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: iv dye, iodine containing / keflex / codeine / isoniazid / indocin attending: chief complaint: melena and hypotension. major surgical or invasive procedure: 1. nasogastric lavage history of present illness: 66 yo female with pmh significant for dm i, lupus, esrd on hd (tues, , sat), afib on coumadin who is admitted for melena x 2 days and hypotension. pt states that she developed mild abd discomfor and nausea on sun (5 days prior to admission). she then developed abd bloating and had one episode of melena on wed. she describes as 100cc of black tarry stool. she had another small episode of dark stool on and had dark semi-formed stool today. she had one prior episode of melena many years ago due to diverticulitis that self resolved. she had egd and colonoscopy ~ 1 year ago which showed gastritis and she had polyps that were biopsy and "pre-cancerous". she denies having any fever or chills. she states that some people had the "stomach flu" at her hd unit, but denies having any sick contacts. other episodes of emesis, no hematemesis. she is drinking and eating without any problems. on her hd yesterday her bp was lower than at her baseline of 120s/50s-60s as she was coming off. so, she was given 1.5l to get her to her dry weight. her hgb was found to be 11 and her inr 3.9. she continued to feel unwell today and her pcp recommended that she come in to the ed. she also had one episode of fall on monday when she lost balance and hit her head on the floor. she denies loosing conscious. no ha, no changes in vision, no weakness noted, or lethargy. she has a small lump on the right side of her head. . in the ed, initial vs were: t 97.8, 111/51, 20, 96% on ra. her bp dropped to 84/50 after pt has taken her morning meds including 360mg of dilt and her 200mg of metoprolol for her a-fib. she was given 1 l of iv fluids and her bp responded 97/69. her labs were notable for hct 34.4, hgb 11.6 which is unchanged from yesterday. inr of 3.8. patient had ng lavage with 120 cc clear fluid. a foley was placed, but no urine return. pt states that she is oliguric at baseline and had recent hx of uti with e.coli for which she was treated with cipro. prilosec 40 mg iv given, dilt 120mg (home dose), gi consulted they will follow. . on arrival to the icu, pt is comfortable in nad. her vitals afebrile, hr in 110s, bp 100/63, sating 94% on ra. 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: - dmi - esrd, on hd since - chronic anemia - gastritis - afib on coumadin, metoprolol and dilt - pace maker in place - lupus, + anti-phospholipid antibody - recurrent utis with e.coli - arthritis with spinal stenosis - cholecystitis social history: patient is a retired nurse who lives by herself. she denies smoking, drinking or using ilicits drugs. family history: sister with breast ca yo. father with ca and brother who died of esophageal ca. physical exam: upon admission: general: alert, oriented, no acute distress heent: sclera anicteric, mm dry, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, tachy, no murmurs, rubs, gallops abdomen: soft, obese, mildly tender on epigastric area, and diffusely tender on bil lower quads, non-distended, + hyperactive bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. + 1 bil le pitting edema of le. venous stasis of bil le. fistula on r arm with + bruit and thrill. old fistula on l arm skin: dry and , ecchymotic area around fistula on righ arm, no hematoma neuro: cn ii-xii, eom intact, perrla, symmetrical strength on bil ue/le. . at discharge: general: alert, oriented, no acute distress, sitting in chair heent: sclera anicteric, perrl, mmm, oropharynx clear neck: supple, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: rrr, nl s1, s2, no murmurs, rubs, gallops abdomen: soft, obese, nontender, non-distended, + bowel sounds, no rebound tenderness or guarding gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ le edema with compression stockings on. venous stasis of bil le. fistula on r arm with + bruit and thrill. old fistula on l arm. large hematoma on left forearm with newly placed piv. skin: dry and , ecchymotic area around fistula on right arm, no hematoma neuro: cn ii-xii pertinent results: admission labs: 11:20am wbc-9.5 rbc-3.71* hgb-11.6* hct-34.4* mcv-93 mch-31.3 mchc-33.6 rdw-15.1 