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: penicillins / ciprofloxacin / benzodiazepines attending: chief complaint: altered mental status major surgical or invasive procedure: 1. diagnostic paracentesis 2. hemodialysis m/w/f during this admission 3. cardiac catheterization history of present illness: this is a 54 year old female with a history of esld hcv complicated by hrs and sbp in past, htn, dm who presents with one day of worsening mental status. per husband patient was in usual state of health one day prior to admit. over course of day her mental status decreased until she was answering one word answers. she has not been oriented to person, place or time and has been having increasing agitation over the past 24 hours. per husband who spoke to renal fellow, no n/v/c/d, no f/c. last hd was on friday. of note patient recently admitted and d/ced for ams, at that time no etiology could be found but patient improved with lactulose. durring last admit patient started on cefpodoxime for sbp proph. in the ed initial vitals were: 98.0 78 117/101 20 100 on ra. labs were significant for a ua which appeared infected. a ct head was done, the prelim read was no acute process. the patient was given 2mg of ativan for agitation after which she became minimally responsive. a diagnostic para was performed which was negative for sbp, cx pending. on the floor, patient was somnolent and was not able to answer questions. 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: hep c cirrhosis c/b ascites and encephalopathy, known grade i varices last egd in , active on list esrd on hd started schedule mwf cerebral infarction - multifocal, thought to be embolic patent foramen ovale - open, not repairable per cards diabetes on insulin hypertension mitral regurgitation (2+) s/p hernia repair by dr. h/o sub-segmental pe in not on anticoagulation social history: worked as staff accountant at sound life financial. lives in with husband who is primary caretaker. children. nonsmoker. no etoh. no ivdu family history: no history of liver disease. father with cva in 50s. mother with dm and chf sister with dm. physical exam: general: somnolent heent: sclera anicteric, mmm, oropharynx clear, pupils 4-5mm, reactive to light 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: midline abdominal inscision. soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. ascities present. gu: foley, reducible mass palpated. ext: warm, well perfused, no clubbing, cyanosis, + pitting edema in le b/l neuro: patient withdraws to pain, occasional movement of all four limbs. pertinent results: labs on admission: 11:08pm type-art temp-35.7 po2-108* pco2-34* ph-7.53* total co2-29 base xs-6 07:00pm ascites wbc-155* rbc-216* polys-0 lymphs-4* monos-12* macrophag-84* 03:20pm glucose-151* urea n-27* creat-7.4*# sodium-136 potassium-4.7 chloride-100 total co2-27 anion gap-14 03:20pm estgfr-using this 03:20pm urine hours-random 03:20pm urine gr hold-hold 03:20pm pt-18.5* ptt-40.2* inr(pt)-1.7* 03:20pm urine color-amber appear-clear sp -1.016 03:20pm urine blood-sm nitrite-neg protein-75 glucose-neg ketone-15 bilirubin-sm urobilngn-1 ph-5.0 leuk-tr 03:20pm urine rbc-* wbc-* bacteria-few yeast-none epi- trans epi-0-2 renal epi-0-2 03:20pm urine wbcclump-many 02:45pm glucose-162* lactate-1.9 na+-137 k+-4.8 cl--95* tco2-29 02:45pm wbc-4.4 rbc-3.39*# hgb-10.6*# hct-34.7*# mcv-102* mch-31.2 mchc-30.5* rdw-17.5* 02:45pm neuts-64.5 lymphs-21.4 monos-11.2* eos-1.4 basos-1.5 02:30pm ammonia-158* 12:18pm creat-6.9*# sodium-132* potassium-5.0 chloride-96 12:18pm estgfr-using this 12:18pm tot bili-4.2* 12:18pm albumin-2.5* 12:18pm pt-18.6* inr(pt)-1.7* labs on discharge: 07:00am blood wbc-5.7 rbc-2.56* hgb-8.1* hct-26.9* mcv-105* mch-31.8 mchc-30.2* rdw-18.0* plt ct-45* 07:00am blood pt-21.8* ptt-49.3* inr(pt)-2.0* 07:00am blood glucose-161* urean-23* creat-6.6*# na-135 k-4.5 cl-100 hco3-27 angap-13 07:00am blood alt-17 ast-45* alkphos-155* totbili-3.9* 07:00am blood calcium-9.4 phos-4.4 mg-1.9 micro: studies: ecg - sinus rhythm. borderline q-t interval prolongation. since the previous tracing of probably no signifiant change. cxr (port ap) - low lung volumes, but no focal consolidations. nchct - suboptimal exam due to patient motion. no acute intracranial pathology seen. cxr (port ap) - no pneumothorax is identified. allowing for low lung volumes, no definite lung infiltrate is seen. tte - the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is a mild resting left ventricular outflow tract obstruction. the right ventricular cavity is borderline dilated with normal free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the mitral valve leaflets are elongated. moderate (2+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: hyperdynamic left ventricular systolic function. mild resting outflow tract . minimal aortic stenosis. moderate pulmonary hypertension. moderate mitral regurgitation. compared with the prior study (images reviewed) of , the severity of mitral regurgitation has increased while the severity of tricuspid regurgitation has decreased. right ventricular size is smaller. estimated pulmonary artery pressures are higher. the heart rate is faster. ecg - normal sinus rhythm. non-specific st-t wave abnormalities. compared to the previous tracing of there is no diagnostic interim change. ruq u/s 1. patent portal vein and hepatic veins. 