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: altered mental status major surgical or invasive procedure: right and left sided cardiac catheterization right internal jugular line placement lumbar puncture ankle arthrocentisis history of present illness: chief complaint: altered mental status 38 m with alcoholic hepatitis, recently admitted for altered mental status and pna, found to have a new cardiomyopathy felt to be related to etoh, although viral idiopathic cardiomyopathy also possible, with lvef=15% and also bilateral pe with rv strain, now on coumadin, who presents to the ed with ams in setting of diarrhea and dehydration. most of the history is obtained from the patient's wife given his mental status. she reports that since his discharge on , he has had soft bms which have since become explosive diarrhea for the last days, associated with decreased po intake. wife reports that he has been less mentally sharp for last 6 weeks (cannot remember atm password etc) and has never returned to baseline of being very functional. . in the ed, initial vs were 98.6 86 82/53 18 96% 4l nc. he was triggered for hypotension (sbp in 70s) and ams. physical exam was notable for asterixis, no ascites, fobt negative. bedside ultrasound showed no evidence of pericardial effusion. inr was noted to be 19.2 (2.1 on ), wbc=19.3 with left shift, cr=5.8, bun 91. cxr showed no new pneumonia and ruq u/s showed no ascites and patent portal vein. ekg without ischemic changes. he was given vancomycin and zosyn, protonix bolus, lactulose 40g. he also received 6l ivf, reportedly with no variation in the ivc on ultrasound, suggesting adequate volume resuscitation. his sbps remained in the 80s-90s, however, and peripheral dopamine was started and changed to norepinephrine (0.09 mcg/min) in the setting of tachycardia. no cvl was placed given elevated inr and he received 10mg iv vitamin k and 2 units ffp. he also received one dose of stress dose hydrocortisone given concern for adrenal insufficiency. uop was 200cc in ed. vs at time of transfer: 97.0 93 85/59 12 100% 2l nc. . in the icu, the patient is confused but mentating. he has no specific complaints. . review of systems: unobtainable. . . . past medical history: past medical history: -cardiomyopathy, attributed to etoh, lvef 15% 1. bilateral p.e. with rv strain , on coumadin 2. gout-seen at 3. non-hodgkin's lymphoma diagnosed at age 2, treated with several years of chemotherapy. apparently had ? liver recurrence at age 6, but liver biopsy showed only scarring 4. elevated lfts on recent work at 5. hyperlipidemia 6. alcoholism since his 20s. always been very functional, working full time job. social history: the patient lives with his wife in . he has no children. - tobacco: none for last month, social tobacco use - alcohol: abstinent x 1-2 months, 4 drinks/night, ?withdrawal during hospitalization. wife insists that patient has not been drinking alcohol. - illicits: never family history: history of diabetes in his father, history of asthma in his grandfather. history of early mi, malignancy, or stroke. (per recent discharge summary) physical exam: admission exam: vitals: t: bp: p: r: 18 general: awake, alert, confused, no acute distress, not using accessory muscles heent: mild scleral icterus, mm dry, oropharynx clear, no frenular jaundice neck: supple, jvp not seen lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, ii/vi systolic murmur at lusb abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no hepatosplenomegaly gu: foley with clear urine ext: warm, well perfused, 1+ dp b/l, no clubbing, cyanosis or edema, l mtp joint erythematous and swollen, tender to palpation, +asterixis skin: erythema over r ankle, l mtp joint, no jaundice or spider angiomata neuro: moving all extremities spontaneously, oriented to person only, thinks he is at hotel and year is . able to recite 6/7 days of week backwards. knows wife's name. discharge exam: general: aaox3 in no acute distress heent: perrla, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, jvp non elevated chest: ctab no wheezes, no rales, no ronchi cv: s1 s2 and s4 normal in quality and intensity rrr no murmurs rubs or gallops abd: soft, non-tender, non-distended, bs normoactive. no rebound/guarding, neg hsm. neg sign. ext: wwp, no edema. dps, pts 2+. skin: no rash psych: patient appropriate and pleasant pertinent results: admission labs: 05:00pm blood wbc-18.9* rbc-4.93 hgb-14.9 hct-43.9 mcv-89 mch-30.1 mchc-33.9 rdw-16.5* plt ct-590* 05:00pm blood neuts-89* bands-1 