia, hypertension, diabetes, tobacco use * cardiac history: - cabg: ; lima-lad, svg-d1, svg-om1 . - pci: multiple pcis, mostly to lad - most recent cardiac catheterization in showing widely patent grafts * : nstemi s/p coronary atherectomies to lad/d1 bifurcation lesion with placment of 2 stents and ptca to jailed d1 * : elective cath revealed in-stent restenosis and 90%d1 restenosis; ptcra was performed for in-stent restenosis as well as kissing balloons to lad/d1 with residual 20% d1 lesion * : ua with cath/no intervention but lvedp 38 * : chest pain with diagnostic cath showing widely patent lima-lad and svg-d1-om1. lmca with 50% stenosis, lad with 80% proximal and mid, lcx with 70-80% proximal, and rca with 80% ostial lesion. lvedp severely elevated to 36 mmhg. . - pacing/icd: history of non-sustained vt on telemetry in the setting of mi, sustained t-wave alternans on stress testing (was worked up for icd in but did not receive one) . past medical & surgical history: 1. systolic congestive heart failure (2d-echo in showing lvef 20-25%) 2. hypertension 3. hyperlipidemia 4. diabetes mellitus, type 2 5. peripheral vascular disease 6. hypothyroidism 7. nephrolithiasis (s/p right nephrectomy with chronic renal insufficiency, creatinine 1.1-1.4 at baseline) 8. peptic ulcer disease 9. plantar fasciitis 10. reflux esophagitis, gerd 11. peripheral neuropathy 12. s/p right inguinal hernia operations x 4 13. s/p laparoscopic cholecystectomy () 14. s/p hysterectomy social history: patient is divorced and has 6 children. long-time smoking history (4-cigarettes a day for 50-years) and quit 1-3 months prior; denies alcohol use or recreational substance use. retired 911-operator and works part-time as a crossing gaurd at a school. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission physical exam: vitals: 96.6 / 96.6 85-96 109/66 14-16 96-100% 6l nc cvp: 19-21 general: appears in no acute distress. alert and interactive, somnolent at times, but responds to verbal commands. heent: normocephalic, atraumatic. eomi. perrl. nares clear. mucous membranes moist. neck: supple without lymphadenopathy. jvd 2-3 cm above the clavicle while laying flat. cvs: pmi located in the 5th intercostal space, mid-clavicular line. irregularly irregular, with a holosystolic murmur heard best at the apex, without rubs or gallops. s1 and s2 normal. no s3 or s4. resp: respirations unlabored, no accessory muscle use. decreased breath sounds bilaterally. no wheezing or rhonchi. bilateral inspiratory crackles at bases. abd: soft, non-tender, non-distended, with normoactive bowel sounds. no palpable masses or peritoneal signs. abdominal aorta not enlarged to palpation, no bruit. extr: no cyanosis, clubbing, 2+ peripheral pulses; + peripheral edema noted to the mid-shins derm: no stasis dermatitis, ulcers, scars. neuro: cn ii-xii intact throughout. alert and oriented x 3. strength 5/5 bilaterally, sensation grossly intact. gait deferred. pulse exam: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: admission labs: . 06:10pm blood wbc-11.2* rbc-4.26 hgb-13.7 hct-41.9 mcv-99*# mch-32.2* mchc-32.7 rdw-13.5 plt ct-245 06:10pm blood neuts-81.9* lymphs-13.6* monos-2.8 eos-1.2 baso-0.4 06:10pm blood pt-13.1* ptt-32.7 inr(pt)-1.2* 06:10pm blood glucose-268* urean-40* creat-2.2* na-137 k-4.5 cl-102 hco3-21* angap-19 06:10pm blood calcium-9.3 phos-5.3* mg-1.9 . pertinent labs and studies: 01:35am blood ck(cpk)-67 06:10pm blood ctropnt-0.04* 01:35am blood ck-mb-4 ctropnt-0.06* 09:49am blood ck-mb-3 ctropnt-0.07* 03:25pm blood ck-mb-3 ctropnt-0.08* 03:35am blood tsh-6.0* 09:49am blood free t4-1.3 06:17pm blood lactate-2.1* 01:55am blood lactate-1.5 blood culture staph coag negative preliminary blood culture negative urine culture negative mrsa negative blood culture negative x2 urine culture negative . cxr 1. appropriate positioning of right internal jugular central venous catheter without evidence for pneumothorax. 