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: zofran attending: chief complaint: hypotension major surgical or invasive procedure: none history of present illness: this is an obese 64 year old woman with a medical history significant for mr, dm, htn, hyperlipidemia, pulmonary htn with cor pulmonale, obstructive and restrictive pulmonary disease, chronic afib on coumadin, recently cardioverted (with one month of flecanide preceding dccv), now transferred from icu for bradycardia, hypotension and arf with supratherapeutic inr. . the patient had noticed fevers up to 103 during end of /beginning of . she denied any more recent f/c/n. also no cough, sinus problems, diarrhea. she cannot walk more than a few feet at baseline due to chronic lung disease. her baseline sob worsened several months ago but did not change significantly since then. the patient felt nauseous for the last two weeks but contributed to her baseline gerd. she also noted 30 lbs weight gain, increased le edema and somewhat decreased urine output during this time period. . the patient was started on flecanide one month ago for dccv at . she was cardioverted successfully on but developed weakness, dizziness (with three falls over the weekend) and further inability to void over the last three days. her beta blocker was discontinued on . patient went to the er at on and was found to be bradycardic in the 40s (although known to be slightly bradycardic in the past), have a creatinine of 5.6 and hypotension requiring a dopamine drip via piv (no cvl placed due to an inr of 10.7). she also received atropine and her hr went up to the 50s. in addition, she was gently hydrated with ivf at 100cc/hr after an initial ivf bolus of 500cc (unclear total volume based on osh records but estimated 1-2l). labs at the osh revealed a bun/cr of 76/5.8, a wbc of 11, bnp of 125 and cpk of 63 with troponin i of 0.04. a cxr showed cardiomegaly but no infiltrate. ekg revealed rad with first degree av block. . on transfer, she was still on a dopamine drip at 11 mcg/kg/min but her bp was 113/84 with a hr in the 50s. the admission ekg was essentially unchanged from one in the morning at the osh. she denied any cp or recent increase in sob. she was admitted to the ccu for further workup and treatment. past medical history: * mitral regurgitation * hypertension * hyperlipidemia * diabetes * neuropathy * depression * pulmonary hypertension with cor pulmonale * obstructive and restrictive pulmonary disease * chronic afib, on coumadin, cardioverted on with one month of flecanide * obesity * chronic anemia, treated with weekly iron infusions * stool positive for occult blood 1 year ago * sleep apnea - uses cpap * home oxygen 2l nc continuous . past surgical history: * cholecystectomy & knee surgery done simultaneously last year - had to be reintubated post operatively and was intubated for less than one day * benign tumor removed from right leg * appendectomy social history: married, recently moved to , mass from ny. 70 pack/year history of cigarette smoking but quit 15 yrs ago. only rare alcohol consumption. family history: nc physical exam: vs: t 97.0, bp 113/84 (on dopamine), hr 54, rr 21, o2 92-100% on 4l nc gen: obese middle aged male in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. very dry mm. neck: supple with distended ej, no jvp appreciable. cv: bradycardic, regular hr, normal s1, s2. 2/6 systolic murmur over precordium without any pmi. no radiation to carotids. no rub or gallop. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were mildly labored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, sparse bs, obese, ntnd. ext: 2+ pitting le edema up to the knees b/l. no cyanosis or clubbing. skin: no stasis dermatitis, ulcers, scars, or xanthomas. neuro: a&o x3, but disorganized thoughts, moving all extremities, flapping tremor. . pulses: right: dp 1+ left: dp 1+ pertinent results: 08:48pm wbc-12.8* rbc-4.25 hgb-10.7* hct-33.3* mcv-78* mch-25.1* mchc-32.1 rdw-17.7* 08:48pm neuts-90.8* lymphs-4.1* monos-4.4 eos-0.2 basos-0.5 08:48pm calcium-8.4 phosphate-8.6* magnesium-2.4 08:48pm glucose-163* urea n-73* creat-6.2* sodium-132* potassium-5.4* chloride-95* total co2-21* anion gap-21* . ekg demonstrated sinus bradycardia with hr of 58, rad and prolonged pr interval and no significant st changes, with no significant change compared with prior ekg from this morning at osh. . 2d-echocardiogram performed on demonstrated per outside records moderately severe mitral regurgitation, moderately severe pulmonary hypertension but preserved lv function. . tte on : the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is dilated. global rv free wall motion appears grossly preserved (not fully visualized). there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets are mildly thickened. the mitral valve leaflets are mildly thickened. moderate to severe (3+) mitral regurgitation is seen (views suboptimal). moderate to severe tricuspid regurgitation is seen (views suboptimal). there is no pericardial effusion. . cxr: at osh with cardiomegaly but no infiltrate. . abdominal u/s at osh (): abdominal organs wnl, kidneys without hydronephrosis, no free intraabdominal fluid, increased bowel gas. . renal u/s : no evidence of hydronephrosis. four-quadrant ascites. pulsatile flow within the main portal vein. . renal u/s : impression: limited exam. normal sized kidneys without evidence of hydronephrosis, unchanged from prior. elevated resistive indices bilaterally, with decreased perfusion and very limited flow detectable in the right kidney. differential considerations include global hypoperfusion, as well as acute tubular necrosis. . . laboratory data (see attached): at osh: bun/cr of 76/5.8, wbc of 11, bnp of 125 and cpk of 63 with troponin i of 0.04. brief hospital course: hospital course: the patient is an obese 64 year old woman with a medical history significant for mr, dm, htn, hyperlipidemia, pulmonary htn with cor pulmonale, obstructive and restrictive pulmonary disease, chronic afib on coumadin, recently cardioverted (with one month of flecanide preceding dccv). she was transferred from the icu for bradycardia, hypotension and arf with supratherapeutic inr. on presentation to , she was on a dopamine gtt. her nodal agents were held and she underwent cvvhd, she had a tunneled catheter placed. dopamine was weaned to off and her bradycardia resolved. she remained in nsr. . 