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: vancomycin attending: chief complaint: shortness of breath hypoxia hypercapneic respiratory failure pulmonary hypertension major surgical or invasive procedure: cardiac catherization history of present illness: 67yo male with h/o liver transplant , severe osa, pulmonary hypertension, and progressively worsening dyspnea over the last two weeks, admitted for diuresis after elective cardiac cath revealed biventricular elevated filling pressures, and now transferred to ccu in setting of acute on chronic respiratory acidosis requiring treatment with bipap. . patient has had mild dyspnea on exertion at baseline for approx. last 1-2 years, but over past several weeks has noted progressively worsening dyspnea. he has been unable to eat for the last few days seocndary to dyspnea while eating. recent work-up by his pulmonologist, including pfts, indicated severe restrictive pulmonary dysfunction with reduced lung volumes, but normal dlco when calculated for lung volumes. his pulmonologist also felt there may be a component of diastolic heart failure contributing to his worsening dyspnea, and he was referred for an elective right cardiac cath which was performed earlier today. cath revealed severely elevated biventricular filling pressures, as well as severe pulmonary arterial hypertension with only moderate elevation of pulmonary vascular resistance. pcwp was 38, pasp was 96. after cath, patient was admitted to the cardiology service for diuresis, as it was felt his dyspnea was primarily related to cardiac etiology vs. a pulmonary etiology. he received furosemide 40mg iv once (home dose furosemide 20mg po daily). on arrival to floor, he appeared lethargic and was difficult to arouse. an abg revealed a respiratory acidosis: 7.23/70/73/31. of note, he had taken benadryl 75mg po at home prior to the procedure, and also received fentanyl 25 mcg while in the the cath lab. respiratory therapy , and patient transferred to ccu for bipap. on arrival to ccu, vitals were: 95.5 100 176/86 32 100% on 5l nc. he had been started on a nitro gtt in the cath lab after sbps noted to be elevated to 200s, and after arrival in ccu his nitro gtt was titrated to keep sbp <160. patient denied any chest pain, abdominal pain or nausea. he was unable to fully answer questions secondary to his lethargic state, and a full review of systems could not be obtained. per medical records, no prior history of stroke, tia, dvt, or known pe. no recent fevers, chills, or rigors. no history of asthma or copd, but patient does have h/o smoking 1-1.5 ppd for 45 years. he has a h/o osa and has been non-adherent to using cpap in the past. however per family report he has been using cpap consistently at night over past several months, and has also been using for several hours a day. . of note, patient has hematoma in right neck after failed right ij placement for procedure; procedure performed through left femoral. past medical history: morbid obesity tobacco dependence (quit 1 yr ago, now using e-cigarettes) etoh cirrhosis and portal hypertension; s/p liver transplant splenorenal shunt renal insufficiency restrictive pulmonary dysfunction pulmonary hypertension obstructive sleep apnea dm type 2 - resolved, occurred after olt in setting of steroids s/p incisional, ventral hernia repairs c/b infection social history: married but currently separated from his wife for 15 years. he has 2 grown children. per notes, he attended business school and has been involved in a number of businesses including owning a bank. he lives in . tobacco: 1-1.5 ppd since age 20, quit one year ago (45 year history) and currently uses e-cigarettes. etoh: previous heavy etoh use, no current use. family history: positive for cirrhosis, otherwise non-contributory. physical exam: vs: t=95.5 bp=176/86 hr=100 rr=32 o2 sat=100% on 5l nc general: lethargic appearing, awakes to voice, but falls back to sleep within sevearl minutes. oriented to name, hospital setting, and year. heent: ncat. sclera anicteric. pupils constricted but reactive. eomi. neck: right sided hematoma at site of attempted right ij, dressing stained with blood but no evidence of active bleeding, hematoma has not increased in size since markings previously drawn. unable to assess jvd given body habitus. cardiac: rrr, normal s1 s2, ? slight systolic murmur but difficult to assess as heart sounds distant lungs: slightly labored breathing, but no significant accessory muscle use. poor airmovement bilaterally with decreased breath sounds at bases. ?scattered crackles. abdomen: obese. soft, ntnd. abdominal incisional scars. extremities: bilateraly lower ext edema 3+ to level of knees. skin: chronic venous stasis changes with brawny