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: mold attending: chief complaint: lethargy major surgical or invasive procedure: none history of present illness: 46-year-old female with history of acute alcoholic hepatitis and biopsy-proven cirrhosis complicated by anemia, hepatic encephalopathy, fluid overload, and synthetic dysfunction was brought in by family concerned for lethargy x2 days. it appears that on her diuretics and lactulose were discontinued for an elevated creatinine of 1.5. today, pt was biba because family was concerned that she has been acting lethargic x 2 days. she does have a history of hepatic encephalopathy and her symptoms were consistent with prior presentations. of note, her lactulose seems to have been discontinued recently in the setting of diarrhea and creatinine elevation out of concern for further dehydration. she was too lethargic to answer questions appropriately in the , ems had complained of abdominal pain on the ride over. most of the history was obtained from family. pt has had many recnet hospitalizations recently at : from (liver failure) and then again (s/p fall). her last hospitalization for worsening hepatic encephalopathy, which had improved since starting lactulose therapy. she was also on rifaximin, lasix 20mg daily and spironolactone 50mg daily past medical history: 1. recent diagnosis of alcoholic hepatitis and cirrhosis as above. 2. hypertension. 3. elevated bmi. 4. cholecystectomy. 5. anemia (likely thalassemia and anemia of chronic disease) 6. s/p gastric bypass social history: lives with her mother in . alcohol excess with last sip of alcohol reportedly 5/. at most, drank 7+ alcoholic beverages a day for at least 10-plus years. has a daughter, , who is 24 years old and is a good support system. quit tobacco. family history: the patient's father had what was appraently alcoholic cirrhosis. no family history of heart disease, early mi. physical exam: admission physical exam vs: 97.6 88/58 --> 94/72 71 12 100%ra general: well appearing female in nad. sleeping. jaundiced heent: sclera icteric. mmm. cardiac: rrr with ii/vi systolic murmur lungs: cta b/l with no wheezing, rales, or rhonchi - difficult to assess as pt somnolent and quite large abdomen: distended but soft, tender to palpation in right upper and lower quadrants in particular. no clear shifting dullness or fluid wave but difficult to assess due to subcutaneous fat extremities: 1+ edema b/l. warm and well perfused, no clubbing or cyanosis. neurology: asterixis - unable to assess as pt could not follow commands well enough discharge physical exam vs: 98, 90s, 110-120s/60-70s, 20, 98-100% ra general: obese african american female, lying in bed, in nad heent: sclera slightly icteric. mmm. periorbital edema of r eye inferiorly cardiac: rrr with ii/vi sem lungs: ctab with slight decreased bs at bases; no wheezing, rales, or rhonchi. poor aeration abdomen: soft, nontender, nondistended, +bs extremities: + pitting le edema b/l. warm and well perfused neurology: no asterixis. a and o x3 pertinent results: 02:26am blood wbc-10.3 rbc-3.92* hgb-9.7* hct-32.3* mcv-83 mch-24.8* mchc-30.1* rdw-19.8* plt ct-180 06:00am blood wbc-8.6 rbc-3.07* hgb-7.5* hct-24.9* mcv-81* mch-24.5* mchc-30.1* rdw-22.4* plt ct-107* 06:20am blood wbc-9.2 rbc-3.16* hgb-8.1* hct-26.6* mcv-84 mch-25.7* mchc-30.6* rdw-23.5* plt ct-186 04:15am blood pt-19.7* ptt-41.8* inr(pt)-1.9* 07:28am blood pt-26.3* ptt-52.7* inr(pt)-2.5* 06:20am blood pt-20.4* inr(pt)-1.9* 02:26am blood glucose-74 urean-30* creat-3.4*# na-122* k-greater th cl-104 hco3-18* 04:09am blood glucose-122* urean-29* creat-4.1* na-142 k-4.9 cl-113* hco3-18* angap-16 06:20am blood glucose-95 urean-24* creat-2.2* na-127* k-6.6* cl-100 hco3-15* angap-19 01:50pm blood na-128* k-3.2* cl-102 hco3-16* angap-13 02:26am blood alt-54* ast-199* alkphos-228* totbili-4.9* 05:00am blood alt-23 ast-72* alkphos-120* totbili-5.6* 06:20am blood alt-29 ast-76* alkphos-121* totbili-3.2* 04:15am blood calcium-8.4 phos-4.5 mg-1.7 06:20am blood calcium-8.5 phos-1.5* mg-2.0 06:20am blood calcium-8.6 phos-2.8 mg-2.0 11:38am blood vitb12-1372* folate-greater th 04:48am blood hapto-10* 04:09am blood c3-47* c4-15 02:33am blood lactate-1.7 12:23pm urine color-dkamb appear-hazy sp -1.011 12:34pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.5 leuks-lg 12:34pm urine rbc-180* wbc-33* bacteri-none yeast-none epi-1 12:34pm urine casthy-67* 12:23pm urine hours-random urean-409 creat-211 na-less than k-42 cl-16 10:00am urine hours-random urean-620 creat-212 na-less than k-15 cl-14 03:00pm urine hours-random urean-524 creat-92 na-89 k-32 cl-66 12:23pm urine osmolal-335 03:00pm urine osmolal-442 12:33pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg 04:05pm ascites wbc-185* rbc-145* polys-64* lymphs-2* monos-0 mesothe-1* macroph-33* 04:05pm ascites totpro-1.6 glucose-97 creat-3.5 ld(ldh)-62 totbili-1.1 albumin-<1.0 micro:gram positive coccus(cocci). in pairs and clusters. gram positive rods. consistent with corynebacterium or propionibacterium species. . images: tte : impression: mild aortic valve sclerosis. no pathologic flow or focal