1) hypotension: probably due to accumulation of nodal blocking agents in the setting of her arf. other possibilites were chf exacerbation with poor forward flow, although her tte was without lv systolic dysfunction but did show rv hypokinesis. tamponade was ruled out by echo. she was not septic and did not have adrenal insufficieny. her tft's were within normal limits. all nodal agents were held on admission and she was given 1l ivf with bicarbonate. she was initially continued on domapine and started on cvvhd in hopes of aiding in the removal of nodal agents. dopamine was weaned. she did have one episode of hypotension for which dopamine was up titrated and she was given a 500cc fluid bolus. with time her hemodynamic profile improved and dopamine was turned off. her home medications were gradually restarted. regarding the patient's antihypertensive regimen, lopressor was substituted for atenolol, diltiazem was discontinued, losartan was restarted and hydrochlorothiazide was discontinued (in the setting of renal failure). amytriptaline, which the patient was taking for depression, was held because of it's propensity to cause long qt and the patient's ongoing conduction issues. she tollerated holding the medication well. . 2) arf: the patient had a baseline cr of 0.8 in per osh note. on admission, the patient had a cr of 6.2 wtih an ag of 16. the ddx was initially poor forward flow from chf vs prerenal state / hypotension. per report an osh rus showed no obstruction. further workup revealed a high fena and feurea-35, which is borderline prerenal. however, she had nephrotic range proteinuria. as above, she received hco3 x 1l on admission. medications were renally dosed. initially a temporary femoral dialysis catheter was placed to start cvvhd, this was replaced by a tunnel catheter. after several days of cvvhd the patient began to produce urine and her bun and creatinine improved significantly. renal us showed no hydro, elevated resistive indices bilaterally. renal was consulted and a workup up for nephrotic/nephritic syndrome was initiated. this work up was unrevealing and the renal consultants ultimately felt that the patient's renal failure was likely atn. she eventually made urine on her own and cvvh was discontinued. her creatinine came down to 1.1. . 3) cad: the pt. did not have chest pain and her cardiac enzymes were negative. . 4) bradycardia: she responded transiently to atropine given at osh er. flecanide and bb were likely contributing to bradycardia in the setting of arf. she received calcium gluconate for possible calcium channel blocker toxicity on admission and nodal agents were held. cvvh was initiated. her heart rate returned to and metoprolol was started. . 5) afib: the patient had recently had dccv () and converted to nsr. at home, she was taking coumadin and flecanide. she is currently in nsr. flecanide was initially held for bradycardia as was atenolol. when hemodynamically stable, metoprolol and flecanide were started. also, she initially had a supratherapeutic inr. this was reversed with vit k and 3 units of ffp for line placement. a heparin gtt was started for ease of stopping when the dialysis line needed removal. the line was removed safely, but the cause of the elevated inr was not certain. the patient will be discharged on low dose coumadin with follow up with her pcp and dr. . . 6) pump: a tte from at osh showed preserved lv function. similarly preserved function on a bedside tte at but with a hypokinetic rv consistent with cor pulmonale. her bnp at the osh only 129. she did however have a clinical exam consistent with chf, including le edema and weight gain. cvvh was used to slowly remove volume. . 7) anemia: her hct on admission was 33. this fell to 22 over several days. the patient has known iron deficiency anemia, however, it is unclear whether this was the cause of the hct drop. her initial hemolysis labs wer negative and her ua was positive for blood. she was transfused 1u of prbcs and responded appropriately. further workup revealed iron deficiency anemia. she was started on feso4 325mg tid. . 8) hyperlipidemia: held fibrate given mimimally elevated lfts. the patient's elevated lfts was attributed to poor liver perfusion. the fibrate was restarted on discharge. . 9) dm: metformin and rosiglitazone were held. she was covered with a riss. upon discharge, she was restarted on metformin and rosiglitazone. . 10) diabetic peripheral neuropathy: neurontin was held in the setting of arf. we continue b6/b12/folate. the neurontin was restarted on discharge. . 11) obstructive and restrictive lung disease: the patient has known osa with cpap at home. the patient refused cpap in house. . 