2. mild pulmonary edema. . ct abdomen and pelvis 1. inflammatory changes in the infrahepatic region of uncertain etiology characterized by fat stranding and ascites, centered primarily near the colon but without diverticulosis or wall thickening to confirm a colonic etiology. the degree of stranding seems greater than might be expected for post-operative changes after prior nephrectomy and would also probably not explain regional ascites in most cases. a small part of the fluid tracks medially up to the duodenum, which may be significant. fat necrosis, trauma, or duodenal ulcer perforation could be considered and colonic etiologies are not excluded. correlation with clinical features is important in interpreting the findings. this was called to dr. on at 11:00p.m. 2. basilar opacities which are non-specific. 3. suspected nephrolithiasis. . echocardiogram the left atrium is mildly dilated. the estimated right atrial pressure is at least 15 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis (lvef = 20%), with regional variation, most c/w multivessel cad. a left ventricular mass/thrombus cannot be excluded. right ventricular chamber size is normal. with mild global free wall hypokinesis. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. there is no mitral valve prolapse. severe (4+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: dilated left ventricle with severe global systolic dysfunction, most c/w multivessel cad. severe mitral regurgitation. moderate tricuspid regurgitation. moderate pulmonary hypertension. . renal us 1. non-obstructing nephrolithiasis. 2. mild hydronephrosis, but not necessarily due to an obstructive process; it may be secondary to mild renal atrophy or subclinical ureteropelvic junction obstruction. however, if renal failure were to worsen, then short-term follow-up ultrasound could be considered. 3. echogenic liver suggesting fatty infiltration; however, other forms of liver disease including more advanced forms of liver disease such as significant hepatic fibrosis/cirrhosis cannot be excluded by this study. . 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. the left ventricular cavity is dilated with severe global hypokinesis (lvef <20 %). right ventricular free wall motion is depressed. there are simple atheroma in the ascending aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. trace aortic regurgitation is seen. the mitral leaflets are mildy thickened. severe (4+) posteriorly directed mitral regurgitation is seen. there is moderate tricuspid regurgitation. there is no pericardial effusion. impression: no spontaneous echo contrast or thrombus in la/laa/ra/raa. left ventricular cavity dilation with severe global left ventricular hyopkinesis. right ventricular free wall hypokinesis. severe mitral regurgitation. brief hospital course: 68f with a pmh significant for cad (s/p cabg in ; lima-lad, svg-d1, svg-om1 and s/p multiple pcis with most recent cardiac catheterization in showing widely patent grafts), systolic chf (ef 20-25% in ), htn, hld, diabetes mellitus type 2, pvd who presented to with 1-week of abdominal pain associated with some dyspnea and chest discomfort found to have possible omental infarction vs. perforated peptic ulcer found to be in atrial fibrillation with evidence of acute systolic congestive heart failure exacerbation. . acute care # hypogastric abdominal pain ?????? the patient initially presented with hypogastric abdominal pain and she experienced this pain intermittently throughout her hospitalization. her physical exam remained benign and non-surgical, with a soft, non-tender abdomen, no distention and normo-hypoactive bowel sounds. ct read suggestive of potential omental infarct with lesser concern for peptic ulcer perforation. given she has newly recognized atrial fibrillation, there is some concern for embolization from an atrial thrombus which may have caused an omental infarct. gerd is also a likely etiology given that it is quick in onset and often occurs after eating. acs was consulted and there is no surgical intervention indicated. lactate normalized soon after arrival to the floor. received metronidazole and ceftriaxone on but was discontinued due to low concern for intra-abdominal infection. . # hypotension - patient presented with hypotension in the setting of acute abdominal complaints and concern for worsening systolic chf - started on levophed gtt at outside institution; etiologies that were initially considered included poor forward flow vs sepsis from intraabdominalpathology. levophed gtt was successfully weaned and her maps improved with better control of her heart rate after