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: no known allergies / adverse drug reactions attending: chief complaint: hypotension major surgical or invasive procedure: right heart cath with cardiac biopsy on history of present illness: mr is a 77yo male with history of idiopathic cardiomyopathy (ef 25-30% ), atrial fibrillation (on coumadin), pulmonary hypertension, chronic renal insufficiency initially admitted to the due to concern for hypotension transferred to the ccu for management of chf. . per report patient was sent in from the nursing home due to "abnormal labs" though had no focal complaints. he had been recently discharged from on with the diagnosis of dvt/pe, lle cellulitis and pna. he was continued on warfarin (once inr was not supratherapitic) and treated with doxycycline and levofloxacin with planned 10 day course to be completed on for the lle cellulitis and pna respectivly. patient was sent from the nursing home because of "abnormal labs." no further history able to be obtained. patient believes he is here because of pain in the leg. overall says he feels ok, with main concern being leg pain in the left lower extremity. says breathing is "good." denies dyspnea, cough, productive cough, wheezing, pleuritic chest pain, fevers/chills, abdominal pain, dysuria. . in the ed, initial vs were: 97.4 107 91/65 20 98%. labs were notable for wbc 22.3, creatinine of 5.0 up from baseline 2.5-3.1; glucose of 42 (received 2 amp of dextrose), inr of 4.1, despite not having taken coumadin in a week per report. patient was started on vanc/cefepime due to concern for evolving sepsis vs pulmonary embolus given recent peroneal vein dvt/presumed pe. (though baseline sbp in 80-90's) cta was held because of impaired renal function. a right ij central line was obtained along with two peripherals. prior to transfer blood pressures remained in 80s-90s and norepinephrine was started for pressure support. . in the there was concern for septic shock and he was started on levophed, gental hydration, and placed on vanco/cefepime. his wbc remained constant in low 20's. he was changed to vanco/zosyn and his wbc trended down. his initial central venous sat was 70 increasing concern for sepsis. he was evaluated for infection source and his abd u/s and oral con ct were non-diagnostic. his cxr was concerning for a pna, worsening over previous studies. over his 3 day stay in the his co/ci worsened and his central venous sat decreaased to the 40's increasing concern for cardiogenic shock. his maps were low and his pressor was transitioned from levophed to doputamine without improvement. at this point he was transfered to the ccu for further evaulation and treatment. past medical history: - idiopathic cardiomyopathy - systolic and diastolic congestive heart failure ef 20% - hyperlipidemia - diabetes mellitus type 2 - a-fib on coumadin - hypertension (now with baseline sbps of mid 80s-100s) - pulmonary hypertension - left ventricular hypertrophy - chronic renal insufficiency, cr baseline 2.5-3.1 in - history of shingles social history: patient lives at home with his wife. ambulate with a cane usually. no history of tobacco use. no alcohol, no drugs. family history: his parents may have had history of heart disease physical exam: admission physical: t 98.2 hr 88 bp 110/80 16 100% 4lnc cvp 10 general: alert, oriented to person, place, time, no acute distress heent: sclera anicteric, mucous membrane dry, oropharynx clear, eomi, perrl neck: supple, jvp not elevated at ~7cm, no lad cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops lungs: bibasilar crackles, otherwise cta without wheezes, rales, ronchi abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: foley ext: 2+ peripheral edema left worse than right, left lower extremity with superficial ulceration without drainage on posterior aspect of calf neuro: cnii-xii grossly intact, strength upper/lower extremities grossly intact, grossly normal sensation, gait deferred. . ccu physical exam: general: alert, oriented to person, place, time, no acute distress heent: sclera anicteric, mucous membrane dry, oropharynx clear, eomi, perrl neck: supple, jvp not elevated at ~7cm, no lad cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops lungs: bibasilar crackles, otherwise cta without wheezes, rales, ronchi abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: foley ext: 2+ peripheral edema left worse than right, left lower extremity with superficial ulceration without drainage on posterior aspect of calf neuro: cnii-xii grossly intact, strength upper/lower extremities grossly intact, grossly normal sensation, gait deferred. pertinent results: admission/relevant labs: 01:20pm blood wbc-22.3* rbc-3.43* hgb-11.2* hct-33.6* mcv-98 mch-32.6* mchc-33.2 rdw-17.4* plt ct-142* 01:20pm blood neuts-91.3* lymphs-4.5* monos-3.5 eos-0.6 baso-0.1 04:29pm blood pt-41.3* ptt-46.1* inr(pt)-4.1* 10:21am blood fibrino-597* 08:44pm blood glucose-110* urean-144* creat-4.5* na-126* k-4.0 cl-92* hco3-20* angap-18 01:20pm blood alt-24 ast-64* ck(cpk)-587* alkphos-170* totbili-2.1* 01:20pm blood ck-mb-7 ctropnt-0.41* 06:46am blood probnp-* 08:44pm blood calcium-8.8 phos-4.6* mg-2.1 10:21am blood d-dimer-577* 04:30am blood tsh-2.1 04:30am blood cortsol-28.8* 08:44pm blood hbsag-negative hbsab-negative hbcab-negative 04:30am blood hbsag-negative hbsab-negative hbcab-negative 05:25pm blood hiv ab-negative 04:30am blood hcv ab-negative 01:19pm blood lactate-1.7 12:24am blood o2 sat-71 04:30am blood free kappa and lambda, with k/l ratio-test 02:35pm blood free kappa and lambda, with k/l ratio-test . discharged labs: . micro: blood cultures, urine culture: no growth c-diffx2 negative . abx xr : single frontal image of the abdomen shows nonspecific bowel gas pattern with no evidence of obstruction. there is no pneumatosis or free gas. there are numerous seeds in the prostate unchanged since the most recent. ct of the abdomen and pelvis. there are degenerative changes of the lumbar spine. impression: nonspecific bowel gas pattern with no evidence of bowel obstruction. . abd u/s : 1. cholelithiasis and sludge without son evidence of acute cholecystitis. 2. pulsatile portal vein and distended hepatic veins most likely related to right heart failure. . cxr : considerable consolidation has developed at both lung bases in the absence of edema or even much vascular engorgement in the upper lungs, and therefore could be considered pneumonia rather than asymmetric edema. severe cardiomegaly is chronic. right internal jugular line ends centrally. . hida : abnormal hepatobiliary study. delayed uptake compatible with hepatic dysfunction. there is initial gallbladder visualization indicating no acute cholecystitis. the gallbladder does not respond to a cck analog (sincalide) indicating gallbladder dysfunction. . cxr : findings: in comparison with study of , there is continued globular enlargement of the cardiac silhouette with essentially normal pulmonary vasculature, consistent with the clinical diagnosis of cardiomyopathy. the basilar regions are substantially clear than on the previous study with only minimal residual atelectatic change. . lenis of lle : impression: no deep vein thrombosis in the left lower extremity. . lenis: : no evidence of deep vein thrombosis in either leg. note is made that the calf veins of the left leg could not be visualized due to open skin lesions. . right heart cath with biopsy : site sys end mean a wave v wave hr pa 64 22 32 79 rv 64 9 24 60 ra 18 21 21 94 . tte: overall left ventricular systolic function is severely depressed (lvef= 20-30%). the right ventricular cavity is markedly dilated with severe global free wall hypokinesis. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , the present study was done to localize right heart biopsy. post biopsy, no evidence of pericardial effusion or vsd seen brief hospital course: 77 yo m with chf with idiopathic cardiomyopathy (ef 25-30% echo), pulmonary hypertension, t2dm, afib (on coumadin), chronic renal insufficiency cr baseline 2-2.5, recently discharged on after several day admission for dvt and presumed pe, lle cellulitis and pna, initially re-presented () to with hypoglycemia, , leukocytosis, as well as hypotension. transferred from to ccu for presumed chf and ?cardiogenic shock. . # hypotension: patient presented to the with hypotension in 70s-80s initially which in the setting of leukocytosis, low cvp and high central venous o2 