discoloration and verrucous appearing areas, more notable on left. pulses: pt, dp 1+ bilaterally pertinent results: admission labs: 10:54pm lactate-1.1 08:38pm glucose-126* urea n-34* creat-2.0* sodium-141 potassium-4.2 chloride-105 total co2-30 anion gap-10 08:38pm calcium-8.8 phosphate-5.7*# magnesium-2.0 01:00pm pt-15.6* inr(pt)-1.4* 06:17pm abg: po2-73* pco2-70* ph-7.23* total co2-31* base xs-0 : wbc 4.9, hgb 12.3, hct 37.1, plt 91 . pertinent labs: : cyclosporine level 262 : cyclosporine level 70 : cyclosporine level 100 . : ldh 267 : albumin 3.1 : ammonia 63 . : ph 7.30 / pco2 70 / po2 79 / hco3 36 : ph 7.31 / pco2 72 / po2 77 / hco3 38 : ph 7.30 / pco2 68 / po2 57 / hco3 35 : ph 7.31 / pco2 61 / po2 73 / hco3 32 : ph 7.29 / pco2 64 / po2 76 / hco3 32 : ph 7.30 / pco2 63 / po2 66 / hco3 32 : ph 7.23 / pco2 70 / po2 73 / hco3 31 . discharge labs: : wbc 4.0, hgb 11.1, hct 34.6, plt 93 : na 143, k 3.7, cl 99, hco3 38, bun 46, cr 2.8, glu 71 : ca 8.3, mag 2.1, phos 3.5 : pt 16.7, inr 1.5 : alt 19, ast 21, alkphos 79, tbili 1.1 : ck 71 . microbiology: mrsa negative, urine culture negative . reports: tte this study was compared to the prior study of . general comments: suboptimal image quality - poor echo windows. conclusions: the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy. 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%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the right ventricular free wall is hypertrophied. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , there is no definite change. unable to compare pulmonary artery systolic pressure estimates. . cxr: in comparison with the study of , the patient has taken a somewhat better inspiration. there is again enlargement of the cardiac silhouette with worsening pulmonary vascular congestion and bilateral pleural effusions. atelectatic changes are seen at the left base, and the possibility of supervening pneumonia cannot be definitely excluded (especially in the absence of a lateral view). . cxr: 1. new right lower lobe and middle lobe atelectasis. 2. improvement of degree of vascular congestion in both lungs. 3. stable moderate cardiomegaly and right pleural effusion . cxr: moderate cardiomegaly, widened mediastinum, right middle lobe and left lower lobe atelectasis are unchanged. moderate right pleural effusion. . ekg : sinus rhythm and atrial ectopy, atrial bigeminy. the atrial ectopy is new as compared with previous tracing of . the t wave inversion previously recorded in leads i and avl persist and the t waves are now biphasic to inverted in leads v3-v6 and the st segments are downsloping in lead ii with associated t wave inversions. these findings raise question of active anterolateral and apical ischemic process. followup and clinical correlation are suggested. . cardiac catherization procedure: right heart catheterization: was performed by percutaneous entry of the right femoral vein, using a 7 french pulmonary wedge pressure catheter, advanced to the pcw position through an 8 french introducing sheath. cardiac output was measured by the fick method. hemodynamics results body surface area: 2.53 m2 hemoglobin: 12.0 gms % fick **pressures right atrium {a/v/m} 24/22/20 right ventricle {s/ed} 96/24 pulmonary artery {s/d/m} 96/51/72 pulmonary wedge {a/v/m} 42/43/38 **cardiac output heart rate {beats/min} 97 rhythm sinus o2 cons. ind {ml/min/m2} 125 a-v o2 difference {ml/ltr} 32 card. op/ind fick {l/mn/m2} 9.9/3.9 **resistances pulmonary vasc. resistance 275 **% saturation data (nl) svc low 73 pa main 75 ao 95 other hemodynamic data: the oxygen consumption was assumed. technical factors: total time (lidocaine to test complete) = 33 minutes. arterial time = 0 minutes. fluoro time = 3.5 minutes. contrast injected: non-ionic low osmolar (isovue, optiray...), vol 0 ml premedications: fentanyl 25 mcg iv anesthesia: 1% lidocaine subq. anticoagulation: other medication: furosemide 40 mg iv tng 20 mcg/min iv gtt cardiac cath supplies used: - allegiance, custom sterile pack - merit, right heart kit 7.5fr , swan-ganz vip comments: 1. resting hemodynamics revealed elevated right and left heart filling pressures with rvedp 24 mmhg and pcwp 38 mmhg. there was severe pulmonary arterial hypertension with pasp 96 mmhg. the cardiac index was preserved at 3.9 l/min/m2. the pulmonary vascular resistance was elevated at 275 dyn-sec/cm5. final diagnosis: 1. severely elevated biventricular filling pressures. 2. severe pulmonary arterial hypertension with only moderate elevation of pulmonary vascular resistance. 