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: codeine / cortisone / lipitor / lisinopril attending: chief complaint: positional occipital headache and dizziness major surgical or invasive procedure: none history of present illness: the patient is a 84y/o f with pmh of atrial fibrillation on coumadin, polycythemia , diastolic heart failure presenting to ed with worsening positional occipital headache and dizziness since last evening. the patient reports intermittent headache since her discharge from on from chf exacerbation. since discharge she reports daily occipital headaches exacerbated with changes in position. reports pain as and non-radiating. last pm her pain worsened in severity prompting her to call ems. pain not relieved with tylenol. associated symptoms includes dizziness decribing a "spinning sensation in her head". no other associated symptoms including n/v, vision changes, hearing changes, photophobia, neck pain or loc. denies presyncopal symptoms. in ed she also reported "veering to the left" with ambulation. . recently hospitalized in with exacerbation of chf due to medication noncompliance. pt. on amiodarone with slow hr and first degree av block. in outpatient cardiology appoint. pt. reported occassional lightheadedness and dizziness that does not appear to be positional. physical activity minimal due to fear to leave her home since her hospitalization. pt. losing 1lb/day since discharge. wt. in clinic 163lb. continued on lasix 40mg daily, valsartan and amiodarone. . in ed orthostatics negative. fs 115. vitals t97, hr 59, bp 160/82, rr 15, o2 sat 97% ra. ct head performed negative. pt. seen by neurology, exam notable for positional vertigo and intention tremor l>r. head ct negative for obvious mass. given positional nature of patient's symptoms and daily episodes since , unlikely tia or stroke. . on floor, pt. complains that her head is "unclear". she reports feeling tired and weak since her discharge from rehab. she states she feels that she "veers" to the left due to "breakage and pain" in her l foot. she denies palpitations, shortness of breath and increased edema at home. no recent medication changes. past medical history: 1. a fib- on coumadin 2. diastolic chf - ef 60% 3. tia 4. polycythemia -phlebotomized in past, maintained on hydroxyurea 5. htn 6. hypercholesterolemia 7. cataracts 8. known lbbb 9. asthma-dx in her 70's 10. peripheral neuropathy 11. first degree av block social history: lives alone in . independent adls. previously worked as a bookkeeper. daughter who she would like to be her hcp although not formally established lives in and helps her out as needed (klickstein smoked as a teenager and no etoh. family history: father died 61 of mi, mother died in 70's of an mi, brother died age 43 of mi, no other hx of cad, cva, dmii . physical exam: vitals: temp 98.6 laying bp 120/76, hr 50, sitting 128/72 hr 54, standing 122/78 hr 57, rr 16, o2 sat 97% ra wt. 74.5 lb gen: alert and oriented x3, nad heent: perrla, eomi, mmm, oropharnx clear cv: rrr, nl s1/s2, iii/vi systolic murmur radiating to neck, ii/iv dm loudest at base resp: decreased bs at bases, scattered crackles abd: soft, nt/nd, +bs ext: no edema, varicose veins b/l neuro: ms: alert, orientx4, memory recent and remote intact, attention wnl, speech spontaneous and fluent strength 5/5 throughout, sensation decreases to light touch bl, greater deficit in lle to mid shin pt. with lightheadedness on moving from laying to sitting position pertinent results: : inr 1.3, hct 31.2, bun 25, cr 1.2, vit b12 672, hba1c 5.7%, tsh 7.3, free t4 pending. 02:58am wbc-11.6* rbc-4.49 hgb-10.4* hct-33.5* mcv-75* mch-23.1* mchc-30.9* rdw-19.6* 02:58am neuts-61.5 lymphs-32.6 monos-3.7 eos-1.9 basos-0.3 02:58am plt count-640* 07:05am pt-42.6* ptt-44.2* inr(pt)-4.9* 02:58am glucose-93 urea n-24* creat-1.3* sodium-139 potassium-5.0 chloride-102 total co2-28 anion gap-14 02:58am alt(sgpt)-20 ast(sgot)-25 alk phos-60 amylase-80 tot bili-0.5 02:58am lipase-27 04:52am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 09:28am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg . reports: cxr - bedside ap and lateral views labeled "upright" with lordotic positioning, are compared with most recent studies dated and . allowing for technical differences, the overall appearance is not much changed. there is moderate cardiomegaly with left ventricular configuration, but no pulmonary vascular congestion, pleural effusion, or other evidence of chf. there is linear scarring involving the left mid lung, and minor atelectasis