11:20am neuts-83.4* lymphs-8.9* monos-4.9 eos-2.4 basos-0.3 11:20am plt count-221 11:20am pt-37.0* ptt-59.7* inr(pt)-3.8* 11:20am glucose-148* urea n-43* creat-6.0* sodium-138 potassium-6.0* chloride-90* total co2-23 anion gap-31* 11:20am alt(sgpt)-32 ast(sgot)-74* alk phos-149* tot bili-0.7 11:20am lipase-51 11:20am albumin-3.8 calcium-9.1 phosphate-7.1* magnesium-2.3 11:20am ctropnt-0.08* 11:30am lactate-2.9* k+-4.2 09:48pm ck-mb-4 ctropnt-0.07* labs prior to discharge: 07:45am blood wbc-4.9 rbc-3.21* hgb-10.2* hct-30.0* mcv-94 mch-31.8 mchc-34.1 rdw-14.8 plt ct-207 06:41am blood pt-37.4* ptt-57.4* inr(pt)-3.9* 06:20am blood pt-36.7* ptt-57.4* inr(pt)-3.8* 09:30am blood pt-28.8* ptt-46.3* inr(pt)-2.8* 05:40pm blood pt-24.3* inr(pt)-2.3* 07:45am blood pt-19.2* ptt-36.8* inr(pt)-1.8* 07:45am blood glucose-147* urean-39* creat-6.4* na-140 k-3.9 cl-98 hco3-26 angap-20 07:45am blood calcium-8.6 phos-5.2* mg-2.1 micro: blood culture pending urine culture pansensitive klesiella urinalysis: contaminated specimen with >50 epithelial cells brief hospital course: 66 yo female with pmh significant for dm i, lupus, esrd on hd (tues, , sat), and afib on coumadin who is presented with melena x 2 days and hypotension concerning for upper gi bleed in the setting of a supratherapeutic inr. while waiting for the inr to trend down, her hospital course was complicated by afib with rvr and difficult iv access. . # gi bleed: pt presented with 2 day history of melena in the setting of epigastric pain and prior egd findings most likely upper gi bleed secondary to gastritis. she had a negative ng lavage and brown guaiac positive stool in the rectal vault. patient was monitored overnight in the micu where her vitals and hematocrit remained stable. inr was not reversed in the setting of her stable hct and no active bleeding, though coumadin was held. she was put on ppi . her diltiazem was continued but her metoprolol was held to avoid hypotension. she has a history of gastritis and diverticulitis seen on egd and colonoscopy 1 year ago. gi was consulted and recommended endoscopy. she had a brown bowel movement prior to transfer from the micu to the floor. she had only one peripheral iv and a request for a power picc was placed, but the patient refused picc placement. her diet was advanced as she remained stable. her inr drifted down as her warfarin was held. she was ordered for a heparin drip once her inr was less than 2.5, but she lost iv access at this time. a peripheral iv was placed after many attempts. at that point, the patient refused the heparin drip despite acknowledging the risk of significant and possibly fatal clot when off anticoagulation. egd was planned for the afternoon on the day of discharge as her inr was 1.8 that morning. prior to the procedure she lost iv access, and refused further peripheral or central access. gi was unable to proceed with an egd. as she had recently been stable, she was discharged to follow up with gi as an outpatient. she will take lovenox as a bridge to a therapeutic inr of 2.5-3 which she has previously done and is comfortable with. . # afib with rvr: pt has hx of a-fib on metoprolol/diltiazem with a pacemaker for rate control. she was given a lower dose of dilt in the ed and hr tachy on admission. she was continued on diltiazem given her hemodynamic stability, but held her metoprolol 200 mg . she had one episode of afib with rvr without hemodynamic instability. her metoprolol was restarted and uptitrated to her home dose. given her chads2 score of 2, she is anticoagulated with warfarin at home. her goal inr is 2.5 to 3 given her history of antiphopholipid antibody syndrome. her coumadin was held given concern for possible bleed, but restarted at 4.5mg per day per her upon discharge. . # esrd: pt receives hd on t, th, sat. renal was notified about the patient's admission and arrangements were made for dialysis the following morning. she was ultrafiltrated during the first session given concern for hypotension in the setting of ugib. she was continued on home nephrocaps and sevelamer and underwent a normal dialysis session on the day of discharge. . # lupus: continued home plaquenil 200mg 3x week. . # back pain: continued on gabapentin. . # s/p fall: pt had fall on monday and hit head on floor with subsequent small lump on the side