2. the portal vein has normal hepatopetal flow; however, the splenic vein demonstrates a hepatofugal flow. this appearance suggest underlying spontaneous porto-systemic shunt, most likely splenorenal. 3. unchanged cholelithiasis with no signs of cholecystitis. 4. findings compatible with cirrhosis. increasing ascites. cxr (port ap) - low lung volumes which is unchanged. nasogastric tube ends in the stomach. a right central venous catheter ends in the right atrium, unchanged from the previous study. there is no pneumothorax. cardiac, mediastinal, and hilar contours are unchanged. cardiac catheterization (right heart) comments: 1. resting hemodynamics revealed normal right sided filling pressures with rvedp 13mmhg and mildly elevated pulmonary capillary wedge pressure with pcwp 14mmhg. the pulmonary arterial pressure was normal with pasp 33mmhg. the cardiac index was preserved at 3.4 l/min/m2. the pulmonary vascular resistance was normal at 147 dynes-sec/cm5. final diagnosis: 1. normal filling pressures. 2. pulmonary pressures consistent with those seen on echocardiogram. ecg sinus rhythm. non-specific inferolateral st-t wave changes. q-t interval prolongation and slowing of the rate as compared with prior tracing of . the st-t wave changes have improved. otherwise, no diagnostic interim change. chest x-ray impression: ap chest compared to : there is no pneumothorax, pleural effusion or mediastinal widening. bronchial cuffing both hila is new which could be the earliest indication of cardiac decompensation though heart size is stable. there is no edema manifested elsewhere in the lungs and pleural effusion if any is minimal. a dual-channel right-sided central venous line ends close to the anticipated location of the tricuspid valve. us vein study findings: focus color and doppler son evaluation of bilateral subclavian and internal jugular veins demonstrated normal flow and compressibility. wall-to-wall flow is demonstrated within the internal jugular veins. there was no hematoma in the surrounding soft tissue. impression: normal flow and compressibility of bilateral internal jugular veins without evidence of internal jugular vein thrombus. brief hospital course: micu course: - episode of hypertension to 190/82 overnight treated with an extra home dose nadolol - obtained abg due to concern regarding tachypnea although saturating well, 7.53/34/108/29 basexs . - renal: hd last night, 1.5 liters removed. - : - as noted by hepatology team, rifaximin, lactulose, cultures,f/u head ct; surgery will follow. f/u peritoneal cultures, blood cultures, stool cultures. monitor mental status exam - abd us with doppler: cirrhotic liver, ascites, gallstone, reverse flow in her splenic vein (some type of shunt), portal vein is patent. - echo: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is a mild resting left ventricular outflow tract obstruction. the right ventricular cavity is borderline dilated with normal free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the mitral valve leaflets are elongated. moderate (2+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: hyperdynamic left ventricular systolic function. mild resting outflow tract . minimal aortic stenosis. moderate pulmonary hypertension. moderate mitral regurgitation. compared with the prior study (images reviewed) of , the severity of mitral regurgitation has increased while the severity of tricuspid regurgitation has decreased. right ventricular size is smaller. estimated pulmonary artery pressures are higher. the heart rate is faster. - tox screen: negative - mental status/bowel movement: increased lactulose to q4hrs moving bowels, flexiseal placed. decreased back to q6hrs given copius bowel movements. patient slightly more arrousable to pain. -tachycardic during hd. ekg with sinus tachycardia. resolved after hd. - mental status clearing. - had in early afternoon, with 1.2 l taken off. was tachycardic at times during , but maintained pressure. - stated was thirsty in the evening so started sponge sticks and ice chips. - several runs of vt, often around 20 beats. on 20 mg qd nadolol. did not increase overnight, but would consider this in the a.m. - sustained svt at 115 later with maintained pressures, sbp ~ 100s. distinct from runs of vt. - ekg 115 bmp, normal intervals and axis. sinus tachycardia. - very dry on physical exam with flat jvp, dry mouth and thirsty. gave 500 ml lr. - reduced lactulose from 45 mg q6 to q8 given loose stool. ===== floor course: the following issues were addressed during this admission after the patient was transferred to the floor: # altered mental status. the patient continued to improve while on the floor and became progressively more alert. she was initially only partially oriented (confusion over date, place), but was fully oriented at the time of discharge. her confusion was attributed to hepatic encephalopathy. there was no clear precipitating factor - diagnostic tap was negative for sbp, no evidence of gib, per husband patient had been medication-compliant and was having 3 bowel movements daily. worsening cirrhosis is a possibility. she was continued on her home medications and lactulose was titrated to bm daily. # pulmonary hypertension. patient had no further arrhythmia after arrival to the