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 / hayfever attending: chief complaint: dark stool major surgical or invasive procedure: enteroscopy history of present illness: 75 year old male with past medical history of clear cell carcinoma s/p right nephrectomy and adrenectomy with metastasis to pancreas, duodenal wall and pulmonary (nodules) s/p whipple procedure in complicated by injury to hepatic artery. he had dvt in for which coumadin was started with subsequent gi bleed requiring 9 units of prbc thought to be secondary to jejunal avm. repeat endoscopy showed small gastric angiodysplasia which was treated with bicap. he was noted to have increase in jejunal mass on routine surveillance ct scan by oncology in which was decided to be managed conservative. . he reports being in his usual state of health until two days ago when he noted half a bucket full of bowel movement which was mahogany colored. he subsequently went to ed where his hct was 27.8 from 34 one week prior. he had guiaic positive stool though no symptoms of chest pain, fatigue, lightheadedness, shortness of breath, hemoptysis. he was given one unit of prbc. egd which observed esophagus, stomach and jejunum was normal. he subsequently underwent colonoscopy after a prep today which was normal except for diverticulosis. he had 500 cc of frank bright red per rectum after the procedure. he was also noted to have fever (unsure if during or after prbc). blood and urine culture were drawn. he was also noted to have runs of nsvt for which magnesium and potassium was given. labs notable for creatinine of 1.4 which improved to 1.2 with prbc and ivf. he was subsequently transferred to for further evaluation and management. . on arrival to the micu, he reports no complaints. while there, he remained hemodynamically stable and received an additional 2u prbcs as his hct was 19. hct was monitored closely and stablized at 25 over the last 2 days. his total bilirubin transiently rose (? to transfusion) but is now trending down. per gi, a cta was ordered and found increased size of epigastric mass since , now 3.7 x 3.2 cm (previously 3.3 x 2.8) in addition to a stable sized enhancing mass protruding into jejunum. cta also noted slightly increased intra and extra hepatic biliary dilation, concerning for mass obstructing the hepaticojejunostomy. there was no evidence for acute bleeding. gi performed enteroscopy on , which revealed a clot in hepatic limb with no clear source of bleed. given that he was stable, he was transferred to the medicine floor for further management. . on arrival to the floor, vital signs were t:98.0 bp: 118/64 p: 73 r: 20 o2: 98% on ra. patient was comfortable with no acute complaints. his last bowel movement was yesterday and he denies any dizziness, lh or chest pain. past medical history: clear cell carcinoma with metastasis to pancreas, lung and duodenal wall htn type 2 dm dvt in tkr in transamnitis s/p pacemaker for symptomatic bradycardia social history: - tobacco: never - alcohol: sometimes a glass of wine with dinner - illicits: no family history: mom with cancer physical exam: admission physical exam: vitals: t:97.2 bp:89/42 p:95 r:18 o2:99%2lnc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp at 8 cm, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: bibasilar crackles abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley. rectal vault without frank blood. guiaic positive stool ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation. pertinent results: 10:07pm wbc-6.9# rbc-2.45*# hgb-6.4*# hct-19.8*# mcv-81* mch-26.3* mchc-32.5 rdw-17.0* 10:07pm pt-18.4* ptt-33.9 inr(pt)-1.7* 10:07pm plt count-156 10:07pm fibrinoge-228 10:07pm albumin-1.5* calcium-4.9* phosphate-1.1*# magnesium-1.3* 10:07pm ck-mb-1 ctropnt-<0.01 10:07pm alt(sgpt)-37 ast(sgot)-89* ld(ldh)-120 alk phos-156* tot bili-2.4* 10:07pm glucose-113* urea n-6 creat-0.6 sodium-142 potassium-2.4* chloride-121* total co2-13* anion gap-10 10:18pm lactate-1.6 12:24am blood wbc-6.7 rbc-2.49* hgb-6.4* hct-19.9* mcv-80* mch-25.8* mchc-32.3 rdw-16.9* plt ct-185 01:20am blood wbc-7.0 rbc-2.63* hgb-7.0* hct-21.1* mcv-80* mch-26.6* mchc-33.1 rdw-17.0* plt ct-193 09:37am blood hct-28.4*# 01:49pm blood hct-25.7* 08:57pm blood hct-25.8* 03:28am blood wbc-5.6 rbc-3.14* hgb-8.6* hct-24.8* mcv-79* mch-27.4 mchc-34.7 rdw-17.0* plt ct-189 08:00pm blood hct-25.1* 06:25am blood wbc-5.1 rbc-3.36* hgb-9.1* hct-27.3* mcv-81* mch-27.1 mchc-33.3 rdw-17.8* plt ct-212 04:15pm blood hct-29.3* 06:32am blood wbc-4.6 rbc-3.57* hgb-9.7* hct-29.8* mcv-83 mch-27.0 mchc-32.5 rdw-17.1* plt ct-261 10:07pm blood pt-18.4* ptt-33.9 inr(pt)-1.7* 