3. no evidence for intracardiac shunt. brief hospital course: 67yo male with h/o liver transplant , severe osa, and pulmonary htn, admitted after elective right cardiac cath revealed severely elevated biventricular filling pressures as well as severe pulmonary artery htn, and who was transferred to ccu in setting of acute on chronic respiratory acidosis. . # acute on chronic respiratory acidosis - after cardiac cath, patient noted to be lethargic, and abg revealed ph 7.23, pco2 70. this acid-base disturbance was thought to be an acute on chronic respiratory acidosis, most likely due to increased sedation in setting of cardiac cath with underlying obesity hypoventilation syndrome and pulmonary htn. copd seemed less likely given recent outpatient pulmonary work-up, which was more consistent with restrictive physiology, however the patient does have a significant smoking history. respiratory therapy was consulted, and the patient was placed on bipap overnight. repeat abgs showed a persistent acidosis, with mild improvement in hypercapnia following bipap. the patient was prescribed nebulizers with some symptomatic improvement, and these were no longer needed prior to discharge. he was continued on bipap at night when tolerated, but generally he complied with cpap. he became more drowsy and disoriented at times, and this was thought to be due to his respiratory status - his ammonia was only mildly elevated at 63 and there were no indicators of infection. repeat abgs revealed a similar respiratory acidosis profile despite therapy, but he improved clinically. he was noted at times to be hypoxic on o2 sats and was given supplemental oxygen. prior to discharge, he was able to ambulate without oxygen (did not meet criteria for long-term o2 therapy on abg) and his respiratory status had improved following diuresis. #) pulmonary htn - patient noted to have severe pulmonary htn during cardiac cath, which was likely contributing to his dyspnea. the differential diganosis for the cause of his pulmonary htn is broad, and includes left heart diastolic failure, severe osa, obesity hypoventilation syndrome, autoimmune causes, neuromuscular disease, and liver disease. outpatient pulmonary work-up revealed severe restrictive pulmonary dysfunction with reduced lung volumes, but normal dlco when calculated for lung volumes, suggesting pulmonary htn not related to a primarily pulmonary vascular etiology. per liver team, his graft function has been normal, and hepatopulmonary syndrome not playing a role in his pulmonary htn. a tte was performed on , but given suboptimal image quality, was unable to better characterize pulmonary artery systolic pressures. a pulmonary consult was called, and the team felt the patient would not be an ideal candidate for a vasodilator challenge at this time, but that the issue could be re-addressed once the patient had undergone diuresis for his diastolic heart failure exacerbation. the patient was treated for his dchf with aggressive diuresis (including furosemide drip), and bipap/cpap for his osa at night. ultimately, the patient would benefit most from lifestyle changes including weight loss, smoking cessation, and increased physical activity, and he is aware of these recommendations. could consider autoimmune work-up and evaluation for neuromuscular disease (note normal ck 71), however dchf and osa are most likely etiologies of his pulmonary htn. he will follow-up with dr. for further outpatient pulmonary care. . # diastolic heart failure - biventricular elevated filling pressures demonstrated on cardiac cath c/w diastolic heart failure. these elevated pressures are significantly elevated from previous cardiac cath in which showed mildly elevated right sided filling pressures and mild/moderately elevated left-sided filling pressures. echo obtained demonstrated normal ventricular systolic function with lvef>55%, and moderate pulmonary htn. repeat echo this admission again revealed lvef >55%, rv free wall hypertrophy, and increased lv filling pressures, but could not compare pulmonary artery systolic pressures to previous studies given suboptimal image quality of echo. patient was aggressively diuresed following his cath. his fluid balance was difficult to monitor, as the patient refused a foley catheter and was frequently incontinent. daily weights were monitored, and repeat cxr showed improvement in pulmonary vascular congestion. he was also started on a beta blocker, to allow for increased filling time. his respiratory status had improved prior to discharge, and his weight was down 4.8kg since admission (discharge weight 130kg). he was discharged on a regimen that includes metoprolol succinate 150mg po daily and torsemide 80mg po daily. he was not started on an ace inhibitor in the setting of his liver transplant and impaired renal function. he will follow-up with dr. as an outpatient. . #) renal insufficiency - cr 2.0 on presentation, and had been 1.8-2.0 