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: morphine attending: chief complaint: gib major surgical or invasive procedure: egd x 2 history of present illness: 72f on warfarin and aspirin for af, chf ef 35%, cad/pvd s/p multiple stents and interventions, admit 7 months ago for ugib from ulcer requiring massive transfusion p/w 2 days of abd cramps, dry heaves, and today with black tarry guiac + stools. she states she was feeling fine prior to two days ago, noted feeling increasingly fatigued yesterday. had a bm that may have been melena, but didn't see it. this am she had a dark stool and felt extremely weak, called her son to take her to the . . of note in patient had severe ugib requiring massive transfusion. egd at that time showed large necrotic duodenal lesion of unclear nature near a dudenal diverticulum. colonic diverticulosis was seen on ct abdomen/pelvis. at the time, she declined surgical intervention so prophylactic embolization of the gastroduodenal artery was performed by ir. warfarin + low dose aspirin were restarted at discharge due to her high risk of stroke in the setting of afib + cad with s/p stents. . . on presentation to the ed patient was hypotensive to the 80s, hr 100. hct was 24.7 from baseline 30. creatinine 2.2 from baseline 1.6-2.1. inr 2.7. she received 1200cc ns, 1 unit prbcs, 1 unit frozen plasma and 5mg iv vit k. ng lavage with small amount of coffee grounds that cleared after 500cc. advanced ij (3 lumen and sheath) and piv placed. started on protonix drip with bolus and admitted to the icu for close monitoring and egd. vital signs on transfer were 105/48, 98 20 96%ra. . . on the floor, pt is complaining of lower abdominal tenderness, feeling unwell, mostly disturbed by the ng tube. gi came to evaluate the patient, egd showed several gastric and duodenal lesions. prior to further assessment, pt had an aspiration event and procedure was emergently discontinued. o2 sats dropped briefly then improved. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: 1. diabetes 2. hypertension 3. coronary artery disease - mi - pci - cath 4. atrial fibrillation 5. chf, ef 35% ( tte on ), lvh, mod tr/pulm htn 6. pvd s/p multiple lower ext bypasses 7. ckd (baseline cr 1.2) 8. colonic adenoma (on ) 9. anxiety 10. gout social history: lives with daughter, spends most of the day alone, but has a "lifeline" for emergencies. able to get up and down her stairs with some difficulty. occupation: homekeeper tobacco: quit in , 10pack years, etoh: denies family history: lung cancer - son cad/pvd - mother, maternal grandmother physical exam: admission exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: 12:10pm blood wbc-8.4 rbc-3.04* hgb-8.0* hct-24.7* mcv-81* mch-26.3*# mchc-32.3 rdw-16.6* plt ct-244# 12:10pm blood neuts-80.3* lymphs-15.6* monos-3.0 eos-0.9 baso-0.4 10:20am blood pt-28.0* ptt-26.0 inr(pt)-2.7* 10:20am blood glucose-157* urean-129* creat-2.2*# na-139 k-4.7 cl-103 hco3-22 angap-19 10:20am blood alt-18 ast-23 alkphos-54 totbili-0.2 10:20am blood lipase-36 10:20am blood ctropnt-<0.01 10:20am blood calcium-9.2 phos-3.0 mg-2.2 04:20am blood triglyc-195* 09:57pm blood type-mix po2-63* pco2-51* ph-7.24* caltco2-23 base xs--5 intubat-intubated 09:57pm blood glucose-160* lactate-1.7 na-142 k-5.7* cl-117* 09:57pm blood hgb-9.0* calchct-27 09:57pm blood freeca-1.00* 07:20am blood wbc-10.9 rbc-5.10 hgb-15.1 hct-43.8 mcv-86 mch-29.6 mchc-34.4 rdw-14.9 plt ct-583* 07:20am blood glucose-134* urean-67* creat-1.8* na-139 k-4.3 cl-102 hco3-20* angap-21* brief hospital course: 72f on coumadin and baby asa for af, chf ef 35%, cad/pvd s/p multiple stents and previous admission in for ugib from a peridiverticular duodenal lesion admitted for gib. active issues # gastrointestinal bleed: initially suspected to be ugib. pt had coffee grounds on ng lavage and had documented h/o persistent gastritis despite ppi therapy. pt was on anticoagulation and antiplatelet therapy. was hemodynamically stable on admission and underwent egd which showed two small ulcers in the stomach body with overlying clots as well as non invasive gastritis, but egd terminated prematurely when patient went into v-tach and was shocked twice before stabilizing. this occurred shortly after intubation. pt remained intubated and admitted to , where she was monitored with q6h hct checks and transfused numerous times to maintain a hct > 30. she was placed on pressors. she was also given vitamin k and aspirin, anti-hypertensives and coumadin were held. she self-extubated the morning after admission and was breathing well on her own, but was re-intubated on hd3 for repeat egd. second egd showed a few small ulcers in the stomach body with old blood as well as angioectasias of the stomach body which were clipped and injected with epinephrine. she also had duodenal ulcers and a duodenal diverticulum, at which fresh blood was seen. she was then sent to ir for embolization, where she got 300cc of contrast during procedure. bleed was not identified after 4h search. during procedure got prbc and iv fluids and was subsequently weaned off pressors. she continued to require prbc transfusions per day. ir declined further attempts at embolization due to risk of bowel ischemia. surgery was consulted and considered whipple to resect duodenal ulcers, but pt was a poor surgical candidate and pt's family also agreed surgery was not in the patient's best interest. pt's hct stabilized on hd5 and remained stable throughout the the remainder of her hospitalization. her aspirin was held throughout her hospitalization, but, given that she is on high dose ppi, and is off coumadin, it can be restarted, with close attention paid to any signs of recurrent gi bleeding. hpylori ordered and is pending at the time of discharge. # acute on chronic renal failure - creatinine slightly elevated from baseline 