involving that lung base, but no focal consolidation is seen. there are atherosclerotic changes involving the thoracic aorta, without focal aneurysmal dilatation. there is diffuse osteopenia with anterior wedging of mid thoracic vertebrae and resultant kyphosis, unchanged, with no acute thoracic compression seen. impression: cardiomegaly without chf or focal consolidation . ct head - there is no intracranial hemorrhage, edema, mass effect, or shift of normally midline structures. there is no hydrocephalus. density values of brain parenchyma are within normal limits. the -white matter differentiation is preserved. surrounding soft tissues and osseous structures are unremarkable. mastoid air cells and the imaged paranasal sinuses are well aerated. impression: no acute intracranial hemorrhage, mass effect, or edema. no change from . ecg - rate 55bpm, sinus brady, lad, lbbb, 1st degree av block, pr int 324ms . echo : left atrium - long axis dimension: *4.2 cm <= 4.0 cm left atrium - four chamber length: *6.1 cm <= 5.2 cm right atrium - four chamber length: *5.3 cm <= 5.0 cm left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: 4.4 cm <= 5.6 cm left ventricle - systolic dimension: 2.8 cm left ventricle - fractional shortening: 0.36 >= 0.29 left ventricle - ejection fraction: >= 60% >= 55% left ventricle - lateral peak e': 0.14 m/s > 0.08 m/s left ventricle - septal peak e': *0.05 m/s > 0.08 m/s left ventricle - ratio e/e': 13 < 15 aorta - sinus level: 2.9 cm <= 3.6 cm aorta - ascending: *3.6 cm <= 3.4 cm aortic valve - peak velocity: *2.8 m/sec <= 2.0 m/sec aortic valve - peak gradient: *31 mm hg < 20 mm hg aortic valve - mean gradient: 18 mm hg aortic valve - lvot diam: 1.7 cm aortic valve - valve area: *1.0 cm2 >= 3.0 cm2 mitral valve - e wave: 1.2 m/sec mitral valve - a wave: 0.6 m/sec mitral valve - e/a ratio: 2.00 mitral valve - e wave deceleration time: 200 ms 140-250 ms tr gradient (+ ra = pasp): *33 mm hg <= 25 mm hg pulmonic valve - peak velocity: 1.0 m/sec <= 1.5 m/sec findings this study was compared to the prior study of . left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. abnormal septal motion/position. aorta: normal aortic diameter at the sinus level. focal calcifications in aortic root. mildly dilated ascending aorta. aortic valve: mildly thickened aortic valve leaflets (3). mild as (aova 1.2-1.9cm2). trace ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild mitral annular calcification. mild thickening of mitral valve chordae. moderate (2+) mr. tricuspid valve: normal tricuspid valve leaflets. mild to moderate +] tr. mild pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not well seen. physiologic (normal) pr. pericardium: there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. conclusions the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%) right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is mild aortic valve stenosis (area 1.0 cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. impression: mild aortic stenosis. moderate mitral regurgitation. preserved regional and global biventricular sytolic function. mild pulmonary hypertension. biatrial enlargement. compared with the prior study (images reviewed) of , the severity of aortic stenosis is slightly increased. estimated pulmonary artery pressures are slightly higher. . mri/mra head findings: diffusion images demonstrate no evidence of acute infarct. the ventricles and extraaxial spaces are within normal limits and unchanged from previous study. no evidence of territorial infarcts, midline shift or mass effect identified. subtle periventricular hyperintensities are identified indicating minimal changes of small vessel disease unchanged from previous study. following gadolinium, no evidence of abnormal parenchymal, vascular or meningeal enhancement identified. impression: no enhancing brain lesions or acute infarcts identified. no significant change since . mra of the head: the head mra demonstrates normal flow signal within the arteries of anterior and posterior circulation. a fetal right posterior cerebral artery is incidentally noted. a small distal left vertebral artery is also incidentally noted ending in posterior inferior cerebellar artery, a normal variation. impression: normal mra of the head. . bilateral lower extremity ultrasound: scale, color and doppler son of bilateral common femoral, superficial femoral and popliteal veins was performed. these demonstrate normal flow, compression and augmentation. impression: no deep vein thrombosis. . chest (pa & lat) 12:26 