12:24am blood pt-15.8* ptt-31.4 inr(pt)-1.5* 01:20am blood pt-15.3* ptt-30.7 inr(pt)-1.4* 03:28am blood pt-13.4* ptt-32.5 inr(pt)-1.2* 06:25am blood pt-11.5 ptt-32.1 inr(pt)-1.1 06:32am blood pt-11.1 ptt-32.8 inr(pt)-1.0 10:07pm blood fibrino-228 01:20am blood fibrino-357# 10:07pm blood glucose-113* urean-6 creat-0.6 na-142 k-2.4* cl-121* hco3-13* angap-10 12:24am blood glucose-121* urean-7 creat-1.0 na-139 k-3.7 cl-112* hco3-20* angap-11 01:20am blood glucose-115* urean-7 creat-0.9 na-137 k-3.8 cl-111* hco3-19* angap-11 03:28am blood glucose-86 urean-7 creat-1.0 na-139 k-3.8 cl-108 hco3-22 angap-13 06:25am blood glucose-84 urean-7 creat-1.0 na-139 k-3.9 cl-105 hco3-23 angap-15 06:32am blood glucose-90 urean-7 creat-1.1 na-141 k-3.7 cl-108 hco3-26 angap-11 10:07pm blood alt-37 ast-89* ld(ldh)-120 alkphos-156* totbili-2.4* 01:20am blood alt-56* ast-132* alkphos-207* totbili-3.3* 03:28am blood alt-57* ast-97* alkphos-203* totbili-2.3* 10:07pm blood ck-mb-1 ctropnt-<0.01 01:20am blood ck-mb-2 ctropnt-<0.01 10:07pm blood albumin-1.5* calcium-4.9* phos-1.1*# mg-1.3* 12:24am blood calcium-7.0* phos-2.0* mg-1.9 01:20am blood calcium-7.1* phos-2.2* mg-2.6 03:28am blood calcium-7.9* phos-2.3* mg-1.8 06:25am blood calcium-8.1* phos-3.4 mg-1.8 06:32am blood calcium-8.5 phos-3.6 mg-2.1 10:18pm blood lactate-1.6 cta abdomen (): impression: 1. pancreatic and jejunal masses post-whipple procedure, consistent with known renal cell carcinoma metastases. a fungating mass with markedly irregular borders is seen in the jejunal limb at the pancreaticojejunal anastomosis. no definite evidence of active extravasation of contrast observed, with multiple frond-like enhancing projections felt to be connected to the lesion itself. however, please note that in the setting of known gi bleeding, this lesion represents a likely source of bleeding. 2. interval enlargement of pancreatic and jejunal masses consistent with increase in metastatic disease. 3. new intrahepatic biliary ductal dilation to the level of the hepaticojejunal anastomosis. equivocal areas of hypoenhancement within the hepatic parenchyma may be perfusional, although metastases cannot be excluded. continued attention on followup imaging is recommended. correlation with lfts is suggested as regards significance of the progressive biliary dilation. 4. stable right base pulmonary nodule. 5. equivocal increased thickening of the left adrenal gland medial limb; attention on next followup imaging recommended. 6. fluid or soft tissue nodule in an umbilical fat-containing hernia, stable to decreased in size. enteroscopy () impression: esophageal ulcer normal mucosa in the stomach the biliary and enteral limbs were intubated. the biliary limb contained a couple of small blood clots. there was no other evidence of recent bleeding or a source of bleeding. otherwise normal egd to enteral and biliary jejunal limbs recommendations: the findings do not account for the symptoms if rebleeding occurs, would consider a flex sig to ensure no rectal pathology but most likely bleeding related to mets in the biliary limb. if rebleeds, would call ir for embolization of metatatic disease. would also consider discussion with outpatient providers to determine plan of care moving forward as the metastatic disease is likely to process and may well bleed again. brief hospital course: 75 year old male with past medical history of clear cell carcinoma s/p right nephrectomy and adrenectomy with metastasis to pancreas, duodenal wall and pulmonary (nodules) s/p whipple procedure in complicated by injury to hepatic artery and gi bleed in on anticoaguation from jejunal avm presents with mahogany colored stools. 1. gi bleed: source is thought to be secondary to jejunal avm vs erosion from metastatic jejunal mass which has been increasing in size. as mentioned, osh egd negative to jejunum though avm are usually difficult to visualize and intermittent. colonoscopy only showed diverticulosis. enteroscopy on demonstrated no clear source of the bleed. hct trended up during the last three days of admission (25->27->29). patient reports one small "black" bm and another "goopy red" bm on am. he was npo, then advanced slowly to a regular diet, which he tolerated well. lengthy discussion between gi, outpatient oncologist, general surgery, ir and radiation oncology was conducted via email and it was determined that radiation oncology would be the best treatment option at this time. the patient would prefer to receive his daily therapies near his home, which is only 8 miles from hospital. radiation oncology team helped to coordinate care and the patient will follow-up with them after discharge. the patient will follow-up with dr. (radiation oncologist) near his home. he is aware to come to the ed if he experiences repeat bleed. 