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: hematemasis major surgical or invasive procedure: upper endoscopy : two clips were unsuccessfully deployed in the area of the bleeding lesion for the purpose of hemostasis. 2 cc.epinephrine 1/ injection was applied for hemostasis with success. a gold probe was applied for hemostasis successfully. history of present illness: this is an 82 year old male with h/o barrett's s/p egd with rfa of gej, atrial fibrillation on coumadin who woke up at aprox 4:30 am on with hematemasis. he did not tell anyone and cleaned it up. he then had a second episode of hematemasis and then some melana. his wife then became aware of the problem and called an ambulance and he went to ed. . at falmough he had a hct of 30 and inr of 3.3. he received 1 unit of prbc, 2 ffp, 10 vit k. his potassium was noted to be 7, he was given 5 u regular insulin and 1 amp of dextrose. he was started on octreatide gtt at . he also recieved some zofran. in the ed initial vitals were: 36.4 90 114/59 18 100%. he had about 400cc of hematemasis and an ng lavage with frank red blood. he also had maroon stool/melana in ed. two 16g ivs and one 18g iv were placed and he was transfused 2 u of prbc. he then received another 2 of ffp for coagulopathy. the massive transfusion protocol was activated. he was evaluated by gi who felt that he needed to be scoped emergenty in the icu. he was hemodynamically unstable with bp dropping to 83/50 and tachycardic to the low 100s. on transfer his vitals were: 97.8, 112/61, hr 90, 100% 2l. . on the floor, patient feels comfortable prior to egd. he continues to have some bright red blood from his ng tube. he denies abdominal pain, nausea, vomiting. no chest pain, shortness of breath. . 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 constipation, abdominal pain. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: 1. cad status post cabg in 03/84 with four grafts. 2. hypertension. 3. squamous cell carcinoma 03/. 4. atrial fibrillation. 5. cardioversion treated with coumadin and cardioversion. 6. status post appendectomy. 7. status post pacemaker placement. 8. status post defibrillator in 09/. 9. status post right leg popliteal vein patch in 01/. social history: - tobacco: none - alcohol: none - illicits: none married and lives with his wife. family history: noncontributory physical exam: admission exam: vitals: t: 96.8 bp: 123/82 p: 88 r: 18 o2: 94% on ra general: alert, oriented, appears comfortable heent: sclera anicteric, mmm, oropharynx clear, ng tube in place with bright red blood draining from it 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: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . . . . discharge exam: general: alert, oriented, appears comfortable heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: 01:25pm blood wbc-6.2 rbc-2.72* hgb-9.5* hct-27.1* mcv-100* mch-35.0* mchc-35.1* rdw-14.7 plt ct-151 01:25pm blood neuts-56.7 lymphs-33.2 monos-8.4 eos-1.1 baso-0.4 01:25pm blood pt-19.0* ptt-27.5 inr(pt)-1.7* 01:25pm blood glucose-147* urean-56* creat-1.0 na-141 k-4.7 cl-111* hco3-25 angap-10 01:25pm blood alt-15 ast-20 alkphos-34* totbili-1.0 01:25pm blood ctropnt-0.03* 01:25pm blood albumin-3.4* calcium-7.9* phos-3.3 mg-2.0 egd: blood in the middle third of the esophagus, lower third of the esophagus and gastroesophageal junction. there was a hiatal hernia that contained the distal esophagus and gej. within the hernia, at the most distal tip of the jeg there was a protruding lesion with active arterial hemorrhage. (endoclip, injection, thermal therapy). because of the location of the lesion (within the hiatal hernia), intervening upon the lesion was challenging. blood in the stomach body. otherwise normal egd to third part of the duodenum ekg: atrial fibrillation with a single ventricular premature beat. consider lateral myocardial infarction. intraventricular conduction delay of left bundle-branch block type. since the previous tracing probably no significant change. chest x-ray: portable ap radiograph of the chest was reviewed with no prior studies available for comparison. severe