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: vioxx / lipitor / colchicine attending: chief complaint: decompensated heart failure with failure of outpatient management major surgical or invasive procedure: medical icu admission arthrocentesis left knee (, ) history of present illness: 79m with history of severe systolic chf, atrial fibrillation, cad, dm; presents from rehab with dyspnea and edema concerning for chf exacerbation. patient was recently admitted from on cardiology service for similar problems of acute on chronic systolic chf. diuresed with lasix gtt up to 20 mg/hr with 500 mg diuril. improved symptoms and transitioned to torsemide 20 mg twice daily. creatinine 1.4 at discharge (range 1.4-1.7 during hospital course). . since recent discharge to rehab, pt has had some dizziness, fatigue and occasionally hypotensive with sob. on his torsemide was incrased to 25mg . on he had an acute episode of sob and was dizzy/fatigued., he was given zaroxylyn 2.5mg po and 40mg iv lasix w/relief. he was evaluated by neurology at the rehab who felt his symptoms were most likey chf. today, the torsemide was increased to 30mg and was subsequently transferred for ongoing hypotension and sob. . currently patient reporting shortness of breath. denies cp, palpitiations. + pnd. denies lh, dizziness. past medical history: past medical history: 1. cardiac risk factors: +diabetes, -dyslipidemia, +hypertension 2. cardiac history: -cabg: -percutaneous coronary interventions: -pacing/icd: s/p ddp pacemaker placement, ivcd implantation: concerto biventricular icd 3. other past medical history: -cad, s/p cabg in ( and women??????s) -chf, nyha class iv, ef ~ 15% -htn -s/p ddp pacemaker placement, ivcd implantation: concerto biventricular icd -atrial fibrillation (on coumadin) s/p avj ablation and pacer placement -mitral regurgitation -ventricular tachycardia s/p ablation of vt -iddm (type 2) -chronic renal insufficiency -chronic left knee pain, s/p steroid injections -gout with known colichicine myopathy -pseudogout social history: married. former smoker, quit 20 years ago formally, but still smokes once or twice a year. drinks 1 etoh beverage per day. retired mechanical engineer. was a fighter pilot for and then nato, and survived a crash in . also, was a wrestler with the turkish olympic team in . since retiring, he enjoys photography and volunteers at his local senior center. -tobacco history: quit regularly smoking 20 years ago, still smokes 1-2 times per year. -etoh: 1 drink daily -illicit drugs: denies family history: long history of cardiac disease, osteoarthritis in siblings. no history of gout in family. physical exam: on admission: vs: t 96.3 bp 103/64 hr 83 rr 20 96%4l general: elderly male with inability to talk more than 4 words w/o sob, no use of accessory muscles heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink neck: supple with jvp of 12cm cardiac: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. holosystolic murmur lungs: rales heard 1/2 up bases bilaterally abdomen: soft, ntnd. no hsm or tenderness extremities: 3+ pitting edema to knees . on transfer to micu: vs: general: drowsy, waxing/, oriented place and year, month reported as may, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp elevated to jaw, no lad lungs: bibasilar rales, with decreased bs at bases cv: regular rate and rhythm, normal s1 + s2, hs distant, difficult to assess significant respiratory sounds, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: cool, 1+ pulses, pitting edema to knees b/l . on discharge: vs: 97.7 78 (-86) 80-90/50-60 18 95%ra, i/o -350cc/24h, +200cc/8h gen: nad, sleepy but not as drowsy as heent: perrl, eoemi neck: jvp 6cm lungs: cta b/l no crackles cv: rrr nl s1/s2 ii/vi systolic murmur abd: +bs, soft, obese, nt, nt ext: increased edema left foot/ankle, well perfused, fluid reaccumulation and warmth left knee pertinent results: 07:02pm blood wbc-20.7*# rbc-3.41* hgb-10.0* hct-33.0* mcv-97 mch-29.3 mchc-30.3* rdw-19.1* plt ct-238 06:30am blood neuts-91.4* lymphs-5.8* monos-2.2 eos-0.3 baso-0.3 07:02pm blood pt-35.6* ptt-46.1* inr(pt)-3.7* 07:02pm blood glucose-71 urean-58* creat-1.8* na-137 k-4.0 cl-91* hco3-36* angap-14 07:02pm blood calcium-8.9 phos-3.9 mg-1.9 11:24am blood lactate-1.0 . 06:30am blood ck(cpk)-46 ck-mb-notdone ctropnt-0.11* 03:30pm blood ck(cpk)-57 ck-mb-notdone ctropnt-0.11* 10:00pm blood ck(cpk)-114 ck-mb-6 03:33am blood ck(cpk)-24* ck-mb-notdone ctropnt-0.09* . 07:02pm blood probnp-* . , bcx ngtd . urine cx: no growth . urine legionella ag: negative. . : sputum cx: contaminated sample. . 