2. coagulopathy: on admission, inr of 1.7, normal ptt with albumin of 2.2. plt of 160 with normal creatinine. elevated inr thought to be secondary to malnutrition. he received a single dose of vitamin k with normalization of inr. 3. fever likely in setting of blood tranfusion. no source of infection noted on exam or review of labs and imaging here. afebrile during remainder of hospitalization. 4. type 2 dm- patient on metformin and daily levemer 15u at home, placed him on insulin sliding scale with glargine 10u qam (home levemer not formulary here). on discharge, he was resumed on home regimen of metformin and levemer. 5. pancreatic insufficiency: initially held home creon, ursodiol and antidiarreals in the setting of gi bleed. once bleed resolved, resumed home creon and ursodiol but held antidiarrheals on discharge. 6. htn: held home metoprolol in the setting of gi bleed. bps and hr within normal limits without metoprolol while in house so it was held on discharge. we ask the pcp to please determine when and if to resume this medication. # code: full (discussed with patient) medications on admission: ursodiol 600 mg po bid metformin 1000 mg po bid protonix 40 mg po qdaily metoprolol 50 mg po bid creon mg po tid levemer 15 units sc qdaily lomotil 2 tabs po bid tincture opium 1% 0.3 cc qdaily mva po qdaily iron 325 mg po qdaily immodium two tabs po qdaily discharge medications: 1. ursodiol 300 mg capsule sig: two (2) capsule po twice a day. 2. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 3. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. creon 24,000-76,000 -120,000 unit capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po three times a day. 5. tincture merthiolate liquid miscellaneous 6. multivitamin tablet sig: one (1) tablet po once a day. 7. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 8. insulin detemir 100 unit/ml solution sig: fifteen (15) units subcutaneous once a day. discharge disposition: home discharge diagnosis: primary- gi bleed secondary- renal cell carcinoma with metastasis to pancreas, lung small bowel hypertension type ii diabetes mellitus dvt- discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with a gi bleed. an outside hospital egd and colonscopy did not demonstrate any acute source of the bleed and you were transferred to for further management. while here, you underwent a ct scan which demonstrated enlargement of your small bowel mass, which was the most likely cause of the bleed. you also underwent an enteroscopy. while here, you remained hemodynamically stable and your hematocrits improved by discharge. the oncology, gastroenterology, general surgery, interventional radiology and radiation oncology teams discussed your case at length and determined that radiation therapy would be beneficial to you. you would like this to be done near your home, which was arranged prior to discharge. you have an appointment with dr. upon discharge and the plan is to begin radiation therapy as soon as possible. it was a pleasure taking part in your care, mr. . the following changes were made to your medications: 1. stop metoprolol 50mg twice daily please continue all other medications as prescribed by your outpatient providers followup instructions: dr. with radiation oncology on department: primary care name: hseih, nurse practitioner for dr. when: friday at 10:00 am location: core physicians- internal medicine address: . bldg 3a, , phone: department: radiology when: wednesday at 1 pm with: cat scan building: gz building (/ complex) campus: east best parking: main garage department: hematology/oncology when: wednesday at 2:00 pm with: drs. / building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: wednesday at 2:00 pm with: dr. building: sc clinical ctr campus: east best parking: garage procedure: other endoscopy of small intestine diagnoses: unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acquired coagulation factor deficiency unspecified protein-calorie malnutrition secondary malignant neoplasm of lung hemorrhage of gastrointestinal tract, unspecified personal history of malignant neoplasm of kidney acquired absence of kidney other specified diseases of pancreas ulcer of esophagus without bleeding secondary malignant neoplasm of other digestive organs and spleen secondary malignant neoplasm of small intestine including duodenum acquired partial absence of pancreas febrile nonhemolytic transfusion reaction 

Answer: The patient is high likely exposed to