cardiomegaly is noted. mediastinum is dilated, chronicity undetermined. the patient is in moderate-to-severe pulmonary edema, accompanied by bilateral pleural effusions. bibasilar areas of atelectasis are most likely present. pacemaker leads terminate in right atrium and right ventricle. there is no pneumothorax. echo: . results measurements normal range left atrium - long axis dimension: *5.4 cm <= 4.0 cm left atrium - four chamber length: *6.9 cm <= 5.2 cm right atrium - four chamber length: *7.2 cm <= 5.0 cm left ventricle - septal wall thickness: 1.1 cm 0.6 - 1.1 cm left ventricle - inferolateral thickness: 0.9 cm 0.6 - 1.1 cm left ventricle - diastolic dimension: *5.9 cm <= 5.6 cm left ventricle - ejection fraction: 15% >= 55% left ventricle - stroke volume: 81 ml/beat left ventricle - cardiac output: 6.76 l/min left ventricle - cardiac index: 3.35 >= 2.0 l/min/m2 left ventricle - lateral peak e': *0.06 m/s > 0.08 m/s left ventricle - septal peak e': *0.03 m/s > 0.08 m/s left ventricle - ratio e/e': *27 < 15 aorta - sinus level: 3.1 cm <= 3.6 cm aorta - ascending: 3.0 cm <= 3.4 cm aorta - arch: 3.0 cm <= 3.0 cm aorta - descending thoracic: 2.3 cm <= 2.5 cm aortic valve - peak velocity: 1.7 m/sec <= 2.0 m/sec aortic valve - lvot vti: 18 aortic valve - lvot diam: 2.4 cm mitral valve - e wave: 1.2 m/sec mitral valve - e wave deceleration time: *269 ms 140-250 ms tr gradient (+ ra = pasp): *45 mm hg <= 25 mm hg findings left atrium: moderate la enlargement. right atrium/interatrial septum: markedly dilated ra. a catheter or pacing wire is seen in the ra and extending into the rv. left ventricle: normal lv wall thickness. mildly dilated lv cavity. severely depressed lvef. cannot exclude lv mass/thrombus. tdi e/e' >15, suggesting pcwp>18mmhg. no resting lvot gradient. right ventricle: dilated rv cavity. mild global rv free wall hypokinesis. abnormal septal motion/position consistent with rv pressure/volume overload. aorta: normal diameter of aorta at the sinus, ascending and arch levels. focal calcifications in aortic root. normal descending aorta diameter. no 2d or doppler evidence of distal arch coarctation. aortic valve: mildly thickened aortic valve leaflets. no as. trace ar. mitral valve: mildly thickened mitral valve leaflets. severe mitral annular calcification. mild (1+) mr. prolonged (>250ms) transmitral e-wave decel time. tricuspid valve: normal tricuspid valve leaflets. moderate to severe tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. general comments: suboptimal image quality - poor subcostal views. echocardiographic results were reviewed by telephone with the md caring for the patient. impression: biatrial enlargement. severely depressed global left ventricular systolic function with relative preservation of the distal inferoseptal segment. elevated left ventricular filling pressures. mild mitral regurgitation. moderate to severe tricuspid regurgitation. at least moderate pulmonary artery systolic hypertension. ef%15 . . . labs on discharge: 06:27 complete blood count white blood cells 7.1 4.0 - 11.0 k/ul red blood cells 3.29* 4.6 - 6.2 m/ul hemoglobin 10.9* 14.0 - 18.0 g/dl hematocrit 31.9* 40 - 52 % mcv 97 82 - 98 fl mch 33.2* 27 - 32 pg mchc 34.2 31 - 35 % rdw 16.1* 10.5 - 15.5 % basic coagulation (pt, ptt, plt, inr) platelet count 197 150 - 440 k/ul performed at west stat lab 06:27 901 23* 1.0 141 3.9 104 27 14 other pertinent labs: ckmb / cmbr index / troponin 03:27 16* / 9.8*/ 0.38*1 18:09 24*/ 13.6*/ 0.39*1 09:20 27*/ 16.6* /0.27*2 01:31 13*/ 12.1*/ 0.09* brief hospital course: this is an 82 yo m with h/o barrett's esophagus with low-grade dysplasia presenting with hematemesis s/p radiofrequency ablation. . # hematemasis: mr. presented with hematemeis and melena approximately three weeks following rfa of barrett's esophagus at gej. at osh and patient was transfused a total of 6 units prbc, 1 unit of platelets, and 4 units of ffp. the massive transfusion protocol was activated in the emergency department. mr. was admitted to the icu for urgent endoscopy. on egd seen to have protruding lesion with active hemorrhage