1.8 (was 2.2 on admission). pt appeared dry on admission exam, and in setting of acute bleed, prerenal etiology seemed most likely. medications were renally dosed and she was rescuscitated with fluids and prbcs. creatinine returned to baseline, and was 1.8 on day of discharge. # pneumonia: it was difficult to wean the patient off the vent after second intubation. increased secretions and fevers developed so she was suspected to have vap. cxr difficult to interpret, so started empirically on vanc/zosyn. cipro was later added for double coverage of pseudomonas. she was found to have h. flu on sputum on . her vancomycin was discontinued and she completed an 8 day course of zosyn. # afib: the patient was continued on beta blockers, but she developed atrial fibrillation with rvr. she was put on metoprolol 50 mg po qid and started on diltiazem 15 mg po q6 hours. her heart rate is overall controlled, but she still occasionally has brief episodes of heart rate to 120. she needs continued monitoring with telemetry and possible uptitration of diltiazem. #anticoagulation: patient continued on aspirin, but coumadin held for now. i have emailed her pcp and gastroenterologist to consider whether it should be restarted at all given her recurrent large volume gi bleeding. risks of gi bleeding need to be weighed against prevention of stroke secondary to atrial fibrillation. patient has gi appointment with dr at the end of . i discussed the risks of recurrent gi bleeding on asa/coumadin and the benefit of stroke prevention. family understandably concerned about preventing stroke, but they also understand that she has had two large gi bleeds. they will continue to consider this, and i have advised them to discuss further with rehab doctors if they feel strongly that they want to have another trial of restarting coumadin. chronic issues # congestive heart failure: pt had no evidence of fluid overload on admission. she was given prbc and fluids for her gi bleeding and when her hct stabilized, she was diuresed to improve her respiratory status. her po intake has been somewhat poor during this hospitalization, so her lasix has been held. she denies complaints of shortness of breath, and has no e/o volume overload on exam. when she is eating regularly, she can be restarted on her home dose of lasix, which is 60-80 mg by mouth daily. # diabetes mellitus: patient receiving lantus 10 units daily, and blood sugars are well controlled. patient with diabetic neuropathy. was on gabapentin at home, but held in the hospital. # full code medications on admission: furosemide 40mg mwf, 40mg qam and 20mg qpm all other days docusate sodium 100 mg daily prn gabapentin 300 mg tid warfarin as directed trazodone 100 mg qhs simvastatin 40 mg qhs losartan 50 mg daily pantoprazole 40 mg daily aspirin 81 mg daily fluticasone 220 mcg/actuation inhalation aerosol 2 puffs albuterol sulfate (proair hfa) 90 mcg/actuation inhalation hfa 1-2 puffs q4-6h prn lantus 50units daily novolog flexpen 100 unit/ml sub-q (insulin aspart) tid prn senna 8.6 mg tab 2 tabs at bedime daily discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po q12h (every 12 hours). 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po q6h (every 6 hours). 3. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 4. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 5. lantus 100 unit/ml solution sig: 10 units subcutaneous once a day. 6. diltiazem hcl 30 mg tablet sig: 0.5 tablet po qid (4 times a day). disp:*60 tablet(s)* refills:*2* 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: gastrointestinal bleeding atrial fibrillation coronary artery disease (heart disease) congestive heart failure peripheral vascular disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: requiring a walker, assist with movement discharge instructions: you were hospitalized for bleeding in your stomach and duodenum (part of your intestine). you suffered significant blood loss and required many transfusions of blood. you had two endoscopies, which showed that your bleeding was due to ulcers in the stomach and duodenum as well as a diverticulum, or outpouching, in the duodenum. we have held your coumadin for now. you have atrial fibrillation (irregular heart rate). there is a small risk of stroke if you do not take the coumadin. this has to be weighed against the risk of another bleed if you are on coumadin. since you have had two major bleeds this year, you should talk to your primary care doctor, dr , about whether to continue the coumadin in the future. you have had a rapid heart rate during this hospitalization, and we have adjusted some of your medicines to keep your heart rate better controlled. followup instructions: name: , specialty: internal medicine location: address: , , phone: **please discuss with the staff at the facility the need for a follow up appointment with your pcp when you are ready for discharge** name: , md specialty: gastroenterology location: address: , , phone: appointment: thursday at 1pm procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube insertion of other (naso-)gastric tube endoscopic control of gastric or duodenal bleeding endoscopic control of gastric or duodenal bleeding arteriography of other intra-abdominal arteries diagnoses: pneumonia, organism unspecified coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified cardiac complications, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified paroxysmal ventricular tachycardia acute respiratory failure long-term (current) use of insulin primary pulmonary hypertension chronic systolic heart failure long-term (current) use of anticoagulants chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction hyperosmolality and/or hypernatremia diverticulosis of small intestine with hemorrhage 

Answer: The patient is high likely exposed to