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: protamine attending: chief complaint: gi bleed major surgical or invasive procedure: upper endoscopy colonoscopy angiography- ir guided picc line placement and hd line change history of present illness: in brief, ms. is an 83-year-old female with multiple medical problems including esrd on hd (mwf), dm2, pvd, afib, severe as s/p mavr (st. 's valve), recurrent gib diverticulosis s/p colectomy and procedure in with continued gibs, recently d/c'd from after bleeding from ostomy, now transfered from hospital after presenting from rehab with approx ~1l of frank blood from ileostomy. pt noticed blood in ileostomy bag morning of presentation and dropped sbps into 80s (baseline 110-130s). pt denies ever having any abdominal pain, no pain around ileostomy site. denies any increased ileostomy output. denies lightheadedness, weakness, abd pain, cp, nausea, vomiting, fevers or chills. . of note, most recent prior admission, pt was bleeding from ostomy and found to have supratherapeutic inr of 6.6. after this admission, inr goal changed to 2.5-3.0. . in the ed, initial vs were 98.1 84 102/52 16 100%ra. received 3.5l ns and started receiving 1st unit prbc. in the ed, sbps responded to fluids. labs: inr 4.1, hematocrit 26.8 (similar to baseline), plt 159. cr 5.3 (esrd on hd mwf, was 5.6 on ). gi and colorectal surgery were consulted in the ed. vs on transfer were 78, 115/73, 20, 98%ra. . during her icu stay, pt was given 2u ffp and received 5u prbc total. egd that showed gastritis, and colonoscopy that showed diverticulosis in transverse and ascending colon, without a specific source identified. however, likely bleed diverticuli as per gi. she was initially on protonix drip and was later switched to daily ppis. . the patient was also found to be hypocalcemic and given calcium gluconate. day 2 micu patient spiked temp 101-102 and she became hypotensive and associated ams with hypotension, bps minimally responsive to 2.5 l ivf. she was started on levo for <24hours, she has poor peripheral access, unable to get cvl so levo administered through tunneled cath. zosyn/vanc started for possible line infection, cultures negative and she remained hemodynamically stable off pressors so abx stopped, she was given abx for 3 days. fever likely associated with transfusions. ams required pressors <24hours. unclear infection source, patient cdiff negative, blood cx still pending. . upon transfer to the medicine floor, vss with no acute bleeding. patient is an 83-year-old female with multiple medical problems including esrd on hd (mwf), dm2, pvd, afib, severe as s/p mavr (st. 's valve), recurrent gib treated with colectomy and procedure in with continued gibs after the procedures who was transferred from hospital where she presented from rehab with approx ~1l of frank blood from ileostomy. patient's pressures at rehab had been sbp 110-130s until this morning when she first noted bleeding from ostomy; changed the bag once at 11 am. sbp reportedly dropped to 80s. blood has since pooled while she was in the ed. denies lightheadedness, weakness, abd pain, cp, nausea, vomiting, fevers or chills. . ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: 1. history of repeated gi bleeds: past work up revealing various potential sources along her gi tract including small bowl avm's, colonic polyps, ascending and transverse colon diverticulosis. had l hemicolectomy with transverse colostomy and pouch in with pathology examination revealing diverticulosis as the source of bleed. 2. diastolic chf (ef 65-75%) on 2l o2 at home 3. severe as s/p mechanical , 4. hld 5. esrd on hd (mwf) 6. hypothyroidism 7. atrial fibrillation on amiodarone and coumadin 8. pvd 9. diabetes mellitus 10. htn 11. : stenting of left superficial femoral artery/above-knee popliteal artery transition 12. : left calf ulcer debridement 13. : left lower extremity wound debridement 14. : split thickness skin graft from right thigh to left lower calf 15. : left lower extremity angioplasty 16. : debridement of eschar and bone from the posterior aspect of the left heel 17. bilateral tkr 18. open cholecystectomy . orif right periprosthetic femur fracture with rle plate 20. left upper arm radiocephalic av fistula , left upper arm arteriovenous graft angioplasty , l upper arm av graft angioplasty/fistulogram x 5 and x3 social history: denies tobacco, drug or illicit drug use. discharged to rehab. lives at home with husband and 53 year old son who prepares her medications. has been in the hospital or at rehab for last 5 mos, other sons lives in and , daughter lives in . pt is a retired work supervisor at veteran's hospital in jp. retired about 10 years ago. family history: she is an only child. grandfather died of cancer but son is not sure of what type. three sons with htn. pt. denies any other history of ca, dm, or htn in her parents. physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical exam: afebrile, hemodynamically stable with sbps in 120s-130s general - well-appearing in nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple, non-tender, no lymphadenopathy lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - mechanical heart sounds heard throughout precordium. holosytolic murmur heard throughout precordium heard best over apex. rrr no rubs or gallops otherwise abdomen - obese, ostomy bag in place with green stool free of blood or melena evident. nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - chronic