9:07 pm influenza a/b by dfa source: nasopharyngeal swab. direct influenza a antigen test (final ): positive for influenza a viral antigen. reported by phone to alesandra on at 11:15 cc6d. direct influenza b antigen test (final ): negative for influenza b viral antigen tested negative after treatment . ecg: ventricular paced rhythm. compared to the previous tracing of no change. . cxr: findings suggestive of a developing right lower lung and possibly also left lower lung pneumonia. . cxr: no interval change in bibasilar lung findings. considerations would include ongoing chf, though basilar pneumonia can have a similar appearance. . cxr: in comparison with the study of , there is little overall change. enlargement of the cardiac silhouette persists in the patient with what clinically appears to be pulmonary vascular congestion. however, the possibility of supervening areas of consolidation cannot be excluded. lateral view would be most helpful if the condition of the patient permits. . : the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is severely dilated. there is an apical left ventricular aneurysm. there is severe global left ventricular hypokinesis (lvef = 15-20%). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: severely dilated left ventricle with severe global systolic dysfunction, c/w multivessel cad. moderate mitral and tricuspid regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , mitral regurgitation is more clearly visualized, although its severity may have been similar on the prior study. pulmonary pressures are higher today. the other findings appear similar. . caltibc 215, ferritin 117, trf 165 . digoxin : 0.9 . cxr: impression: heterogeneous opacities in right lung with slight improvement in right lower lobe on lateral view. this may reflect improving pneumonia in response to therapy. clinical correlation suggested . : alt 16, ast 22, alkphos 86, tuberculosis 1.1 . blood ctxs : ngtd . : joint fluid, left knee, wbc, <2.0 hct, 92 polys, mod crystal neg birefri, c/w monosodium urate; ctx negative final : wbc, <2.0 hct, 97 polys, few crystals, same make-up ua : no infxn . 8.2 ca, 2.9 ph, 2.0 mg dig 1.4 . labs at discharge: 19.2>8.9/29.7<345 pt 26.3 ptt 35.8 inr 2.5 137/4.1/91/38/51/1.9<95 brief hospital course: floor course prior to micu: on the floor, patient was treated with 80mg iv lasix on admission for concern of chf exacerbation. iv vancomycin and zosyn were also started for possible hospital-aquired pneumonia. on , team noted pt to be more somnolent with increased confusion, and he was triggered for hypotension 60s/30s while sleeping which resolved w/ arousal to 110/60. an abg was obtained 7.39/63/107 on 4l nc and then repeated when his somnolence persisted 2 hours later returning at 7.36/71/81. he was transferred to the micu for monitoring and possible non-invasive ventilation. . micu course: patient was admitted to the micu from the floor for somnolence in setting of pco2 of 70s. . # respiratory distress, hypercarbic/hypoxic: likely multifactorial from influenza, pna, and chf. clinical exam and data showed a mixed picture w/ bnp , peripheral edema, b/l crackles, elevated wbc without fevers. neg. tte showed stable ef with worsened right heart pressures. he received 1 dose of 80mg iv lasix with good urine output. further diuresis was held as patient had borderline low bps (baseline is systolic in the 90s) and other reasons for hypoxia. his cardiac enzymes remained flat. o2 was weaned down. repeat chest xr after lasix was unchanged with bilateral infilrates. dfa was positive for flu and he was started on oseltamivir () and continued on vanc/zosyn for hap as had been living in rehab. sputum culture was rejected and he was continued on nebs. . # transient hypotension: differential included cardiogenic given cool extremities vs. septic given ? b/l ll pna vs. ai given long-standing steroid use. did improve when iv steroids were initiated and he was continued on stress dose steroids (started ). an echo was performed that showed no change in ef or pericardial effusion. resolved without further intervention. . # acute on chronic systolic heart failure: depressed ef of 15% at baseline. chf exacerbation possibly triggered by decreased diuresis in the setting of a rising cr at the rehab facility. also question of lv pacer wire has also been failing to capture properly although ep team feels its working properly. cardiac enzymes were cycled and remained flat. digoxin, ace, and beta blocker were continued. repeat tte was essentially unchanged as above. he was given one dose of 80mg iv lasix and had good uop. further lasix was held given hypotension and he continued to be net negative without meds. . # gout: continued allopurinol, renally dose. switched outpt methylpred to stress dose. . . floor course after micu: . # drowsiness- on am . pt. was drowsier than usual with bg in 40s, given food and 1amp glucose-> bg 200. pt. was still drowsy though responsive. his vs were within normal, the repeat glucose was in the 100s, and there were no significant morning lab abnormalities. during the course of the morning the patient became more alert and it was determined that that this episode of