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: history of present illness: ms. is a year-old female with sever aortic stenosis, hypertension, congestive heart failure, resident of rehab who by report was found at 1:30 on the morning of admission acutely dyspneic. she was administered 40 mg of lasix, 2 mg of morphine and .25 inch of nitropaste and transferred to hospital. initially she was hemodynamically stable with a blood pressure of 170/90. the patient was then intubated at approximately 5:00 a.m. on the morning of admission and was transferred to the emergency room. she had arrived on a dopamine drip at 5 mcs with a systolic blood pressure in the 50s. the dopamine drip was increased and nitropaste was removed with an increase in blood pressure and an increase in her heart rate to the 130s. the patient received versed for sedation. chest x-ray performed was consistent with a right lower lobe pneumonia and she was administered ceftriaxone at and levofloxacin/flagyl at the emergency department. on review of nursing notes from it appears that the patient was initially diuresed with lasix 40 mg times two, and then she had a decline in her blood pressure and several normal saline boluses were given. the dopamine was started after the normal saline boluses did not raise her blood pressure. the decision was to intubate her at that time. past medical history: 1. congestive heart failure. normal ef greater then 55%, left ventricular hypertrophy, severe atrial fibrillation on echocardiogram . she has acute pulmonary edema approximately one time per month. 2. aortic stenosis. 3. chronic right pleural effusion. 4. osteoporosis being treated with alendronate. 5. status post left hip fracture and repair - open reduction and internal fixation . 6. osteoarthritis - status post humeral fractures, vertebral compression fractures. 7. frozen left shoulder status post surgery. 8. chronic anemia - likely iron deficiency. 9. recurrent urinary tract infections. 10. chronic colonization of c-difficile, multiple admissions. she has a history of recurrent colitis. 11. seizure in the setting of siadh, which ocurred postop after her open reduction and internal fixation and once again in . 12. history of zoster on the right chest and back. 13. hypertension - blood pressure on medications approximately 120/60. 14. dementia, mild memory problems. medications on admission: 1. alendronate. 2. os-cal. 3. pepcid. 4. lasix. 5. lopressor. 6. multivitamin. 7. potassium supplement. allergies: aspirin and non-steroidal anti-inflammatory drugs. social history: the patient lives at rehab. the patient's daughter is her health care proxy. physical examination on admission: temperature 99. heart rate 133. blood pressure 90/33 on a dopamine drip at 5 micrograms, respiratory rate 14, oxygen saturation 100% on simv, respiratory rate 12 with tidal volume 500, peep of 5. fio2 was 50%. general, heent right pupil surgical, left pupil round and reactive to light. mucous membranes are dry. neck prominent external jugulars. chest decreased breath sounds on the right side and no wheezes. cardiovascular tachycardic, regular s1 and s2, 3 out of 6 harsh systolic murmur at the upper sternal borders bilaterally. abdomen soft, nontender, nondistended. no guarding or rebound. no hepatosplenomegaly. extremities no edema, warm to touch. neurological sedated, not responding to stimuli. right toe with a positive babinski. laboratories on admission: white blood cell 8.9, hematocrit 33.3, platelets 181. pt 12.7, ptt 28.1, inr 1.1. urinalysis was unremarkable. sodium 138, potassium 3.6 (hemolysis), chloride 96, bicarb 26, bun 52, creatinine 1.3, glucose 136. alt 34, ast 78, ck 127, alkaline phosphatase 64, amylase 94, total bilirubin 0.4, lipase 33. first set of cardiac enzymes demonstrate a ck of 127, mb of 5, calcium 8.3, magnesium 1.8. laboratories on the day prior to discharge: white blood cell 18.5, hematocrit 33.2, platelets 262, sodium 147, potassium 3.6, chloride 115, bicarb 26, bun 41, creatinine 0.5, glucose 92. calcium 7.8, phosphorus 2.7, magnesium 2.3. arterial blood gas demonstrated ph 7.4, pco2 45, po2 of 81. notable studies: echocardiogram on demonstrated a left ventricular ejection fraction at 75 to 80%, mild left atrial dilatation, normal right atrium, severe aortic valve stenosis, 1+ aortic regurgitation. moderate to severe mitral regurgitation, mild tricuspid regurgitation. there was mild pulmonary artery systolic hypertension noted. cardiac catheterization on demonstrated prevalvuloplasty, left ventricular systolic and diastolic pressures of 205/14 and aortic systolic/diastolic mean pressures of 100/45/65. cardiac output was 4.7 with a cardiac index of 3.7. the valve area calculated prior to valvuloplasty of the aortic valve was 0.45 cm squared. post valvuloplasty left ventricular systolic/diastolic pressures were 210/14. the aortic/systolic/diastolic/mean pressures were 150/60/95. cardiac output/cardiac index was 3.6/2.8 positive valvuloplasty. the valve area was calculated to be 0.7 