pm chest (pa & lat) reason: improvement of edema, etiology of hemoptysis. medical condition: 84 year old woman with dizziness, confusion, pulmonary edema, hemoptysis. reason for this examination: improvement of edema, etiology of hemoptysis. history: pulmonary edema. pa and lateral radiographs of the chest demonstrate a similar cardiomediastinal contour to that seen on . mild-to-moderate copd is again noted. abnormal interstitial pattern on the current study is attributable to copd. no evidence of pulmonary edema. there is a very small left-sided pleural effusion and left basilar atelectasis. trachea is midline. soft tissue anchor projects over the right humeral head. degenerative change is noted to involve the thoracic spine without evidence of spondylolisthesis or fracture. impression: interval improvement of previously seen pulmonary edema. persistent small left basilar atelectasis and left-sided pleural effusion. mild-to-moderate copd. brief hospital course: 84f h/o atrial fibrillation on warfarin, as/mr, chronic diastolic chf, admitted with weakness and worsening positional occipital headache. . # respiratory distress: soon after transfer from the ed to the floor, pt noted r-sided chest pain x 1 hour, then was acutely 'not feeling well.' pt noted to be in respiratory distress by the team. abg 7.35/48/52, lactate 1.8, tachypneic to 30's, sao2 low 70's on nrb, bp 170/110, hr 80's. pt was intubated and transferred to micu. given initially unclear etiology of patient's hypoxic respiratory failure, ekg was done to r/o possible acute ischemic event; this demonstrated questionable pathology. cardiac enzymes were negative. transthoracic was obtained and demonstrated new areas of wall hypokinesis at the left and right ventricle. this new pathology, patient's known medication noncompliance, existing aortic stenosis, and chronic diastolic dysfunction, were considered to be the likely contributors to her acute respiratory decompensation. while intubated, patient initially received nebulizers and furosemide drip; diuresis was moderated given low bp. valsartan was initially held in micu given low bp. pt was extubated and then converted to home regimen of furosemide po before transfer to the floor. sputum gram stain obtained after intubation demonstrated gram-positive cocci in clusters, and pt was started empirically on vancomycin for pna. upon further review gram stain was read as gram positive cocci in pairs, not clusters. she was switched to levofloxacin before transfer to the floor. she will need to continue levofloxacin for three more days to complete a seven day course. . # worsening positional occipital headache/gait instability: pt reported symptoms of lightheadedness on exam with positional change, although orthostatics negative in ed and on floor. pt was at her baseline sinus bradycardia with 1st degree av block, with no pauses on ecg. ct and mri head were negative for acute pathology. neurology was consulted and believe her headache and gait instability may be a manifestation of cervical spondylosis. valsartan was considered a possible contributor to her headache and dizziness, and was therefore discontinued in the icu. however, her dizziness persisted upon transfer to the floor. the dizziness gradually improved and her valsartan was re-administered the day before discharge. the patient worked with physical therapy on the floor and was still experiencing gait instability. in addition, she still experienced occasional headaches. . # weakness - pt. reports that she "veers of to the left with ambulation" she feels her left leg is weaker than right. on exam she has peripheral neuropathy of both le extremities. unclear etiology of neuropathy. no history of diabetes. vit b12 is normal, tsh is elevated and free t4 is pending. she has also had recent hospitalization and illness and is likely decompensated from baseline. patient worked with pt and was still experiencing gait instability at discharge. she will need to be followed in neurology clinic upon discharge. . #back pain: patient began complaining of left sided thoracic back pain. ekg did not show new ischemic changes and her cardiac enzymes were negative. she was later found to have point tenderness just medial to her scapula on her back, and her pain was attributed to musculoskeletal causes. . #hemoptysis/epistaxis: patient began complaining of hemoptysis while in the icu, thought to be secondary to intubation in setting of elevated inr. her hemoptysis and epistaxis persisted on transfer to the floor. the etiology is felt to be