vegetations identified. normal biventricular cavity sizes with preserved regional and global biventricular systolic function. renal u/s: : impression: normal appearance of bilateral kidneys with normal doppler evaluation of bilateral renal vessels. . ekg: : sinus rhythm. normal ecg. compared to the previous tracing of no diagnostic interim change ct head: : wet read: jbre wed 5:44 am no intracranial hemorrhage. no fracture. large left parietal subgaleal eeg : impression: this telemetry captured no pushbutton activations. there was possible muscle artifact, but the legible portions of the recording showed a slow background indicative of an encephalopathy. systemic illness and medications are the most common causes. there were no clearly epileptiform features or electrographic seizures. discharge labs: 05:03am blood wbc-8.1 rbc-2.86* hgb-7.5* hct-24.1* mcv-84 mch-26.2* mchc-31.2 rdw-23.4* plt ct-162 05:03am blood pt-21.7* inr(pt)-2.1* 05:03am blood glucose-87 urean-23* creat-2.0* na-128* k-4.3 cl-104 hco3-16* angap-12 05:03am blood alt-26 ast-55* alkphos-113* totbili-2.8* 05:03am blood albumin-2.7* calcium-8.2* phos-2.9 mg-1.9 brief hospital course: micu course 46 year old female with history of alcoholic cirrhosis and anemia presenting with hepatic encephalopathy, acute kidney injury, and worsening anemia. active issues: #altered mental status: has had multiple admissions for encephalopathy. on admission to icu had an dobhoff tube placed for administration of lactulose. received 30 cc's lactulose every two hours with mild improvement in mental status. patient initially unresponsive to name, and would withdraw from pain with asterixis and clonus on the lower extremities and upgoing babinski reflexes. after lactulose patient opening eyes and occasionally saying name, however cannot follow commands. workup prior to icu admission did not reveal portal vein thrombus, or evidence of blood stream infection or sbp. an lp was not performed given elevated inr. one blood culture from the emergency room did return positive with multiple organisms felt to be consistent with contamination. patient received a 7-day course of vancomycin and ceftriaxone. other contributions to her mental status may be from worsening renal failure causing encephalopathy. of note, the patient has not had an egd in the system, however her stools have been guiac negative. neurology was consulted and eeg was ordered. there was no signs of status epilepticus. ct scan was negative for an acute process and there was thought that there would be benefit to obtaining an mri. while an mri was not obtained due to patient agitation, she eventually recovered from her encephalopathy without a etiology being known. the leading thought that it was a toxic-metabolic insult caused by her not being able to clear a substance with her liver dysfunction and worsening kidney status. #normocytic anemia: patient has a baseline hematocrit of about 27, possibly secondary to alpha thalasemia. initially presented with hct of 32, which decreased why she was an inpatient. she remained guaiac negative with no apparent source of bleeding. hemoconcentration definitely played a role, but patient did need to be transfused on multiple occasions. prior to discharge, her hematocrit stayed stable around 25. #acute kidney injury: patient had an acute on chronic rise in her creatinine. creatinine was 3.4 on admission, it spiked to 4.1 and then came down to 2.0 with rehydration. her creatinine had been increasing since before her heme-onc appointment on , at which time it was 1.5 from a baseline of <1. #decompensated alcoholic cirrhosis: biopsy proven cirrhosis, being managed by dr. . inr 2.4, and the albumin was low on presentation. not a candidate for transplant. paracentesis was negative for sbp. patient received increased dose of thiamine acutely, but then transitioned to home dose of 100mg daily. she has not had an egd and will require one as an outpatient. #bacteremia: grew 1+ gpc in pairs and clusters and 1+ gpr c/w corynebacterium species. likely contaminant as it is only in one bottle. however, given patients clinical status, she was treated with 7 days of vancomycin and ceftriaxone. #delirium w/ paranoia- patient was recovering from her encephalopathy and over started having some nonsensical talk that evolved to be paranoid delirium. she spontaneously improved after two days. b12 and folate were normal. psychiatry was consulted and they noticed frontal release signs which they thought might be due to her known history of being abused. on discharge, patient was alert and oriented x 3 and very pleasant. she was agreeable to seeing outpatient psychiatry. she should get a psychiatrist via best 1- and services 1-. # hx of abuse: patient with restraining order against ex-boyfriend, however, has still expressed desire to see him. today, has said she would like to move on. frontal release signs and atrophy likely a result of chronic trauma. the center for violence prevention saw the patient while she was admitted. she is also willing to see a psychiatrist as an outpatient as listed above. she was put on a privacy alert while patient admitted, all male visitors should show id at front desk #hyper/hyponatremia: pt presented with na 122. with a combination of free water restriction and then later water replacement, her sodium fluctuated greatly. on discharge her sodium was 128 and she was asymptomatic. transitional issues: - she should receive a follow up with a psychiatrist via best 1- and services 1- - patient needs to have egd completed as an outpatient. this has been scheduled with dr. . - patient will be going to rehab for functional improvement - she will require labs to be drawn as an outpatient weekly (chem7, cbc, lfts) medications on admission: . information was obtained from . 