venous changes in le bilaterally with evidence of multiple vascular surgeries. wwp, no c/c/e, 2+ peripheral pulses. she has evidence of a rue hand tremor skin - no rashes or lesions other than chronic changes neuro - awake, a&ox3, cns ii-xii grossly intact pertinent results: admission labs: 07:40pm blood wbc-3.7* rbc-3.13* hgb-8.9* hct-26.8* mcv-86 mch-28.5 mchc-33.2 rdw-17.4* plt ct-159 07:40pm blood neuts-41.5* lymphs-48.9* monos-5.3 eos-3.7 baso-0.5 07:40pm blood pt-40.1* ptt-32.7 inr(pt)-4.1* 07:40pm blood glucose-97 urean-32* creat-5.3* na-135 k-4.4 cl-101 hco3-27 angap-11 11:14pm blood calcium-7.5* phos-3.3 mg-1.8 bcx negative x2 c.diff toxin negative x2 colonoscopy: multiple non-bleeding diverticula with mixed openings were seen in the transverse colon and ascending colon. diverticulosis appeared to be of moderate severity. throughout the colon red flecks consistent with old blood was noted in the colon. impression: diverticulosis of the transverse colon and ascending colon otherwise normal colonoscopy to cecum egd: normal mucosa in the whole esophagus erythema in the whole stomach compatible with gastritis normal mucosa in the whole duodenum otherwise normal egd to third part of the duodenum discharge labs: 07:50am blood wbc-3.4* rbc-2.54* hgb-7.4* hct-23.8* mcv-94 mch-29.0 mchc-30.9* rdw-17.0* plt ct-182 07:50am blood pt-21.4* ptt-116.6* inr(pt)-2.0* 08:32am blood glucose-84 urean-38* creat-3.0*# na-136 k-4.5 cl-101 hco3-26 angap-14 08:32am blood calcium-8.0* phos-2.8 mg-2.0 inr trend 07:50am blood pt-21.4* ptt-116.6* inr(pt)-2.0* 09:00am blood pt-18.8* ptt-79.7* inr(pt)-1.7* 06:40am blood pt-18.4* ptt-83.5* inr(pt)-1.6* 05:50am blood pt-15.6* inr(pt)-1.4* 06:38am blood pt-13.5* ptt-72.6* inr(pt)-1.2* 05:46am blood pt-13.3 ptt-67.4* inr(pt)-1.1 labs of note: 09:00am blood hbsag-negative hbsab-positive hbcab-positive hbv viral load pending brief hospital course: 83 year old female with multiple medical problems including esrd on hd (mwf), dm2, pvd, afib, severe as s/p mavr (st. 's valve), multiple gib treated with colectomy and procedure in , continued gibs after the procedures now presents with bleeding from ileostomy.colonoscopy and egd showed no active bleeding but evidence of diverticulosis and evidence of prior gib. #. gi bleed: resolved, most likely diverticular in origin considering significant past history of diverticular bleeds and evidence on colonoscopies. each of these past bleeds have occurred in the setting of supratherapeutic inrs, consistent with this admission. stable hct and no gi complaints. patient requires a total colectomy for definative treatment of her recurrent bleeds, though patient does not want surgery because complicated post-op course last time. her coumadin appears to be therapeutic when she is at home but at rehab center she became supratherapeutic. she will likely benefit long term from having a home inr monitor to prevent future episodes. gib did not recur after coumadin/heparin bridge was started. her hct trended down to 23.8 on discharge without gross bleeding. this information was shared with the accepting physician, . , at rehab macu where they will monitor her hct and potentially provide transfusions as needed. #. subtherapeutic inr: patient continued to be subtherapeutic despite titrating up coumadin to 10mg daily. her inr started uptrending after 10mg were given and she was tapered down to 7.5mg and down again to 4mg on day of discharge when her inr was 2.0. likely related to large doses of vitmain k given in micu. given active bleeding and concern for hemodynamic instability for now will aim for lower end of therapeutic range (goal inr 2.5-3.0). heparin drip should be continued until she is therapeutic. discharged on coumadin 4mg home dose. #. hypotension and fever: septic etiology was entertained initially in micu. the patient was started on ceftazidime and vancomycin. this was discontinued in micu prior to transfer to floor. the patient was also worked up for clostridium difficile infection, despite her lack of diarrhea. patient was started on empiric p.o. flagyl, this was also discontinued. pt's blood culture and c.diff screening remained negative. this was most likely tranfusion related rather than an active infection as fever/hypotension occured following 5 units prbcs and 2 units ffp. #. mechanical aortic valve: given the concern for active hemorrhage, we were judicious with the use of heparin. the patient initially came in supratherapeutic, and throughout her stay her inr is monitored. after coumadin was held some time her inr became sub-therapeutic and she was bridged to heparin (see above). # thrombocytopenia: her platelets downtrended during her stay but stablizes around 112. uunclear etiology, ddx abx related vs consumptive. low suspicion for hit. it was monitored and she continued uptrending after transfer out of micu. #. goals of care: she was seen by palliative care during hospitalization. patient aware of her prognosis but enjoys living and expects to live past her 84th birthday. pal care initiated conversations which can be addressed again in the future but for now she remains fc. pal care continues to follow. chronic stable conditions: #. esrd on hd: no urgent indication for hd. the patient was continued on a regular hemodialysis schedule. her dialysis access was used to draw laboratory tests, and infuse antibiotics. #. afib: in sinus rhythm during admission. continue amiodarone. #. hypothyroidism: continued levothyroxine. #. hyperlipidemia: continued pravastatin. #. dm: hiss #. diastolic heart failure: chronic, well compensated. last echo lvef >55% on 2l nc home o2. continued oxygen and home meds. #. fen: prbc transfusion prn, replete lytes prn, npo for now transitional issues: - continue heparin drip until inr becomes therapeutic - monitor hct as she has had borderline low hct and has a history of gibs. she has not had any melena or brb per ostomy. she has not required prbcs since transfer out of micu. - she should be set up with a home inr monitor to prevent future admissions for gibs - goals of care discussion was initiated by our palliative care department. she remains full code which has been confirmed with family and outpatient providers. if she is hospitalized again for gib and requires significant resucitation this should be readdressed. - of note she had hepatitis panel and hiv drawn because an interventional radiologist had a needle stick during procedure. hbsag and hbcag were positive, hbv viral load still pending on discharge. hiv never came back but patient was consented by blood bank. - picc line is not completely central but is superior to svc and so is okay to use for labs and heparin drip. angio tried to advance but she has some subclavian stenosis and so unable. medications on admission: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily 2. folic acid 1 mg tablet sig: one (1) tablet po daily 3. levothyroxine 88 mcg tablet sig: one (1) tablet po daily 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily 5. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous asdir (as directed): as per sliding scale. 6. sevelamer carbonate 800 mg tablet sig: three (3) tablet po tid w/meals 7. cinacalcet 30 mg tablet sig: one (1) tablet po daily 8. pravastatin 20 mg tablet sig: one (1) tablet po daily 9. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. insulin lispro 100 unit/ml solution sig: one (1) unit subcutaneous asdir (as directed): continue to use your home insulin sliding scale as prescribed. 4. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 8. cinacalcet 30 mg tablet sig: one (1) tablet po once a day. 9. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm: coumadin dosing should be titrated by your clinic for an inr goal 2.5-3.5. 10. heparin (porcine) in d5w 25,000 unit/250 ml parenteral solution sig: six y (650) units intravenous qhr: please continue heparin drip until inr therapeutic (2.5-3.5). discharge disposition: extended care facility: for the aged - macu discharge diagnosis: active: - gi bleed - diverticulosis chronic: - chronic diastolic heart failure (lvef >55%) - severe aortic stenosis s/p st. - hld - esrd on hd (mwf) - hypothyroidism - a.fib on amiodarone - diabetes mellitus - htn - pvd s/p multiple vascular surgeries discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: ms. , it was a pleasure treating you during your hospitalization. you were admitted to with a gi bleed requiring micu stay. in the micu you were stabilized with ivfs and you received 5 units of packed red blood cells and 2 units of fresh frozen plasma. your coumadin was held and you received 2 doses of vitamin k to reverse the anticoagulation. upper and lower endoscopies revealed gastritis and diverticulosis. your bleed stopped and when hemodynamically stable you were transferred to the general medicine floor. on the floor you were hemodynamically stable and did not have anymore gibs. you had an interventional radiology guided picc line placement and hd line change. your coumadin was restarted, you were bridged with heparin drip and you were discharged with an inr of 2.0(goal 2.5-3.5). you were discharged in stable condition without anymore gibs. medication changes: - continue coumadin at your 4mg qdaily home dose - please continue to take your medications as prescribed - heparin drip per weight based protocol. continue heparin drip until patient inr therapeutic 2.5-3.5 discharge instructions - please monitor inr daily until she is therapeutic - please provide patient with a home inr monitor so she can more closely titrate coumadin doses. she has had recurrent gibs requiring hospitalization for periods of supratherapeutic inr. followup instructions: name: , location: address: 545a centre st, , phone: *your primary care physician will be following up with you at your home within 3 days. procedure: other endoscopy of small intestine hemodialysis venous catheterization for renal dialysis colonoscopy central venous catheter placement with guidance central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: thrombocytopenia, unspecified hypocalcemia end stage renal disease abnormal coagulation profile renal dialysis status congestive heart failure, unspecified acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism atrial fibrillation peripheral vascular disease, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia heart valve replaced by other means other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure hypotension, unspecified compression of vein other postprocedural status knee joint replacement diverticulosis of colon with hemorrhage unspecified gastritis and gastroduodenitis, without mention of hemorrhage chronic diastolic heart failure personal history of colonic polyps other dependence on machines, supplemental oxygen other colostomy and enterostomy complication acquired absence of intestine (large) (small) febrile nonhemolytic transfusion reaction 

Answer: The patient is high likely exposed to