drowsiness was likely secondary to hypoglycemia and insomnia as well as decreased blood pressures from recent diuresis. - would follow glucose closely and adjust insulin regimen as needed. . #influenza continued oseltamivir (d1=) x 5 days. mantained droplet precautions during that time only. oxygen requirement continued to improve. . #hcap - remained afebrile, wbc# trending down, oxygenation stable. mr was continued on zosyn (d1=) x 7 days. vanco was continued for a 7 day course, dosed by vanco troughs, stopped , given pts severe presentation and lack of positive cult data, and propensity for staph infections with flu. he was continued on ipratropoium and albuterol nebs. blood cultures were negative . #dizziness / vertigo/ diplopia - on presentation had dizziness and diploplia which was positional, after call out pt with continuous diplopia and dizziness (intermittently vertigo like). supratherapeutic inr raised concern for ich. ct head negative for hemmrhogage. neurology was consulted who felt his symptoms were a combination of othrostatic hypotension and orthopnic dyspnea. . #vt s/p biv-icd - multiple runs of 30+ beats on telemetry; icd did not fire as rate was below threshold for capture. icd just interogated without signs of abnormality. after discussion with ep increased carvedilol to 6.25 . #hypotension - resolved though baseline in 90s without symptoms; likely overdiuresis (recent uptitration of torsemide and admit wt below dry wt on last discharge). adrenal insufficiency also possible and mr was continued on a hydrocortisone taper until methylprednisolone 4mg daily. this dose will be continued at least until rheumatology follow-up for gout. -if patient sbps <80, place in bed and elevate legs before any ivf to see if it resolves as this has worked in the past and any ivf may cause pulmonary edema given heart failure severity. . #chronic systolic heart failure - stable oxygenation, wt consistent with dry wt on last discharge. therefore sob thought to be mostly infectious etiology. he was continued on torsemide 20mg with a goal volume status even to -500 x 24 hrs. he was continued on bb, acei, digoxin, spironolactone. palliative care consult was obtained as mr has end stage chf and family desires to take pt home. pt. was eventually places on toresemide 40mg , and after switched to a lasix gtt 5-10cc/hr for approximately 3 days with good urine output and decreased peripheral edema. on because of some proclaimed difficulty with ambulation with pt, and bps to the 80s, lasix was stopped and torsemide was resumed. pt.'s weight on day of discharge was: 81.8kg with low of 79.9kg two days prior. . #cad s/p cabg - stable, contined asa, bb, acei (allergy to statin) . #afib - pacer functioning appropriately per ep. continued on coumadin, dig, and bb. . #ckd - cr stable, una <10 reflects intravascular volume depletion and poor forward flow (as well salt retention corticosteroids). creatinine decreased with increased diuresis on lasix to 1.9. . #macrocytic anemia - stable @ b/l; folate, b12 wnl in . #dm - continued basal, sliding scale insulin. pt. had multiple episodes of asymptomatic early morning hypoglycemia with bg 30s-40s, resulting in decreasing long term and evening and dinner short acting insulin s/s. . #gout: continued steroid taper, as above. continued allopurinol. on pt. c/o left knee pain and on hematology was consulted due to fluid accumulation. the knee was tapped on , and again on . though the knee was painful to passive extension/flexion, it was not believed to be a septic joint. the ctx from was negative (final read) and the wbc in the first aspiration was 165,000 while the second was 85,000, both with needle shaped, monosodium urate crystals c/w gout. vancomycin was started again on because of concern of infection with a high peripheral blood wbc count and the knee fluid accumulation, however was stopped on because of continued wbc count, no fever, and belief that the wbc count was from gout flare due to increased steroid taper and increased diuresis. the pt. will be followed by rheum as an outpatient with possible steroid injection and plan for long term antibiotics and washout if knee declares itself as septic over the next several days. . #fen -hh/dm diet -1500 cc fluid restriction . #prophylaxis: -systemic ac -ppi while on steroids -bowel regimen . #code: full (confirmed with patient & wife ) . #communication: patient; , wife, . #disposition: patient & wife prefer to return home with many services after short term rehabilitation stay. . medications on admission: combivent 2 puffs qid flovent mdi 1 puff spironolactone 25 mg tablet sig: one (1) tablet po daily carvedilol 3.125 mg captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day). digoxin 125 mcg tablet sig: one (1) tablet po every other day aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). pantoprazole 40 mg tablet, delayed release (e.c.) sig: one 1)tablet, delayed release (e.c.) po q24h (every 24 hours). allopurinol 100 mg tablet sig: four (4) tablet po daily (daily). methylprednisolone 2mg qod until trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. docusate sodium 100 mg capsule sig: one (1) capsule po bid senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. warfarin 3mg daily torsemide 30mg bisacodyl 10 mg tablet, delayed release (e.c.) sig: tablet, delayed release (e.c.)s po daily (daily) as needed for constipation. acetaminophen 500 mg tablet sig: one (1) tablet po every six 6) hours as needed for pain. lantus twenty eight (28) units subcutaneous once a day. humalog sliding scale os cal d 500mg mvi discharge medications: 1. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. allopurinol 100 mg tablet sig: four (4) tablet po daily (daily). 8. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 10. combivent 18-103 mcg/actuation aerosol sig: two (2) puffs inhalation four times a day. 11. carvedilol 6.25 mg tablet sig: one (1) tablet po bid (2 times a day). 12. torsemide 20 mg tablet sig: two (2) tablet po bid (2 times a day). 13. warfarin 2.5 mg tablet sig: one (1) tablet po daily (daily). 14. methylprednisolone 2 mg tablet sig: two (2) tablet po daily (daily). 15. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 16. trazodone 50 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 17. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation. 18. os-cal 500 + d 500 mg(1,250mg) -200 unit tablet sig: one (1) tablet po twice a day. 19. multivitamin tablet sig: one (1) tablet po once a day. 20. lantus 100 unit/ml cartridge sig: twenty (20) units subcutaneous at bedtime. 21. humalog 100 unit/ml cartridge sig: one (1) units subcutaneous four times a day: see insulin sliding scale sheet attached. 22. venlafaxine 37.5 mg tablet sig: one (1) tablet po bid (2 times a day). 23. outpatient lab work check inr daily with goal of 2.0-3.0 and increase or decrease coumadin as necessary, continue to check electrolytes 24. outpatient physical therapy 25. pm snack be sure to give evening snack since glucose has a tendency to drop in the early morning. 26. lisinopril 5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 27. glucose fingersticks check glucose on fingersticks with meals and at night 28. hypotension control patient can have asymptomatic systolic blood pressures from 80s-90s. if this happens, place patient in bed with legs raised and then recheck as this usually resolves and the patient does not tolerative iv fluids because of his chf. discharge disposition: extended care facility: - discharge diagnosis: influenza a hospital acquired pneumonia class iv heart failure diabetes hypertension cad atrial fibrillation s/p pacer cri gout pseudogout discharge condition: stable, breathing improved discharge instructions: you were transfered to for evaluation of low blood pressure and shortness of breath. you were found to have influenza and a pneumonia. you were treated with antiviral and antibacterial medications. your heart failure was not felt to be a significant contributor to your shortness of breath. your dizziness was evaluated by neurology who felt that it was because of low blood pressure from taking too much fluid off of your body too quickly. you lost a lot of weight in fluid which helped your lungs and your swelling. you had a flare of gout in your left knee. . the following changes were made to your medication regimen: coreg was increased to 6.25mg twice a day torsemide was increased to 40mg twice a day venlafaxine 37.5 mg twice a day was added for depression lisinopril 5mg once a day was added for blood pressure methylprednisolone was increased to 4mg daily since you are being slowly tapered off of steroids . please follow up with your doctors as detailed below. . if you develop fevers, chills, chest pain, worsening shortness of breath, vomiting, abdominal pain, or any other worrisome symptom please call your doctor or go to the emergency room. . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet and <1000 fluid restriction. followup instructions: rheumatology for left knee gout follow-up: provider: , md phone: date/time: 10:00 . cardiology (you should also have your pacmaker interrogated at this appointment): provider: , m.d. phone: date/time: 3:20 . provider: / phone: date/time: 10:00 md, procedure: arthrocentesis arthrocentesis diagnoses: mitral valve disorders congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status personal history of tobacco use chronic kidney disease, unspecified acute respiratory failure long-term (current) use of insulin chronic systolic heart failure cardiac pacemaker in situ toxic myopathy unspecified hereditary and idiopathic peripheral neuropathy unspecified deficiency anemia influenza with pneumonia uric acid metabolism drugs causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to