floor. however, echocardiogram raised concern for possible pulmonary hypertension that could represent a contraindication to . an attempt was made to place a swan catheter, but it could not be advanced. the patient was evaluated by cardiology and referred for right heart catheterization. she tolerated the procedure well. mean pulmonary artery pressure was 23 mmhg, compatible with . # wheeze, shortness of breath. once transferred to the floor, the patient experienced no further symptoms. repeat cxr showed no evidence of worsening infiltrate. # ue venous study. as swan catheter was not possible to place, there was concern for possible venous occlusion in the upper extremity. patient underwent an ultrasound study which showed patent vessels. # uti. patient was treated with ceftriaxone for a possible uti, but culture showed no growth, so this medication was discontinued. # esld, esrd. patient is on the liver-kidney list. the patient was continued on hemodialysis per renal consult team throughout this admission. she was clinically volume-overloaded, with abdominal exam pertinent for full but not tense abdomen. she considered this degree of ascites consistent with her baseline and had no pain or shortness of breath so therapeutic tap was deferred. her meld score remained in the low 30s throughout this admission. # diabetes mellitus type ii. patient was maintained on an insulin sliding scale. # fen: no ivf, replete electrolytes, regular diet # prophylaxis: pneumoboots # access: pivs # communication: patient, husband # : full medications on admission: lactulose 30ml po qid titrate to bms daily lansoprazole 30mg po daily rifaximin 400mg po tid cefpodoxime 200mg po qhd insulin ss aranesp 300mcg/ml with hd b-complex vitamins 1capsule po daily caltrate 600mg (1500mg) po daily ferrous sulfate 325mg (65mg iron) po tid nephplex rx 1-60-300-12.5 mg-mg-mcg-mg tablet po daily miconazole nitrate 2% cream topical daily nadolol 20mg po daily discharge medications: 1. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 2. lactulose 10 gram/15 ml syrup : 15-30 mls po three times a day: increase dose until you are having at least 3 bowel movements a day. 3. rifaximin 200 mg tablet : two (2) tablet po tid (3 times a day). 4. cefpodoxime 100 mg tablet : two (2) tablet po qhd (each hemodialysis). 5. aranesp (polysorbate) 300 mcg/ml solution : one (1) injection injection qhd (on hemodialysis days). 6. b complex vitamins capsule : one (1) capsule po once a day. 7. caltrate 600 600 mg (1,500 mg) tablet : one (1) tablet po once a day. 8. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po tid (3 times a day). 9. nephplex rx 1-60-300-12.5 mg-mg-mcg-mg tablet : one (1) tablet po once a day. 10. miconazole nitrate 2 % cream : one (1) application topical once a day: apply to affected area. 11. insulin please continue your insulin sliding scale according to your home regimen. 12. nadolol 20 mg tablet : one (1) tablet po daily (daily). discharge disposition: home with service facility: discharge diagnosis: primary: - hepatic encephalopathy - cirrhosis of the liver secondary to hepatitis c virus secondary: - diabetes mellitus type ii - end stage renal disease, on hemodialysis discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - requires assistance or aid (walker or cane) discharge instructions: you were admitted to with confusion. you were unable to take medication by mouth, so you were admitted to the medical intensive care unit and a feeding tube was placed. two days later, you appeared improved so you were transferred to the liver floor service. you were taken for a cardiac catheterization procedure to make sure that the vessels supplying blood to your lungs are healthy enough for you to undergo a surgery - it appears that they are. you tolerated this procedure very well. the following day, your feeding tube was removed and you were able to walk with physical therapy. your confusion improved, and you were discharged home. we have made no changes to your medication regimen. please remember to take your lactulose regularly and increase the dose until you are having at least 3 bowel movements daily. this will help to prevent confusion in the future. please schedule follow up with the liver clinic as directed below. followup instructions: please call the liver clinic at to schedule an appointment for 1-2 weeks from the time of discharge to discuss this admission. procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances hemodialysis percutaneous abdominal drainage pulmonary artery wedge monitoring other nonoperative cardiac and vascular measurements diagnoses: anemia in chronic kidney disease end stage renal disease cirrhosis of liver without mention of alcohol diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled chronic hepatitis c with hepatic coma hepatorenal syndrome portal hypertension other chronic pulmonary heart diseases paroxysmal ventricular tachycardia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease ostium secundum type atrial septal defect long-term (current) use of insulin other ascites personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits awaiting organ transplant status esophageal varices in diseases classified elsewhere, without mention of bleeding paroxysmal supraventricular tachycardia 

Answer: The patient is high likely exposed to