cm squared post dilatation. the patient received 10 milliliters of nonionic osmolar contrast for this study. impression: ms. is a year-old female with severe aortic stenosis with a prevalvuloplasty valve area of 0.45 cm, which has been complicated by congestive heart failure. she presented to hospital in decompensated congestive heart failure and hypotensive secondary to diuresis. ms. was transferred to for further management. hospital course: 1. cardiovascular: on presentation ms. was hypotensive requiring support with fluids and pressors. likely etiology was an exacerbation of congestive heart failure in which she was administered diuresis. as the patient's cardiovascular physiology requires her to be preload dependent, the patient could not handle this loss of intravascular volume. the patient was noted to have critical aortic stenosis prior to her presentation to . on echocardiogram, the patient's valve area was estimated to be 0.5 cm. to assess ms. hemodynamics a swan-ganz catheter was placed on , which demonstrated a mixed venous sat of 65 to 67%, cardiac index of 3.8 to 4, cardiac output at 4.8. it was felt that without fixing this patient's critical aortic stenosis, she would have a very difficult time to come off the ventilator. despite the limited efficacy and a mortality of this procedure the health care proxy wanted to pursue this option for the patient as this would have been the patient's wishes. on the patient was taken to the cardiac catheterization laboratory and had a aortic valvuloplasty performed. her peak left ventricular to aortic gradient was approximately 100 prior to the procedure, and was reduced to 60 post procedure. the patient's valve area was increased from 0.45 to 0.77 cm squared. status post valvuloplasty the patient improved clinically with increasing urine output and improving mental status. throughout ms. hospital course she had required blood pressure support with vasopressors. initially she presented with a dopamine drip, however, this was changed to a neo-synephrine. ms. required vasopressor support with neo-synephrine throughout the admission intermittently. however, ms. was noted to be adrenal insufficient and was placed in cortical and mineral corticoids and remained normotensive not requiring vasopressors for approximately one week prior to discharge. she had received multiple fluid boluses to sustain her blood pressure prior to the initiation of steroids. post initiation of corticosteroids, ms. had several fluid boluses, however, this was to sustain her urine output to acceptable values. on presentation, ms. have ruled in for a myocardial infarction. her peak ck was 157, peak troponin i was 31.7. this was associated with small st changes consistent with her previous strain pattern and some small t wave inversions were noted in v2 through v3. she was initially started on a heparin drip and administered aspirin. the heparin was quickly discontinued. 2. pulmonary: ms. arrived to on mechanical ventilation. she required mechanical ventilation throughout this admission. i was very difficult to wean the patient off of her mechanical ventilator. a valvoplasty was pursued secondary to an inability to manage her congestive heart failure, which was likely the underlying pulmonary process preventing weaning. status post valvuloplasty the patient still required a significant amount of ventilatory support. she was maintained on assist control for the majority of her hospitalization. secondary to the long term intubation, ms. a tracheostomy on . this procedure was complicated by some bleeding in to the trachea, which formed a blood clot. the patient became acutely hypertensive, tachycardic and tachypneic. she was suctioned and a bronchoscopy was performed to evaluate the patient's airways. significant amount of blood clot and tissue was removed from the patient's airway, several cm above the carina for several days status post trach, the patient required more vigorous tracheal suction, but she had no further episodes of blood clots obstructing her airways. prior to discharge the patient tolerated up to 12 hours on a tracheal tent with arterial blood gases demonstrating adequate ventilation and oxygenation. ms. was known to have a chronic right pleural effusion. she thoracentesis to evaluate this pleural effusion secondary to her difficulty weaning. this was performed on . the pleural fluid demonstrated no organisms or pmns on gram stain. fluid analysis demonstrated that this was consistent with a transudative process, specifically congestive heart failure related. secondary to persistent fevers and an infiltrate on the left lung on chest x-ray consistent with pleural effusion, a repeat thoracentesis was performed on on the left side of the lung. this was also consistent with a transudative process. there was no concern for empyema. status post both thoracentesis, the patient had experienced pneumothoraces. chest tubes were placed after each procedure to drain fluid and air that had accumulated in the spaces. the left chest tube that had been placed on did not drain a significant amount of fluid despite chest x-ray decrease in lung volumes and increasing fluid. a repeat chest tube was placed on . this chest tube drained a significant amount of fluid from the left space. initially, the left chest tube had a high output up to 600 to 800 cc per day, as these volumes decreased significantly the chest tubes were placed to water seal, which demonstrated a significant amount of output. the patient's chest tubes were removed on . repeat chest x-rays demonstrated no significant reexpansion, however, there was no significant accumulation of fluid post removal. it is felt that the patient has trapped lung physiology with scarring of the lungs peripherally. 