being dig loaded. central venous catheter removed on . she did have one out of four bottles positive for coagulase negative staphylococcus but a septic cause of hypotension was thought to be unlikely and this was considered a contaminant. . # atrial fibrillation - no documented prior atrial fibrillation of note. patient presented with evidence of atrial fibrillation with rapid ventricular response to 130-140s at with hypotension. etiologies would include: worsening heart failure vs. thyroid dysfunction vs. hypertension vs. catecholingeric surge in the setting of abdominal issues - chads2 score is 3. it is also possible that she went into afib which worsened her chf and caused her current exacerbation. hr is now well controlled after dig loading. also treated with metoprolol. the patient had tee/cv which was successful and she remained in nsr after the cardioversion on . digoxin was discontinued after her cardioversion and she was started on amiodarone therapy. the patient was also started on coumadin for anticoagulation. . # acute on chronic renal insufficiency ?????? creatinine remains elevated at 2.5, by report cr is 1.1-1.4 at baseline. she is s/p right nephrectomy in the for recurrent nephrolithiasis. the etiology of the acute worsening of her renal function may be poor forward flow from her depressed ef and volume overload and decreased perfusion to her single kidney. arguing against this is that her feurea was >35%, suggesting that she is not pre-renal and may have progressed to atn. also consider obstruction given single kidney and mild hydro on us. . # acute systolic congestive heart failure - 2d-echo from demonstrating severe global hypokinesis and inferior wall akinesis with lvef of 20-25% and moderate-severe mitral regurgitation was noted. repeat tte here showed ef of 20% with worsening mitral regurgitation, from 2+ to 4+. she presented with evidence of volume overload (elevated jvp, peripheral edema and inspiratory crackles) with cxr imaging showing pulmonary edema. acute decompensation considerations: medication non-compliance vs. dietary indiscretion vs. acs/mi or ischemia (unlikely given reassuring serial cardiac biomarkers) vs. valvular disease (worsening mitral regurgitation noted) vs. tachycardia-inudced cardiomyopathy given her atrial fibrillation (although it appears recent and her hr has not exceeded 130s, tsh 6.0 with normal free t4 of 1.3). on exam, her volume status improved prior to admission, with resolution of crackles and edema. we held her acei in setting of hypotension and acute renal insufficiency. she was dosed lasix and a beta-blocker. . # gram positive cocci bacteremia, likely contaminant- 1 of 4 bottles of admission blood culture was positive for coagulase negative staphylococcus. she has been afebrile since admission and her wbc was normal. most likely cause was a contaminant, especially given the speciation and subsequent blood cultures had been negative. . chronic care: # coronary artery disease - patient has substantial coronary artery disease history with cabg in (lima-lad, svg-d1, svg-om1) and s/p multiple pcis with most recent cardiac catheterization in showing widely patent grafts. she presents with atypical and vague chest complaints this admission, with some exertional dyspnea. troponin trend and ck-mb have been flat and no evidence of ami causing her symptoms. we continued her home aspirin 81 mg po daily and pravastatin. . # hypertension - home regimen includes acei, beta-blocker and k-sparring diuretic with thiazide diuretic combination. she reports controlled blood pressure as an outpatient, currently hypotensive. these were held in setting of hypotension. . # hyperlipidemia - will continue on pravastatin 20 mg po daily. developed myalgias in the past to atorvastatin. . # diabetes mellitus, type 2 - history of diet-controlled diabetes with insulin use only remotely - she did not tolerate levemir therapy and discontinued this months ago for gi complaints; she rarely checks her blood sugars - no record of an hba1c in our system. she was maintained on iss during her hospitalization. . transitions of care issues: 1. at the time of discharge, the patient's blood cultures from and were pending without growth and her abdominal x-ray imaging from was pending a final read, but was overall reassuring. 