lymphs-4* monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 05:00pm blood hypochr-normal anisocy-1+ poiklo-normal macrocy-normal microcy-normal polychr-normal 05:00pm blood pt-150.0* ptt-47.9* inr(pt)-19.2* 07:35pm blood glucose-85 urean-91* creat-5.8*# na-133 k-5.0 cl-98 hco3-17* angap-23* 07:35pm blood alt-28 ast-23 ld(ldh)-183 alkphos-181* totbili-0.5 07:35pm blood lipase-71* 07:35pm blood phos-7.9*# mg-2.0 05:00pm blood ammonia-35 07:35pm blood cortsol-20.5* 08:05am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 05:09pm blood lactate-2.3* k-5.4* discharge labs: 06:50am blood wbc-19.3* rbc-3.88* hgb-11.5* hct-34.8* mcv-90 mch-29.6 mchc-33.0 rdw-19.2* plt ct-305 06:10am blood neuts-85* bands-0 lymphs-10* monos-4 eos-0 baso-0 atyps-0 metas-1* myelos-0 06:50am blood glucose-118* urean-29* creat-0.8 na-136 k-3.5 cl-95* hco3-33* angap-12 11:00am blood alt-24 alkphos-135* amylase-73 06:50am blood calcium-8.6 phos-3.1 mg-2.1 03:00am blood digoxin-1.9 micro 09:06pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-0.2 ph-5.5 leuks-tr 09:06pm urine uric ax-mod 08:45pm urine bnzodzp-neg barbitr-neg opiates-pos cocaine-neg amphetm-neg mthdone-neg 02:16am cerebrospinal fluid (csf) wbc-1 rbc-247* polys-38 lymphs-22 monos-39 eos-1 02:16am cerebrospinal fluid (csf) totprot-23 glucose-83 02:16am cerebrospinal fluid (csf) herpes simplex virus pcr-test reque 05:41pm joint fluid wbc-* rbc-* polys-98* lymphs-1 monos-1 05:41pm joint fluid crystal-many shape-needle locatio-i/e birefri-neg comment-c/w monoso 2:16 am csf;spinal fluid #3 #3. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. viral culture (preliminary): no virus isolated. fungal culture (preliminary): no fungus isolated 2:16 am csf;spinal fluid #3. **final report ** cryptococcal antigen (final ): cryptococcal antigen not detected. performed by latex agglutination. (reference range-negative). results should be evaluated in light of culture results and clinical presentation. 12:17 am blood culture source: line-piv. **final report ** blood culture, routine (final ): no growth 5:41 pm joint fluid source: right ankle. **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. 10:20 am stool consistency: not applicable source: stool. **final report ** fecal culture (final ): no enteric gram negative rods found. no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 9:06 pm urine source: catheter. **final report ** urine culture (final ): no growth. radiology: : pcxr: impression: mild pulmonary edema with small bilateral pleural effusions. previously noted right perihilar and right basilar peripheral opacities previously characterized as infarcts have improved in appearance compared to the prior exam. nchct: no acute intracranial pathologic process. tte: the left atrium is elongated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (lvef< 15 %). the right ventricular cavity is mildly dilated with severe global free wall hypokinesis. there is a mobile thrombus in the apex of the right ventricle. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the right ventricular thrombus appears to be new; was not identified in the prior study. ventricular systolic function appears similar. tricuspid regurgitation is now less prominent. the pericardial effusion appears similar. ekg: : st 100, na/ni, no st changes : sinus tachycardia. peaked p waves consistent with right atrial overload. biphasic and negative p waves in leads v1-v2 also raise consideration of biatrial abnormality. left ventricular hypertrophy by voltage. non-specific st-t wave change. findings raise consideration of cardiomyopathy, biventricular overload state, etc. compared to the previous tracing of heart rate is not as fast. p waves are more peaked. clinical correlation is suggested. right and left sided cardiac cath: final diagnosis: 1. no obstructive coronary artery disease. hemodynamic measurements (mmhg) baseline site sys end mean a wave v wave hr ra 11 13 11 100 rv 35 9 14 94 pcw 26 26 29 104 pa 35 21 28 99 ao 92 76 84 109 brief hospital course: # shock: he presented in shock. initial concern was for septic versus cardiogenic shock, or possibly adrenal insufficiency. sepsis was thought to be most likely given leukocytosis with neutrophil predominance and one band on differential. there was clear source of infecation. chest x-ray was read as no pneumonia, urine cultures and initial blood cultures were negative, csf and joint fluid cultures were also negative. given his diarrhea and recent hospitalization, hcap and c. difficile were presumed and he was empirically treated with an