12) supratherapeutic inr: the patient had an inr of 20 on admission. likely due to arf. she received 5mg po vitamin k at osh and 5mg iv at . her inr was completely reversed after three bags of ffp for cvl and a-line placement. dic labs were within normal limits. inr trended up again later during her hospital course. the etiology of the patient's supratherapeutic inr was not certain. she was sent home on 1mg coumadin per day and close follow up with her pcp for an inr check. . 12) depression: continued on lexapro. held amitriptyline due to side affects of qt prolongation. . 13) neuro: pt. reported hallucinations, which she has not had previously. this was thought to be due to uremia. halluicnations eventually resolved once renal function improved. . 14) arthritis: continued tylenol 650mg qhs prn. . 15) fen: cardiac and diabetic diet. replete lytes prn. medications on admission: flecanide 50mg tab, 1 pill atenolol 25mg daily (d/c'd on ) diltiazem (cartia xt) 300mg daily coumadin 2.5mg (no recent dose change) vitamin b6/b12/folate (folbic) daily hctz/lisinopril (hyzaar) 100-25mg daily rabeprazole (aciphex) 20mg rosiglitazone (avandia) 4mg daily amitriptyline (elavil) 10mg-2tabs in the am, 1 tab at noon, 2 tabs at bedtime fenofibrate (tricor) 145mg daily escitalopram (lexapro) 10mg daily gapapentin (neurontin) 800mg tid metformin (glucophage) 500mg tid fluticasone/salmeterol (advair) disk 100-50, 2 puffs tiotropium (spiriva) 18mcg 1puff tylenol arthritis 650mg tabs, 2 at hs lasix/kcl as needed for increased dyspnea and weigh gain discharge medications: 1. amoxicillin 250 mg capsule sig: two (2) capsule po q8h (every 8 hours) for 4 days. disp:*12 capsule(s)* refills:*0* 2. folbic 2.5-25-2 mg tablet sig: one (1) tablet po once a day. 3. coumadin 1 mg tablet sig: one (1) tablet po once a day: please take only this dosage until seen by a doctor. . disp:*30 tablet(s)* refills:*2* 4. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 5. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 6. flecainide 50 mg tablet sig: one (1) tablet po every twelve (12) hours. 7. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: two (2) puffs inhalation (2 times a day). 8. fenofibrate micronized 145 mg tablet sig: one (1) tablet po daily (daily). 9. rabeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 10. toprol xl 100 mg tablet sustained release 24 hr sig: two (2) tablet sustained release 24 hr po once a day. disp:*60 tablet sustained release 24 hr(s)* refills:*2* 11. rosiglitazone 4 mg tablet sig: one (1) tablet po once a day. 12. gabapentin 800 mg tablet sig: one (1) tablet po three times a day. 13. glucophage 500 mg tablet sig: one (1) tablet po three times a day. 14. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation (2 times a day). 15. tylenol arthritis 650 mg tablet sustained release sig: two (2) tablet sustained release po at bedtime. 16. lasix 20 mg tablet sig: one (1) tablet po once a day as needed for shortness of breath or wheezing: as needed for weight gain or shortness of breath. 17. losartan 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: primary diagnosis: 1. acute renal failure 2. hypotension, briefly requiring pressors 3. bradycardia, likely secondary to atenolol in the setting of arf 4. atrial fibrillation, on coumadin and flecanide, s/p recent dccv, now in sr 5. elevated inr (off coumadin) of unclear etiology 6. transient halluzinations, likely secondary to uremia . secondary diagnosis: 1. cor pulmonale 2. sleep apnea, on home cpap and 2l o2 3. copd 4. hypertension 5. hyperlipidemia 6. depression 7. diabetes mellitus 8. polyneuropathy 9. mitral regurgitation discharge condition: afebrile. hemodynamically stable. ambulating. tolerating po. discharge instructions: you have been admitted to the cardiac care unit for a low heart rate and low blood pressure in the setting of acute kidney failure causing your blood pressure medications to accumulate. you briefly needed intravenous medications to keep your blood pressure up. you also were transiently started on dialysis while you were making no urine. your heart rate and blood pressure have recovered to within normal limits. your kidney function slowly improved as well and you were transferred to the regular floor. you were seen by physical therapy who felt that you needed home physical therapy to facilitate your recovery. . please call your primary doctor or return to the ed with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . please take all your medications as directed. . please keep your follow up appointments as below. please ensure that dr. checks an inr on you. followup instructions: please follow up with your primary care doctor (, j. f: ) on at 10am to have your inr checked. please followup with dr. at 10:30am on monday for a followup appt. . dr. was contact and will be calling you for a follow up appointment. he plans to see you either on monday, tuesday or wednesday of next week. his office can be contact at (. procedure: venous catheterization, not elsewhere classified hemodialysis venous catheterization for renal dialysis transfusion of packed cells transfusion of other serum infusion of vasopressor agent diagnoses: other iatrogenic hypotension abnormal coagulation profile esophageal reflux mitral valve disorders acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension chronic airway obstruction, not elsewhere classified atrial fibrillation other chronic pulmonary heart diseases diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes other and unspecified hyperlipidemia other specified cardiac dysrhythmias long-term (current) use of anticoagulants iron deficiency anemia, unspecified other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use cardiac rhythm regulators causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to