at jeg, s/p failed clipping but with cauterization and epi injection. . mr. was monitored in the icu following intubation. surgery consulted and felt that it would be difficult to surgically intervene distal esophagus as it was within hiatal hernia. serial hcts were monitored. following egd patient did not require any further transfusions in the icu and his hct remained stable between 26 - 29. patient was initially treated with ppi gtt, which was transitioned to iv ppi and then further transitioned to po ppi on discharge. over 4 days on the floor he required only 1u prbcs and his hct stabalized around 28-30. his stool turned from tarry black to brown. on he was started on 81mg aspirin without known rebleeding or drop in hematocrit. he was not restarted on coumadin despite the risk of afib-induced strokes given the significant risk of rebleed. he will have follow up with his pcp on as well as gi services on at . . # nstemi: on admission, patient had slightly elevated troponin at 0.03 felt to be secondary to demand in setting of acute gi bleed. on day 3 of admission patient became more tachycardiac and cardiac enzymes peaked with troponin at 0.39, ecg changes with v3-5 st depressions. likely in setting of demand from massive bleeding vs. nstemi. patient was asymptomatic. started patient on atorvastatin 80 mg daily and metoprolol (his simvastatin was stopped). aspirin and anticoagulation were originally held given risk of further bleeidng. aspirin 81mg was started on . coumadin was not restarted on this admission. . patient had echo showing severely depressed global left ventricular systolic function with an ef of 15% (prior known ef was 25%). unclear if related to acute event or more longstanding as patient with significant history of cardiac disease. he did not exhibit any episodes of shortness of breath or dyspnea on exertion during his admission to the floor. he was continued on his home dose of lasix 40mg daily. his lisinopril was decreased to 5mg daily given his borderline low systolic bp (100-110). his metoprolol tartrate was increased to 50mg tid and he was discharged on a higher dose of 150mg toprol daily. . # pulmonary edema ?????? on admissioni, mr. had new oxygen requirement and evidence of pulmonary edema on cxr. he was believed to be volume overloaded in setting of massive transfusions. responded well to diuresis with lasix 20 mg iv. he was then continued on his home dose of 40mg lasix po daily. . # a fib ?????? on coumadin and digoxin prior to admission. patient has icd. had 39 beat run of v tach for which icd did not fire. ep interrogated pacer and was working well, threshold for firing >180bpm, last recorded firing in . patient was tachycardic in a fib with rvr to 120s which was likely worsening demand. responded well to esmolol drip in the icu with improvement in rate control to 80s. patient was transitioned from esmolol gtt to metoprolol tid. metoprolol was titrated up to 50 mg tid. digoxin was restarted in icu and continued on the floor. during his time on the floor, he had several runs of nsvt (6-11 beats) during which he was asymptomatic. . # hypertension: antihypertensives were held during first several days of admission given that patient was hypotensive in setting to gi bleed. prior to transfer from icu, metoprolol was started as above and lower dose lisinopril 5 mg daily was restarted. his bp was borderline low with sbp 100-110. he did not exhibit dizziness, lightheadedness or orthostasis at these blood pressures. . ###################### . transitional issues: 1. gi bleed: patient should have repeat hematocrit as outpatient. he was told to monitor his stool and to return to the ed/call his doctor if he felt lightheaded or began seeing dark tarry stool or frank blood. he will have follow up with gi on for further monitoring of his symptoms and of his bleeding upper gi vessel. he might require further scope in the future. . 2. ntemi/depressed ef: patient had echo showing very low ef 15%. he did not exhibit clinical signs of volume overload and was not dyspneic on exertion or at rest. he will have follow up with cardiology dr. on to further monitor and treat his heart failure and possibly restart coumadin for afib. . 