1. folic acid 1 mg po daily 2. lactulose 15 ml po qid 3. lorazepam 0.5 mg po bid:prn anxiety 4. metoprolol succinate xl 100 mg po daily 5. omeprazole 20 mg po daily 6. potassium chloride 10 meq po daily duration: 24 hours hold for k > 4.5 7. sertraline 50 mg po q4:prn pain 8. rifaximin 550 mg po bid 9. spironolactone 50 mg po daily 10. trazodone 200 mg po hs:prn insomnia 11. thiamine 100 mg po daily discharge medications: 1. lactulose 15 ml po qid 2. folic acid 1 mg po daily 3. rifaximin 550 mg po bid 4. thiamine 100 mg po daily 5. ciprofloxacin hcl 250 mg po/ng q24h 6. nicotine patch 14 mg td daily nicotene withdrawl 7. omeprazole 20 mg po daily 8. sertraline 50 mg po q4:prn pain discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: encephalopathy, not otherwise specified secondary diagnosis: malnutrition acute kidney injury bacteremia discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , it was a pleasure taking care of you at the . your family brought you to the hospital because you had become increasingly tired and lethargic. ct scan of your head repeatedly showed no acute process (nothing new) in your brain that was causing this condition. the neurologists were consulted (brain doctors) and they showed that you were not having a seizure either, but they were unsure of the reason this was happening. you were treated for infection, hepatic encephalopathy (confusion caused by your liver condition), blood electrolyte abnormalities and medication side effects, and eventually, you became less lethargic, despite us not knowing the exact reason that this happened. for one day during your admission, you were transferred to the intensive care unit to ensure that you could be more closely monitored. you received blood while you were in the hospital to ensure that you had an adequate amount of blood for your condition. you also came in with an injury to your kidney that we thought was due to you being dehydrated. this improved as we gave you fluids. to help you get adequate nutrition while you were lethargic, we put a tube down your nose into your gut so we could feed you. now that it is safe, we encourage you to continue feeding yourself. physical therapy saw you and feels due to your current strength, it would be best for you to continue rehabilitation when you leave the hospital, and you can return here to get that done. you should follow up with the liver doctors, and you currently have an appointment for to see them. you should also make an appointment with your primary care physician, . to discuss this admission. please follow up for an egd on . the following changes were made to your medications: these medications were started: ciprofloxacin these medications were changed: lactulose these medications were stopped: ativan tramodol trazodone furosemide metoprolol followup instructions: name: , md specialty: primary care location: hospital - address: , 2, , phone: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. department: liver center when: tuesday at 2:40 pm with: building: lm campus: west best parking: garage department: endo suites when: tuesday at 11:00 am department: digestive disease center when: tuesday at 11:00 am with: , md building: building (/ complex) campus: east best parking: main garage md procedure: enteral infusion of concentrated nutritional substances percutaneous abdominal drainage central venous catheter placement with guidance diagnoses: acidosis hyperpotassemia thrombocytopenia, unspecified anemia of other chronic disease esophageal reflux urinary tract infection, site not specified toxic encephalopathy alcoholic cirrhosis of liver acute kidney failure, unspecified unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified personal history of tobacco use chronic kidney disease, unspecified disorders of phosphorus metabolism other acquired absence of organ other ascites hepatic encephalopathy hyperosmolality and/or hypernatremia accidental fall from bed accidents occurring in residential institution other and unspecified alcohol dependence, unspecified acute alcoholic hepatitis contusion of face, scalp, and neck except eye(s) bariatric surgery status late effects of injury purposely inflicted by other person unspecified paranoid state late effect of intracranial injury without mention of skull fracture history of physical abuse body mass index 34.0-34.9, adult other cerebral degeneration alpha thalassemia 

Answer: The patient is high likely exposed to