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: terbutaline / dicloxacillin / advair diskus / codeine / penicillins / zantac / fosamax / heparin agents / ativan / percocet / vancomycin / glucocorticoids (corticosteroids) / ace inhibitors / amoxicillin / alendronate sodium / nsaids attending: chief complaint: hypoxia major surgical or invasive procedure: cardiac catheterization history of present illness: 82 yo f with history of cad s/p mi in , angina, history of stents to lad and lm (), htn, hl, pvd, aaa s/p repair, cea, ckd (cr 2.5), severe pulmonary hypertension, hit, history of pe, and oxygen-dependent copd who is transferred from with hypoxia. patient was hospitalized at from - for a planned coronay catheterization and underwent stenting w/ des of her left main (known distal 70% stenosis) and lad (mid 80% in-stent restenosis (isr) and a distal 50% stenosis). patient experienced persistent angina and underwent repeat catheterization to assess possible occlusion of her lcx (known 30% and 60% lesions on initial cath), which showed patent stents and stable lcx lesions and no further interventions were done. continued angina and doe were attributed to combination of copd and small vessel disease. cxr two days prior to discharge () was notable for b/l pleural effusions and moderate to severe pulmonary edema. she was discharged on lasix 20 mg po daily w/ the addition of amlodipine to her regimen to health care center for cardiopulmonary rehab. . at rehab, patient noticed progressive sob and episodes of angina with movement- severe episode prior to admission on route to bathroom prompting her to call nurse ambulance. denies fevers, chills, cough, nausea, or vomiting. presented to where initial vitals were t 98.4, bp 122/53, hr 91, rr 22 and o2 sat 73% on ra. labs showed wbc 8.8 w/ 73.6% neutrophils, hct 38.1, plts 142, creatinine 2.9 and bun 35. bnp 442, troponin was 0.04, ck 64. abg showed ph 7.43 pco2 39, po2 44. ekg showed sr w/ occ pvcs and rbbb, q waves in lead iii unchanged from prior. cxr showed significant left pleural effusion, mild effusion at right base, and fluid w/in fissure. patient was given duoneb with minimal improvement, lasix iv x1 (dose not documented in osh paperwork), maintained on cpap, and transferred to on a non-rebreather for further management. . in the ccu, patient reported she felt comfortable. denied cp, sob, nausea, or vomiting. reported a leg cramp, which she notes she gets intermittently. notes productive cough (unable to expectorate) for past two to three weeks. no fevers or chills. . on review of systems, s/he denies any prior history of stroke, tia, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, dysurea, black stools or red stools. s/he denies recent fevers, chills or rigors. all of the other review of systems were negative. . cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: 1. cardiac history: +hypertension +dyslipidemia -diabetes -coronary artery disease s/p mi in -cabg: none (declined ) -percutaneous coronary interventions: rca/lad stents in by dr. (); and lmca and lad at -pacing/icd: none 2. other past medical history: - peripheral vascular disease - history tobacco use - ? history of hit - rectal cancer - copd (oxygen dependent- 2 l/min at night and increase to 3 l/min with activity) -chronic kidney disease (baseline cr 2.5-2.9) secondary to renal hypoplasia - history of pulmonary embolism ( d/c-ed during last hospitalization after discussion w/ pcp) -thyroid disease -iron deficiency anemia -pulmonary hypertension (pa systolic pressure estimated by echo calculated from peak tr velocity is 45 to 75) -abdominal aortic aneurysm -s/p carotid endarterectomy -depressive disorder social history: lives at facility in . most recently in cardiopulmonary rehab. -tobacco history: quit smoking in , 30 pack-years -etoh: denies usage -illicit drugs: none family history: strong family history of cad and cardiac death before age 50. father died from mi at age 45. physical exam: on admission: general: elderly woman breathing comfortably, able to speak in full sentences with non-rebreater in place; oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. dry mm. neck: supple with jvp at clavicle at 45 degrees, appx 3 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. rr with frequent ectopy, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: distant bs throughout, decreased breath sound in b/l bases; faint crackles in bases, but no ronchi or wheezes abdomen: soft, ntnd. active bs, well healed incisional scar with reducible hernia. no hsm or tenderness. extremities: trace pedal edema. no c/c. no femoral bruits. cool les. skin: numerous ecchymoses. no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp dopplerable pt absent left: dp absent pt dopplerable . on discharge: general: sitting in chair, nad. breathing comfortably heent: perrl, eomi. mild pallor, no cyanosis. mm moist neck: no jvd sitting in chair. cardiac: irregular rr frequent premature beats, normal s1, s2. no m/r/g. no s3 or s4. lungs: at bases, l>r, air movement somewhat worse today. no wheezes or crackles. abdomen: soft, ntnd. bs ++, surgical scar with reducible hernia. extremities: no c/c. no edema. skin: numerous ecchymoses on upper limbs. pulses: feet warm. pertinent results: on admission: osh labs: wbc 8.8 w/ 73.6%n; hct38.1 plt 142, mcv 94.6 na 140 k 3.8 cl101 hco328 bun35 cr2.9 mg2.5 ca9.4 tp 7.0 alb3.8 alk 123 ast29 alt21 troponin 0.04; cpk 107, ckmb 2.9, index 2.71 bnp 442 abg: ph 7.43 co2 39 o2 44 a/a gradient 270 ua: yellow, cloudy, neg for bili, ketone, blood, protein, urob, nitrite; trace leuk est; wbc; rbcs 0-1; bacteria: many labs: 02:20am blood wbc-10.1 rbc-3.70* hgb-11.6* hct-34.8* mcv-94 mch-31.4 mchc-33.4 rdw-16.4* plt ct-140* 05:35am blood glucose-109* urean-34* creat-2.6* na-139 k-3.9 cl-104 hco3-25 angap-14 05:35am blood calcium-8.7 phos-2.9 mg-2.2 studies: ekg (osh): sinus rhythm at 84 bpm w/ pvcs. q wave in iii and rbbb. twi in ii, iii, avf, v1-v3 c/w prior. ekg (): sinus rhythm at 80 bpm with rbbb and q wave in iii. twi in iii, avf, v1-v3 c/w baseline. (sinus rhythm with ventricular premature beats. intra-atrial conduction delay. right bundle-branch block. inferior and precordial lead st-t wave changes may be primary and are non-specific. clinical correlation is suggested. since the previous tracing of there is probably no significant change.) cxr: in comparison with the study of , there is continued hyperexpansion of the lungs with substantial, though probably slightly decreasing, left pleural effusion. small right effusion is seen. moderate cardiomegaly persists with some elevation of pulmonary venous pressure. no definite acute focal pneumonia. b/l lenis: no evidence of dvt. tte: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. with depressed free wall contractility. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is a trivial/physiologic pericardial effusion. cxr (rt and left lateral decubitus): pleural thickenings probably organized as they do not change significantly in decubitus positions from what has been observed earlier. chest ct (non con): 1. mild to moderate centrilobular emphysema. 2. bilateral pleural effusions, larger on the left side than on the right associated with marked left lower lobe atelectasis. 3. peripheral opacity in the right lower lobe, which may represent focal pneumonia or aspiration, although an infarct is also considered possible in the appropriate clinical setting. 4. ground-glass opacity accompanied by mild interstitial thickening and fissural fluid suggestive of pulmonary edema. r heart cath: final diagnosis: 1. severe pulmonary hypertension. 2. normal left and right sided filling pressures. 3. mild (17% drop0 in pvr following administration of no. 4. recommendations as per primary cardiology team. discharge labs: 06:05 7.1 3.87* 11.7* 35.9* 93 30.1 32.5 15.2 198 06:05 21.2* 1.9* 06:05 971 32* 2.5* 147* 3.5 99 34* 18 15:31 art 59*1 40 7.44 28 2 brief hospital course: 82 year old woman with history of cad s/p mi in , pci to lm, lad, and rca, angina, htn, hl, pvd, aaa s/p repair, cea, ckd (cr 2.5), severe pulmonary hypertension, hit, history of pe now off warfarin, and oxygen-dependent copd who presents with progressive sob and hypoxia. . # hypoxia- patient was admitted with marked hypoxia and significant a-a gradient with pao2 of 44 on a 50% venti mask. initially given her level of hypoxia and history of pe and recent discontinuation of , pe seemed a likely explanation of her symptoms, espeically as her cxr was not felt to be consistent with significant fluid overload and effusions appeared stable. she was empirically started on argatroban (given history of hit). however, b/l lenis were negative and echo did not show any signs of new right heart strain (echo w/ signs of rv volume and pressures overload and severe pulmonary hypertension. however pa pressure not significantly changed from prior). upon further investigation it was determined patient had recieved in the past for a questionable history of pe based on an indeterminate vq scan at . given her clinical picture and the risk of bleed on triple anticoag (asa and plavix in addition to ) was d/c-ed during prior hospitalization. given the lack of definitive signs of pe as above and the inability to definitively evaluate with contrast ct chest, argatroban was d/ced. non contrast ct was undertaken on after pulmonary was consulted to further illucidate potential