3. infectious disease: ms. was felt to have a right lower lobe pneumonia and was given ceftriaxone at hospital on presentation. upon arrival to the she was administered levofloxacin and flagyl. during her hospitalization she was continued on levofloxacin initially and cultures were followed. all blood cultures, urine cultures, and pleural fluid cultures were negative. the patient did grow mrsa from her sputum and she was felt to have a ventilator required pneumonia. she was switched to vancomycin and treated with a fourteen day course of this antibiotic. throughout her hospitalization she initially had spiked fevers despite treatment for her vap. to workup these fevers she had cat scans of the torso and sinuses on and also . these studies were unrevealing for a source of her fevers. secondary to an increase in her liver function tests, a right upper quadrant ultrasound was performed, which was unrevealing for ductal dilatation. after completing a course of vancomycin for her vap, the patient no longer developed any fevers and has remained afebrile for approximately one week prior to discharge. 4. neurological: ms. remained sedated while on the ventilator with fentanyl boluses and versed boluses. the majority of her stay she was on a low level of fentanyl drip secondary to significant amount of appearance of discomfort. as her alertness improved, she was initiated on a fentanyl patch with oxycodone prn. her fentanyl patch had been increased from 50 to 75 micrograms per hour and she appeared more comfortable with positional changes. much of the discomfort is likely related to the areas of chest tube insertion and the goal is to wean her off of these pain medications as she tolerates. 5. gastrointestinal: ms. was noted to be impacted several times during this admission. she was disimpacted manually and has remained on aggressive bowel regimen. secondary to her prolonged intubation and poor mental status access for feedings was required. she had a percutaneous endoscopic gastrostomy placed on . she tolerated this procedure very well. of note, the clip at the end of the tube should be at 2.5 to 3 cm to maintain close approximation of this tube with her stomach. 6. fluids, electrolytes and nutrition: ms. required a significant amount of electrolyte repletion of potassium, and magnesium throughout this hospitalization. however, upon initiation of her tube feedings with respalor these electrolyte abnormalities were not commonly requiring repletion. nutrition was consulted during this hospitalization and the patient's goal nutrition is maintained with respalor at 30 cc per hour. 7. endocrine: ms. was noted to be adrenal insufficient. she is currently receiving hydrocortisone and fluticasone secondary to multiple episodes of hypotension, which were felt secondary to her adrenal insufficiency. after initiation of the steroids, ms. no longer required vasopressors. as she was significant deplete in her adrenal corticoids, a slow steroid taper is recommended. 8. hematologic: ms. required multiple blood transfusions throughout this admission. her goal hematocrit was above 28. in total the patient received 12 units of packed red blood cells. throughout her admission her coagulation parameters and platelets remained stable. 9. prophylaxis: ms. remained on subcutaneous heparin, h2 blocker and pneumocompression boots during this admission. 10. code status: the patient wishes to be dnr, cpr not indicated per her health care proxy . the remainder of this dictation will be completed at the time of this patient's discharge. dr., 12-761 dictated by: medquist36 procedure: insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more combined right and left heart cardiac catheterization other endoscopy of small intestine enteral infusion of concentrated nutritional substances thoracentesis other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy percutaneous balloon valvuloplasty diagnoses: pneumonia, organism unspecified congestive heart failure, unspecified other convulsions acute respiratory failure mitral valve insufficiency and aortic valve stenosis iron deficiency anemia, unspecified acute myocardial infarction of unspecified site, initial episode of care diastolic heart failure, unspecified 

Answer: The patient is high likely exposed to