over past several months prior to admisison. cr trended up as patient as aggressively diuresed, and reached level of 3.0 on . urine electrolytes obtained, and were consistent with a pre-renal etiology. liver team did not feel cyclosporine toxicity was responsible for the acute rise in cr, however his cyclosporine dose was decreased and his levels were monitored. his cr and electrolytes were closely monitored, and electrolytes were repleted as necessary. his cr on discharge was 2.8 and decreasing, and will be further monitored in the outpatient setting. the patient was noted to have taken nsaids prior to admission, which may also have contributed to acute kidney injury. the patient was encouraged to not take nsaids following discharge. . #) hypertension - patient hypertensive with sbp in 200s in cath lab, was started on nitro gtt, and had sbp in 170s on arrival to ccu. he was started on metoprolol and aggressively diuresed, with resultant improvement in his bp. he was able to be weaned off the nitroglycerin drip within the first day of admission. per the liver team, he should not be started on an ace inhibitor in the community, but he might benefit from the addition of amlodipine if he becomes increasingly hypertensive on his current regimen. his discharge medications include metoprolol succinate 150mg po daily and torsemide 80mg po daily. . # s/p liver transplant: he was continued on cyclosporine, although the dose was decreased from twice daily dosing to once daily dosing after cyclosporine level noted to be elevated. he was continued on his home dose of mycophenalate mofetil, as well as prophylactic bactrim. both the transplant team and liver team were aware of the admission. the liver team recommended checking daily lfts and inr to monitor his graft function. in general lfts were normal and stable throughout admission (ldh and t bili somewhat elevated). . # chronic venous stasis changes - patient seen by wound care nurse, who recommended aloe vesta be applied to bilateral lower extremity venous stasis lesions twice daily. he may also benefit from a dermatology consult in the outpatient setting. medications on admission: cyclosporine modified - (dose adjustment - no new rx) - 100 mg capsule - 1 capsule(s) by mouth twice a day no substitutions diphenhydramine hcl - (prescribed by other provider) - 25 mg capsule - 1 capsule(s) by mouth as needed furosemide - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth once a day mycophenolate mofetil - (prescribed by other provider: . states he takes this once daily) - 250 mg capsule - 1 capsule(s) by mouth twice a day sulfamethoxazole-trimethoprim - 400 mg-80 mg tablet - 1 tablet(s) by mouth daily (daily) calcium carbonate-vitamin d3 - (prescribed by other provider: ) - 500 mg (1,250 mg)-400 unit tablet - 1 tablet(s) by mouth twice a day multivitamin - (otc) - capsule - 1 capsule(s) by mouth qam naproxen sodium - (prescribed by other provider) - 220 mg tablet - 1 tablet(s) by mouth as needed discharge medications: 1. mycophenolate mofetil 250 mg capsule sig: one (1) capsule po bid (2 times a day). 2. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 3. multivitamin tablet sig: one (1) tablet po daily (daily). 4. cyclosporine modified 100 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 5. metoprolol succinate 100 mg tablet sustained release 24 hr sig: 1.5 tablet sustained release 24 hrs po daily (daily). disp:*45 tablet sustained release 24 hr(s)* refills:*2* 6. torsemide 20 mg tablet sig: four (4) tablet po daily (daily). disp:*120 tablet(s)* refills:*2* 7. calcium carbonate-vitamin d3 500 mg(1,250mg) -400 unit tablet sig: one (1) tablet po twice a day. 8. outpatient lab work blood test (to be drawn ): na, k, cl, hco3, bun, cr, glu, ca, mag, phos please fax results to , md fax: 9. outpatient physical therapy patient can walk with a walker or other assistance. 10. outpatient occupational therapy please assist patient with developing strategies to complete activities of daily living. discharge disposition: home with service facility: vna discharge diagnosis: primary: pulmonary hypertension diastolic heart failure acute on chronic renal failure secondary: hypertension obstructive sleep apnea s/p liver transplant on longterm immunosuppression discharge condition: mental status: clear and coherent. level of consciousness: alert but sometimes drowsy activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure looking after you during your stay at the . you presented on for an elective right heart catheterization following workup by your pulmonologist, who had found abnormalities on your pulmonary function tests. the concern was that a degree of heart failure was contributing to your underlying chronic lung problems, most