etiologies for hypoxia and showed "mild to moderate centrilobular emphysema; bilateral pleural effusions left>right with marked left lower lobe atelectasis; peripheral opacity in the right lower lobe, which may represent focal pneumonia or aspiration, although an infarct is also considered possible in the appropriate clinical setting; ground-glass opacity accompanied by mild interstitial thickening and fissural fluid suggestive of pulmonary edema." it was thus felt that her hypoxia was likely multifactorial with contribution from copd, vq mismatch in the presence of large left effusion and atelectasis, phtn, possible mucous plugging as well as pulmonary congestion. the pleural effusions were felt to be organized and not candidates for drainage per both pulmonary and interventional pulmonology. patient was started on azythromycin, inhaled steroids, mucolytics and bronchodilators. sildenafil was started empirically for phtn with no significant improvement. given evidence of pulm congestion per ct iv lasix was started on with balance of neg 1l after 24h and apparent improvement in respiratory status, though oxygen requirement remained similar (sats in low 90s on 5l nc, desated to 70s on ra). the patient had a right heart cath on , which showed wedge of 13, pvrs of 9 units that improved to 8 units with no. pulmonary was asked whether they would recommend treating the pulmonary hypertension. they suggested that sildenafil 20 mg tid could be tried, but would be unlikely to offer significant benefit. pulmonary f/u was scheduled to address this issue as an outpatient. . ccu course #2 ( - ) transferred to the unit for respiratory distress. cxr showed worsening left pleural effusion and stable pulmonary edema. tte showed worsenig right ventricular pressure/overload compard to previous tte. interventional pulmonology was consulted and they performed bedside thoracentesis with removal of 1200 cc of pleural fluid. stain showed no organism and fluid was transudative in nature. culture was negative. she was also diuresed two liters with iv lasix with significant improvement in her respiratory status. she was also started on with concern for pulmonary embolism. . # cad: patient w/ significant h/o cad s/p recent stenting to lmca and lad and prior stenting to rca/lad in . cath on showed patent stents. patient with stable angina- unchanged from prior admission. slight troponin leak at osh, but likely secondary to underlying ckd. ekg appeared at baseline. she was continued on her asa, plavix, metoprolol, statin, amlodipine and imdur without any significant complaints of angina during her hospitalization. . # acute on chronic diastolic chf: no history of systolic heart failure per echo at in (ef 50-55%). she did not appear volume overloaded on exam, but did have stable pleural effusions and evidence of pulmonary congestion per ct chest. cardiac echo shows preserved ef, but depressed rv free wall contractility. given evidence of pulm congestion per ct iv lasix was started on with balance of neg 1l after 24h and apparent improvement in respiratory status and slightly reduced oxygen need. on , rh cath was performed to investigate whether pulmonary hypertension could respond to vasoactive agents. this showed mild (17% drop in pvr) following administration of no. discussed with pulm who felt pt could try sildenafil, however given the interaction with imdur would be concerning for hypotension, therefore pt will follow up with pulm as an outpt, no new intervention at this time. . # rhythm: no history of conduction disease. was monitored on tele and remained in sinus w/ frequent pvcs. . # chronic kidney disease: baseline creatinine appears to be 2.5-2.7. she remained around her baseline during this hospitalization. medications were renally dosed and nephrotoxins were avoided. . # hypertension- currently normotensive on home regimen. continued imdur, amlodipine. . # copd- per pulmonary may be having exacerbation given phlegm despite normal exam. non con ct chest was performed as above and patient was started on azithromycin on for planned 5d course. was also started on advair and standing nebs. spiriva was restarted on discharge. . code: dnr/dni (confirmed w/ pt) medications on admission: 1. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 2. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. 3. pantoprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual prn as needed for chest pain: repeat every 5 minutes 6. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 7. levalbuterol tartrate 45 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 9. multivitamin one (1) tablet po daily (daily). 10. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 11. isosorbide mononitrate 120 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 12. lasix 20 mg tablet sig: one (1) tablet po once a day. 13. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 14. amlodipine 2.5 mg tablet sig: one (1) tablet po bid (2 times a day). 15. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 16. toprol xl 200 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 17. oxygen 2 liters at rest, 3 liters with activity discharge medications: 1. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. folic acid 1 mg tablet sig: one (1) tablet po once a day. 5. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) capsule inhalation once a day. 6. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: give up to three tablets for chest pain 5 minutes apart, hold sbp< 90. 7. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: three (3) ml inhalation q6hr () as needed for sob, wheezing. 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 10. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 11. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 12. multivitamin tablet sig: one (1) tablet po daily (daily). 13. calcium citrate + 315-200 mg-unit tablet sig: one (1) tablet po twice a day. 14. ferrous sulfate 324 mg (65 mg iron) tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 15. isosorbide mononitrate 120 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day: hold sbp < 100. 16. furosemide 40 mg tablet sig: 2.5 tablets po daily (daily). 17. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily). 18. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm: goal inr 1.8-2.2. 19. outpatient lab work check chem-7, cbc and inr on friday 20. acetaminophen 500 mg tablet sig: 1-2 tablets po three times a day as needed for pain. 21. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 22. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for to loosen mucous. 23. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily): hold sbp < 90, hr < 55. discharge disposition: extended care facility: health care center - discharge diagnosis: pulmonary hypertension pneumonia acute on chronic diastolic congestive heart failure: holding ace because of increased creatinine coronary artery disease chronic obstructive pulmonary disease acute on chronic kidney disease hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure taking care of you at . you had trouble breathing and a low oxygen level and was admitted for treatment. we treated you for a pneumonia, increased your diuretics to remove more fluid and removed the fluid on the left side by draining it with a needle. your breathing improved considerably and your oxygen requirement is now the same as when you were home. we performed a cardiac catheterization to see if a medicine, sildenifil, would help the pressures in the vessels inside your lungs. the test showed that there was mild improvment. given the cost of this medicine and difficulty getting the medicine at rehab, we have not started it now but will defer to your pulmonologist, dr. . right now, your weight is 121 pounds and you should consider this your ideal weight. weigh yourself every morning, call dr. if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . we made the following changes to your medicines: 1. start miralax daily and senna as needed to avoid constipation 2. start advair to treat your copd 3. start calcium and vitamin d to prevent osteoporosis 4. increase lasix to 100 mg daily to prevent fluid accumulation in your lungs and abdomen 5. decrease metoprolol to lower your heart rate 6. stop amlodipine 7. start warfarin 3mg daily to prevent a stroke. your goal inr is 1.8-2.2 8. start tylenol for pain 9. start robitussin cough syrup to help your cough 10. start trazadone as needed for insomnia followup instructions: name: , np specialty: cardiology location: address: , , phone: appointment: at 11:50am name: dr specialty: pulmonology pulmonary dept 5th fl phone: ( when: at 11:40 md procedure: thoracentesis right heart cardiac catheterization central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified abnormal coagulation profile unspecified pleural effusion congestive heart failure, unspecified acute kidney failure, unspecified chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified acute on chronic diastolic heart failure coronary atherosclerosis of unspecified type of vessel, native or graft personal history of tobacco use percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified pulmonary collapse other and unspecified angina pectoris personal history of venous thrombosis and embolism do not resuscitate status chronic pulmonary heart disease, unspecified 

Answer: The patient is high likely exposed to