eight-day course of vancomycin and cefepime for the former and metronidazole and po vancomycin for the latter. c. diff was eventually negative. cardiogenic shock initially seemed unlikely given the initial results of his echocardiogram which showed an improvement in his lvef since his prior study. # altered mental status: etiology was unclear. non-contrast head ct showed no obvious cause. infection was considered, but csf cultures and hsv pcr were negative, although he was covered for hsv in the interim. hepatic encephalopathy was considered given his questionable history of alcoholic hepatitis, but seemed unlikely given normal ammonia levels, normal lfts, and lack of evidence that his hepatitis actually progressed to cirrhosis. an eeg showed only diffuse slowing, but was limited due to motion artifact. he was seen by neurology, who had no specific recommendations. after discussion with dr. , his cardiologist, it was decided that a low-perfusion state due to his cardiomyopathy was most likely. he was periodically agitated and confused throughout his icu stay, and required restraints and sedation at times. . # acute kidney injury: colchicine-induced vs atn vs prerenal etiology. colchicine was held, and he received fluid resuscitation. his creatinine improved and he made good urine throughout his icu stay. . # cardiomyopathy and tachycardia: no clear etiology, but consider alcohol induced versus viral. lvef 15% on last tte . subsequent echocardiogram on showed an lvef of 20-25%. right heart cath: ra: rv: 35/9/14 pcw: 26 pa: 35/21/28 ao: 92/76 co: 1.93 medical management was initiated with digoxin started. patient had a good response to the medications, with his sensorium clearing and his heart rate decreasing from the 100s to the 70s. a standard hf medication regimen consisting of ace-i, beta blocker, digoxin and torsemide was started with intention to start an aldosterone antagonist as an outpatient. . # coagulopathy: initial inr was 19.2, was previously 2.1 on . most likely related to excess warfarin dosing and possibly poor nutritional intake, combined with loss of vitamin k due to diarrhea. he received 2 units ffp and 10mg iv vitamin k, and his inr fell to 1.4 in two days. it remained stable between 1.5 and 2 during his icu stay. . # anion gap metabolic acidosis: attributed to uremia. it closed with no specific treatment other than fluid resuscitation. # pneumonia: presumptive diagnosis given leukocytosis with neutrophil predominance and 1 band on differential and shock on presntation. completed iv vancomycin and cefepime for hcap x8 days. . # alcoholic hepatitis versus congestive hepatopathy: patient had hepatitis, attributed to etoh on previous admission. normal plt count implies relatively intact synthetic function, though may be falsely elevated in setting of infection. his lfts were stable throughout his icu course, and it was felt to be unlikely that this was contributing to his altered mental status . # h/o bilateral p.e.: recently diagnosed and was on coumadin on admission, but this was held given his supratherapeutic inr. he was placed on a heparin drip for anticoagulation. it was thought that part of his persistent tachycardia could be attributed to a recurrent pe from the rv clot that was no longer seen on a later echo. . with regards to the coagulopathy work up, we would like to have genetic testing for inherited forms of coagulopathy including antiphospholipid antibody and factor v leiden. these were not measured in the hospital . # gout: appears to be having severe flare now. have been worsened by torsemide. - hydrocortisone 50mg iv q8h x 3 days, followed by repeat 3 day burst of prednisone prior to discharge. patient also was started on 0.6 of colchicine and vicodin (15 pills) for break through pain and told to only take it as prescribed. will follow up with rheumatology as an outpatient. . # follow up for pcp leiden levels for coagulopathy work up if deemed appropriate. - start aldosterone antagonist once ace inhibitor and beta blocker have been uptitrated. - inr check and basic metabolic panel given diuretic use. - pain control for gout - digoxin levels. medications on admission: (per prior discharge summary, not confirmed) 1. omeprazole 40mg po daily (daily). 2. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily). 3. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) as needed for cellulitis for 5 days. 4. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. warfarin 3 mg tablet sig: one (1) tablet po once a day: begin taking this medication today . 