likely due to smoking and being overweight, which can make breathing more difficult. prior to admission you had noticed worsening shortness of breath especially in the past 2 weeks, and this was severely limiting you even with eating. the catheterization revealed high pressures in both sides of the heart and severe pulmonary hypertension (see explanation below). pulmonary hypertension is the progressive constriction of blood vessels supplying the lungs, which leads to progressive stiffening of these blood vessels. as a result, the heart must work harder to pump blood through the lungs, and the right side of the heart becomes strained. the fact that less blood is able to be pumped through the lungs means that less blood can reach the left side of the heart (which pumps the oxygenated blood through the body). therefore less oxygen is available to the body, especially during exercise, which leads to shortness of breath. following your catheterization you were admitted to the ccu as you were having difficulty breathing, and you were put on the bipap machine to help your breathing. it was felt that the problem leading to your shortness of breath was heart failure causing fluid build-up in the lungs. we therefore started you on medications to help remove some of the water, called diuretics, and your breathing improved as a result. your kidney function has been previously impaired, and it worsened somewhat during this admission. this can be an effect of diuretics with you becoming dryer and therefore slightly dehydrating the kidneys. we carefully monitored your kidney function with regular blood tests, and it was improving at the time you were discharged. you were also drowsy and at times disoriented, and we felt that this was because your oxygen levels were low and your carbon dioxide levels were high. the reason for this is likely a combination of your obstructive sleep apnea, heart failure and pulmonary hypertension. we regularly tested your oxygen and co2 levels by taking blood from the artery at the wrist. you used the cpap machine and at times the bipap machine in order to help your breathing. the pulmonology and liver transplant teams saw you during this admission, and based on their advice we changed the dose of your cyclosporine. on you had an episode of worsening shortness of breath, but your chest x-ray showed improvement and there were no abnormalities on the heart tracing (ecg). we started you on a beta-blocker called metoprolol which takes some of the strain off the heart by slowing the heart beat and we changed you from intravenous to an oral diuretic called torsemide. your shortness of breath improved as did your disorientation. you were seen by physical therapy and able to walk holding onto a wheelchair, without requiring additional oxygen therapy. you were stable for discharge and you were discharged home on with outpatient physical therapy, occupational therapy, and a nurse to see you in your house. changes to medications: 1) your cyclosporine dose was reduced to 100mg once daily 2) we stopped your diphenhydramine 3) we started metoprolol succinate 150mg once daily 4) we started torsemide 80mg once daily discharge instructions: 1) you will be seen by dr as an outpatient in addition to pulmonology follow-up with dr ***it is very important that you keep all of your doctor's apointments.*** 2) weigh yourself every morning, md if weight goes up more than 3 lbs. your weight on day of discharge was 130kg (286 lbs). 3) you should try and keep to a low salt diet (2g sodium) and a restricted fluid intake of 1.5 liters per day to stop further fluid overload 4) continue using your cpap machine 5) you will have physical therapy see you as an outpatient in addition to occupational therapy who will assess you and your home to see if there are any adjustments necessary to make your life easier followup instructions: provider: . date: tuesday at 1pm location: building phone number: pulmonology: provider: , m.d. date: , at 12:00 location: e/ksb-23 division: pulmonary and critical care phone: pulmonary function: provider: function lab date/time: , at 11:40 location: - -7 phone: cardiology: provider: . date: please call to make appointment location: building telephone number: procedure: non-invasive mechanical ventilation right heart cardiac catheterization diagnoses: acidosis thrombocytopenia, unspecified obstructive sleep apnea (adult)(pediatric) tobacco use disorder congestive heart failure, unspecified acute kidney failure, unspecified chronic kidney disease, unspecified primary pulmonary hypertension morbid obesity acute diastolic heart failure liver replaced by transplant venous (peripheral) insufficiency, unspecified 

Answer: The patient is high likely exposed to