3. afib: patient on low dose aspirin but his chads score would dictate that he would benefit from coumadin. given the high risk of rebleed from upper gi vessel, the gi service wanted to ensure the patient was stabilized before starting aspirin. and low-dose aspirin was only restarted on . his coumadin should be restarted at a later date once his risk for gi bleed decreases. medications on admission: digoxin 125 mcg daily furosemide 40 mg dialy isosorbide dinitrate 30 mg daily lisinopril 10 mg daily nitro 0.3 mg sl prn omeprazole 40 mg potassium chloride 40 meq propranolol 80 mg daily simvastatin 40 mg daily sucralfate 1 gram qid prn ascorbic acid 500 mg daily aspirin 81 mg daily omega 3 fatty acids coumadin discharge medications: 1. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 3. isosorbide dinitrate 20 mg tablet sig: 1.5 tablets po daily (daily). 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) sublingual as directed. 6. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 7. potassium chloride 20 meq packet sig: two (2) po twice a day. 8. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed) as needed for dry eyes. 11. metoprolol succinate 100 mg tablet extended release 24 hr sig: 1.5 tablet extended release 24 hrs po once a day. disp:*45 tablet extended release 24 hr(s)* refills:*2* 12. omega 3 fish oil oral 13. ascorbic acid 500 mg tablet sig: one (1) tablet po once a day. tablet(s) discharge disposition: home with service facility: vna assoc. of discharge diagnosis: primary: upper gi bleed acute blood loss anemia secondary: gerd with barrett's esophagus nstemi acute on chronic systolic chf hypertension 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 for a gastrointestinal bleed after undergoing radio-frequency ablation of your barrett's esophagus. you were transfused with blood and had ongoing bleeding for several days. during that time you unfortunately had a heart attack that resulted in further damage to your heart. no intervention was performed during your admission because of your gastrointestinal bleeding risk. during he course of your hospitalization your bleeding subsided and your hematocrit remained stable. your aspirin (which had been held because of the bleeding) was reintroduced into your medication regimen. we did not find evidence of bleeding on this medication. we did not restart your coumadin given the risk of bleeding and this should be discussed with your cardiologist dr. during your next appointment. your coumadin decreased your risk of stroke while you have atrial fibrillation. during your hospitalization, some of your medications have changed, please note the following: -start aspirin 81mg daily -start metoprolol 150mg daily -start atorvastatin 80mg daily -decrease lisinopril to 5mg daily -stop coumadin (you may restart this medication by your cardiologist) -stop simvastatin (you will be taking a similar drug atorvastatin) followup instructions: please note the following: you have an appointment with dr. on @ 10:00am you have an appointment with dr. on @ 1:15pm also note following appointment: department: digestive disease center when: friday at 11:30 am with: , md building: building (/ complex) campus: east best parking: main garage md procedure: endoscopic excision or destruction of lesion or tissue of esophagus diagnoses: subendocardial infarction, initial episode of care esophageal reflux unspecified essential hypertension acute posthemorrhagic anemia atrial fibrillation aortocoronary bypass status personal history of tobacco use diaphragmatic hernia without mention of obstruction or gangrene paroxysmal ventricular tachycardia hemorrhage complicating a procedure other specified cardiac dysrhythmias personal history of other malignant neoplasm of skin other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation long-term (current) use of anticoagulants cardiac pacemaker in situ acute on chronic systolic heart failure other specified disorders of esophagus 

Answer: The patient is high likely exposed to