9. eplerenone 25 mg tablet sig: one (1) tablet po daily (daily). 10. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 11. torsemide 60mg po daily 12. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 13. zolpidem 2.5mg po qhs:prn insomnia 14. escitalopram 10 mg tablet sig: one (1) tablet po once a day. discharge medications: 1. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. torsemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. disp:*90 tablet(s)* refills:*2* 6. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). disp:*30 tablet extended release 24 hr(s)* refills:*2* 9. enoxaparin 80 mg/0.8 ml syringe sig: one (1) injection subcutaneous q12h (every 12 hours) for 5 days. disp:*10 injection* refills:*0* 10. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 11. potassium chloride 20 meq tablet, er particles/crystals sig: two (2) tablet, er particles/crystals po once a day. disp:*60 tablet, er particles/crystals(s)* refills:*2* 12. colchicine 0.6 mg tablet sig: one (1) tablet po every other day. disp:*15 tablet(s)* refills:*2* 13. vicodin 5-500 mg tablet sig: one (1) tablet po every eight (8) hours as needed for pain. disp:*15 tablet(s)* refills:*0* 14. outpatient work pt, ptt, inr, basic metabolic panel please have results faxed to pcp's office discharge disposition: home discharge diagnosis: primary: 1. heart failure, systolic, acute 2. cardiomyopathy, nos 3. discharge condition: stable and improved on medical regimen. discharge instructions: you were admitted to the hospital for heart failure. in addition you had some abnormalities in your liver function tests and kidney function. your inr, which is a measure of your coumadin level, was very high as well. finally you were a bit confused. we ran several tests to try to figure out the cause of your confusion but we were unable to determine the exact cause. it may be related to your heart failure and decreased blood flow to your brain. you had a cardiac catheterization to measure the pressures in your heart. it showed some abnormalities including an elevated pressure likely in the left atrium of your heart which we are treating with a medication called digoxin. so far you have responded well to this therapy. it is important to take all of your medications every day exactly as directed and to follow up with all of your appointments below. it is important for you to eat the same amount of leafy vegetables every day to control the level of coumadin/ warfarin that you have in your body and to control your inr (a measure of how your blood clots). weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: / primary care for inr and k check and continued work up of possible inherited coagulopathy (factor v ). cardiology monday at 3:30pm with dr. for continued management of your heart failure. rheumatology for gout treatment. department: when: wednesday at 11:10 am with: post clinic building: sc clinical ctr campus: east best parking: garage department: cardiac services when: wednesday at 11:00 am with: , np building: sc clinical ctr campus: east best parking: garage department: echo when: friday at 10:00 am with: echocardiogram building: gz building (felbeerg/ complex) campus: east best parking: main garage department: when: wednesday at 11:10 am with: dr. address: , location: post clinic building: sc clinical ctr south campus: east best parking: garage this appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. this visit, you will see your regular primary care doctor in follow up. rheumatology appointment: pending building: lm campus: west best parking: . garage **we are working on a follow up appointment in rheumatology within 2 weeks. the office will contact you at home with an appointment. if you have not heard within 2 business days or have any questions please call . procedure: spinal tap incision of lung combined right and left heart cardiac catheterization combined right and left heart angiocardiography arthrocentesis central venous catheter placement with guidance diagnoses: other primary cardiomyopathies acidosis congestive heart failure, unspecified toxic encephalopathy acute kidney failure, unspecified gout, unspecified hypopotassemia other and unspecified hyperlipidemia personal history of other lymphatic and hematopoietic neoplasms long-term (current) use of anticoagulants personal history of venous thrombosis and embolism acute systolic heart failure other and unspecified alcohol dependence, unspecified acute alcoholic hepatitis shock, unspecified 

Answer: The patient is high likely exposed to