2. patient was discharged with supratherapeutic inr of 5.9 and will hold coumadin anticoagulation until primary care follow-up. 3. if her non-specific abdominal pain continues, she will be seen by a gastroenterologist for further evaluation to determine the need for endoscopy. 4. patient was started on amiodarone therapy given her atrial fibrillation; which she tolerated well. 5. we held her lisinopril, amelioride-hydrochlorothiazide and metformin until her renal function improves; can be resumed at her primary care physician's and cardiologist's discretion. medications on admission: 1. pravastatin 20 mg po daily 2. synthroid 100 mcg po daily (5-days a week, weekdays only) 3. aspirin 81 mg po daily 4. zantac 75 mg (10 ml) po bid 5. lisinopril 2.5 mg po daily 6. metoprolol succinate xl 25 mg po daily 7. amiloride-hctz 5/50 mg po daily 8. coenzyme q-10 100 mg po daily 9. lasix 20 mg po daily (recently started) 10. metformin 500 mg po daily discharge medications: 1. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 100 mcg tablet sig: one (1) tablet po 5x/week (mo,tu,we,th,fr). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 5. metoprolol succinate 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). disp:*30 tablet extended release 24 hr(s)* refills:*2* 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 8. coenzyme q10 100 mg capsule sig: one (1) capsule po once a day. 9. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for gas. disp:*120 tablet, chewable(s)* refills:*2* 10. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day) for 12 days: on , decrease dose to one tablet once a day. disp:*24 tablet(s)* refills:*0* 11. amiodarone 200 mg tablet sig: one (1) tablet po once a day: start on . disp:*30 tablet(s)* refills:*2* 12. outpatient lab work please check chem-7 and inr on thursday with results to dr. at phone: fax: discharge disposition: home with service facility: vna discharge diagnosis: atrial fibrillation with rapid ventricular response abdominal pain acute on chronic systolic congestive heart failure secondary diagnosis: diabetes mellitus hypertension acute on chronic kidney disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you had some abdominal pain and vomiting that brought you to . it is unclear why you are having pain with eating and you will need to see dr. again for more testing. at the same time, it was found that you were in an irregular heart rhythm called atrial fibrillation that was very rapid. you received some medicine to help slow the rhythm and was treansferred to for care. your heart was shocked back into a regular rhythm and you were started on amiodarone to help keep it in a regular rhythm. you will take warfarin (coumadin) from now on to prevent strokes caused by the atrial fibrillation. you will need to get your warfarin level checked regularly and dr. office. as your heart rate was very fast, you had some fluid backup in your lungs. your weight this morning is 177 pounds. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. you also should avoid salt in your diet. . we made the following changes to your medicines: 1. increase ranitidine to 150 mg to take at night 2. start taking amiodarone to prevent atrial fibrillation and control the heart rate 3. increase metoprolol to 100 mg daily 4. start pantroprazole and simethicone to help with your stomach pain and gas 5. stop taking lisinopril, amelioride/hydrochlorothiazide and metformin until your kidney function improves. followup instructions: primary care: name: , specialty: internal medicine address: ,, , phone: appointment: thursday at 3:30pm gastroenterology: name: , specialty: gastroenterology address: . , , phone: appointment: tuesday at 2:45pm . cardiology: department: cardiac services when: tuesday at 1:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage procedure: diagnostic ultrasound of heart other electric countershock of heart diagnoses: abdominal pain, unspecified site congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status peripheral vascular disease, unspecified percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified old myocardial infarction acute on chronic systolic heart failure acquired absence of kidney 

Answer: The patient is high likely exposed to