gave concern for distributive/septic shock picture, despite lack of a clear source. however during his recent hospitalization one week prior to this admission, he was being treated for pneumonia and cellulitis which was most likely the source for his septic shock. in addition, patient had with elevated creatinine, dry appearance on exam suggestive of hypovolemic component. he was started on vanc and zosyn for broad coverage for septic shock and was given fluid cautiously given his known cardiomyopathy. an arterial line was started for invasive monitoring of blood pressure given variable cuff readings. in the levophed, which was started in the ed, was continued for pressure support. however patient remained hypotensive, and in context of known cardiomyopathy, dobutamine was started for inotropy. he was transfered to ccu for question of cardiogenic shock compoenent to his hypotension. on echo patient was found to have pattern of restriction physiology with question of amyloid; spep/upep were negative. he was considered to be preload dependend because of this restrictive physiology therefore he continued to receive small fluid boluses. dopamine and levophed were weaned off on arrival to ccu. patient's bp cotninued to remain in the 80s which was considered his baseline. he continued to have good mentation with his low bps. he had a right heart cath with biopsy to get definiteve answer regaring his restrictive pattern. cardiac biopsy showed amyloidosis. repeat echo after biopsy showed worsening cardiomyoptahy. he did not have any significant improvement for functional standpoint. therefore palliative care was consulted and family meeting held during which patient's poor prognosis was dicusses. patient and family agreed to dnr/dni status with discharge to and transition to hospice care. . # pneumonia: patient was to complete course of levofloxacin 750 mg iv q48h for pneumonia from prior hospitalization. cxr appeared benign but given presentation concerning for septic shock and leukocytosis, he was covered for hcap with vanc/zosyn. . # atrial fibrillation/flutter: in the initial course of this hospitlization he continued to have frequent episodes of afib/flutter with rvr in the setting of holding metoprolol for his hypertension. however after controlling patient's pain (from lle cellulitis and ulcer-->see below), his rate was brought under better control. he initially presented with supertherpuetic inr and his coumadin was held (--> see below). once his inr became sub-therapuetic he was switched to hepain gtt. on discharge, unable to obtain labs as pt is a difficult stick and declined further attempts.he was discharge on 3mg of coumadin. he will have his next inr drawn at 8/19 at . . # lle cellulitis/overlying ulcer: patient was to complete doxycycline hyclate 100 mg po q12h for lle cellulitis from his previous hospitalization. however he was covered with vancomycin and zosyn during this hospital stay given leukocytosis and spetic shock. his pain was controlled wtih tramadol, acetominophen and oxycodone. he was seen by wound care for management of his ulcers overlying the cellulitis. his ulcers were thought to be from poor perfusion to his lower extremity given severe history of cad and pvd. he was also seen by vascular surgery who recommended adaptic to open air, compression wrap with coban and follow up in six weeks after discharge. repeat lenis did not show any dvts in the lower extremity. # sacral pressure ulcer: wound care was consulted who continued to monitor his sacral ulcer and changed his dressing on daily basis. . # coagulopathy: on admission he had an inr 4.1 despite reportedly not taking coumadin for two weeks. he did not have any active bleed. his elevated inr was thought to be from vitamin k defiency in the setting of poor po intake and continued antibiotcs use. he was given 1mg of vitamin k with decrease in inr to 1.8. he was started back on heparin gtt and restarted on coumadin. . # acute on chronic renal failure: his baseline cr if 2-2.5 howver on admissin he presented with cr of 5. his elevated cr was thought to be prerenal in etiolgy given poor po intake and poor perfusion to the kidneys from his low bps. hi cr responded well to fluids and returned