secondary to chf, in setting of pneumonia, and dry mucosa from increased ipratropium, as she was receiving 6 puffs every 4 hours for six days. . # chronic diastolic chf: patient was previously being treated for diastolic heart failure. echo obtained in micu demonstrated new wall hypokinesis at the left and right ventricles, with depressed ejection fraction at 40-50%. patient was diuresed with lasix gtt in the micu, and was placed on her home lasix dose upon transfer to the floor. she will be followed in cardiology clinic as an outpatient. . # atrial fibrillation: pt had supratherapuetic inr and warfarin was held in the micu. pt was continued on amiodarone 200mg daily for rate control. her inr gradually came down and on presentation to the floor was at 2.7->1.8->1.5->1.3. she was given warfarin 1mg po on monday, when her inr was 1.5. she was administered warfarin 2mg po on tuesday, when her inr was 1.3. her inr will need to be monitored daily with warfarin dosed accordingly to achieve therapeutic inr level of . . # polycythemia : pt was noted to be anemic with thrombocytosis, both at baseline. pt was continued on home regimen of hydroxyurea. . # hypertension: pt was noted to be hypertensive during respiratory distress, although it was unclear whether htn preceded her respiratory decompensation. soon after transfer to the icu she became hypotensive and her valsartan was discontinued. her blood pressure recovered and she was placed back on valsartan the day before discharge. medications on admission: amiodarone 200mg daily valsartan 40mg daily furosemide 40mg daily hydroxyurea 500mg every other day aspirin 81mg daily warfarin 1mg m-f, 2mg sasun discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for ha/pain. 2. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h:prn as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*0* 3. hydroxyurea 500 mg capsule sig: one (1) capsule po every other day (every other day). 4. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 5. valsartan 40 mg tablet sig: one (1) tablet po daily (daily). 6. levofloxacin 500 mg tablet sig: 1.5 tablets po q48h (every 48 hours) for 3 days: take 750mg on , and 750mg on , then stop. disp:*3 tablet(s)* refills:*0* 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 9. warfarin 1 mg tablet sig: 1-2 tablets po 1mg m-f, 2mg ,: can dose 1 or 2mg until inr is therapeutic . . 10. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation every six (6) hours. disp:*1 inhaler* refills:*2* 11. sodium chloride 0.65 % aerosol, spray sig: sprays nasal tid (3 times a day) for 7 days. 12. valsartan 40 mg tablet sig: one (1) tablet po daily (daily). 13. outpatient lab work please measure pt/inr daily, until therapeutic. goal inr is . discharge disposition: extended care facility: for the aged - macu discharge diagnosis: congestive heart failure--diastolic and systolic dysfunction acute pulmonary edema pneumonia atrial fibrillation polycythemia discharge condition: good 98.4 98.1 112/80 54 18 95%ra discharge instructions: you have been diagnosed with congestive heart failure with an episode of acute pulmonary edema. you were found to have pneumonia. we treated you with diuretics for your heart failure and antibiotics for the infection of your lung. you will need to continue the antibiotics for four more days. you were also found to have cervical disc disease in your neck, causing your headaches and neck pain. you will need to follow up in neurology clinic for this. please follow-up as outlined below weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet . please return to the hospital or call your pcp if you experience chest pain, shortness of breath, light headedness, difficulty breathing, fever, or leg swelling. followup instructions: provider: , m.d. phone: date/time: 3:00 provider: , md phone: date/time: 11:00 provider: phone: date/time: 1:00 please call dr. to schedule an appointment within the next two weeks. appointment. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube diagnoses: pneumonia, organism unspecified abnormal coagulation profile pure hypercholesterolemia congestive heart failure, unspecified unspecified essential hypertension atrial fibrillation acute on chronic diastolic heart failure mononeuritis of lower limb, unspecified acute respiratory failure long-term (current) use of anticoagulants mitral valve insufficiency and aortic valve stenosis chronic obstructive asthma, unspecified epistaxis cervical spondylosis without myelopathy polycythemia vera 

Answer: The patient is high likely exposed to