back to baseline level. per prior omr outpatient renal notes he is not hd candidate per out-pt renal note. . # throat pain: patient developed throat pain on hospital day 1. physical exam likely thrush, 1+ budding yeast on throat swab. hiv, hbv, hcv negative. started nystatin swish and swallows. . # hypoglycemia: patient hypoglycemic requiring d10 drip initially. thought to be secondary to renal failure and difficulty clearing home glipizide dosing. improved after holding glipizide, and d10 was discontinued. pt has been switched to glargine at night and oral diabetic meds discontinued. . # abdominal pain/mild transaminitis: given leukocytosis and abdominal pain, cdiff was sent, which was negative. kub was performed which was reassuring, and ruq u/s was consistent with congestion, likely chf. hida scan also performed which was normal. . transitions of care: - next inr to be drawn on -pt is dnr/dni -pt will follow up as an outpt with cardiology medications on admission: 1. simvastatin 20 mg po daily 2. furosemide 20 mg iv daily:prn sob from pulmonary edema 3. metoprolol succinate xl 25 mg po daily 4. torsemide 60 mg po bid 5. triamcinolone acetonide 0.1% cream 1 appl tp :prn pruritis 6. glipizide 5 mg po daily 7. ammonium,pot.& sodium lactates *nf* grams topical to legs 8. ammonium lactate *nf* 12 % topical daily 9. allopurinol 300 mg po daily 10. doxycycline hyclate 100 mg po q12h for lle cellulitis - last day is 11. valsartan 40 mg po daily 12. levofloxacin 750 mg iv q48h for pneumonia last day is discharge medications: 1. allopurinol 300 mg po daily 2. oxycodone (immediate release) 5 mg po q6h:prn breakthrough pain 3. tramadol (ultram) 50 mg po bid 4. metoprolol succinate xl 25 mg po daily 5. torsemide 60 mg po daily 6. warfarin 3 mg po daily16 7. acetaminophen 1000 mg po q 8h 8. glargine 6 units breakfast discharge disposition: extended care facility: - discharge diagnosis: primary: - septic shock - dilated cardiomyopathy with restrictive physiology secondary to amliod deposition disease. secondary: - acute on chronic renal failrue - atrial fibrillation/flutter with rapid ventricular reposnse discharge condition: mental status: clear and coherent. sometimes disoriented activity status: out of bed with assistance to chair or wheelchair. level of consciousness: lethargic but arousable. discharge instructions: dear mr. , it was a pleasure taking care of your during this hospitalization. you were admitted because of low blood pressure which was thought to from combination of infection and your cardiomyopathy (worsening pump function of your heart). you were treated with antibiotics for your infection. you also had cardiac cathethrization (heart studies) which showed worsening of your heart function and a biopsy of the heart muscle was done and the results are pending. after a family meeting, you decided to change your code status to dnr/dni with focus on aggressive symptom management. during this hospitalization you also had ulcers in your sacrum and in your leg which were cared for by wound care with regular dressing changes. followup instructions: department: cardiac services when: monday at 10:30 am with: dr. building: sc clinical ctr campus: east best parking: garage procedure: arterial catheterization right heart cardiac catheterization diagnoses: pneumonia, organism unspecified other primary cardiomyopathies congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified septicemia hyposmolality and/or hyponatremia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation other chronic pulmonary heart diseases candidiasis of mouth chronic kidney disease, unspecified other and unspecified hyperlipidemia cellulitis and abscess of leg, except foot septic shock long-term (current) use of anticoagulants pressure ulcer, lower back personal history of venous thrombosis and embolism encounter for palliative care venous (peripheral) insufficiency, unspecified pressure ulcer, unspecified stage ulcer of lower limb, unspecified personal history of pulmonary embolism other amyloidosis nutritional and metabolic cardiomyopathy chronic combined systolic and diastolic heart failure personal history of pneumonia (recurrent) 

Answer: The patient is high likely exposed to