of her head. given her elevated inr, this is concerning for subdural hematoma. however given that her neuro exam was normal and there was no ha or any neurologic c/o, did not image with ct. neurologic exam and ms was monitored and wnl. . #contaminanted ua: patient reported symptoms of bladder spasm and dysuria and culture grew gnr's but specimen was contaminated with >50 epi's. she is on hd so likely has colonization of her bladder. repeat ua improved but still with leuk est, bact, and wbc, however at this point her symptoms improved. . # transaminitis: ast elevated on admission due to hemolysis, but was subsequently normal. alk phos elevated, bilirubin normal. patient has history of cholithisis but was without fever, chills, or ruq pain to suggest acute cholecystitis. . # dm: diabetic diet, continued on insulin sliding scale only. sugars well controlled. . # code status: during this admission, the patient was full code. medications on admission: -coumadin 5mg -dilt 360mg po tid -epogen 3x per week on hd days -ferrous sulfate -gabapentin 300mg qday -plaquenil 200mg 3x week -toprol xl 200mg -omeprazole 20mg -nephrocaps -sertraline 100mg daily -sevelamer 1600mg tid discharge medications: 1. warfarin 5 mg tablet sig: one (1) tablet po once a day. (of note: the advised a dose of 4.5mg daily after the patient received her discharge papers. the patient was understood these instructios.) 2. diltiazem hcl 360 mg capsule, extended release sig: one (1) capsule, extended release po three times a day. 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 4. gabapentin 300 mg capsule sig: one (1) capsule po daily (daily). 5. hydroxychloroquine 200 mg tablet sig: one (1) tablet po qmowefr (monday -wednesday-friday). 6. toprol xl 200 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po twice a day. 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 8. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 9. sertraline 100 mg tablet sig: one (1) tablet po once a day. 10. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 11. lorazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for anxiety/insomnia. 12. lovenox 40 mg/0.4 ml syringe sig: forty (40) mg subcutaneous once a day: please use daily until your inr <2.5. 13. epogen injection discharge disposition: home with service facility: discharge diagnosis: primary diagnosis: upper gi bleed, atrial fibrillation with rapid ventricular rate, anticardiolipin antibody syndrome (of note: this is an error recorded in the discharge paperwork. she has antiphospholipid antibody syndrome, not anticardiolipin antibody syndrome.) secondary diagnosis: diabetes mellitus, end stage renal disease on hemodialysis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you during your stay here at . you were admitted for an upper gi bleed in the setting of an elevated inr. your warfarin was held to let your inr fall. an egd was planned once your inr was low enough to minimize the risk of rebleeding. however, due to access issues, they were not able to proceed. you decided instead to use conservative management with watchful waiting for this issue. you understand the risk for this approach which include rebleeding, falls, fainting, and death, especially while on anticoagulation. during your stay your medications for afib were held to avoid low blood pressures if your bleeding continued. you had one episode of fast afib which quickly responded to your home medications. please continue to have your inr checked at each dialysis session. these results should be faxed to dr. office. the following changes were made to your medication regimen: start lovenox daily until your inr is 2.5 restart coumadin tomorrow followup instructions: the following appointments were made for you: name: , location: - address: , , phone: appointment: thursday 3:00pm we would recommend that you follow up with a gastroenterologist to evaluate the location and the cause of your bleeding. please call ( to schedule an appointment. procedure: hemodialysis diagnoses: systemic lupus erythematosus anemia of other chronic disease end stage renal disease renal dialysis status diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled atrial fibrillation hypotension, unspecified long-term (current) use of anticoagulants unspecified gastritis and gastroduodenitis, with hemorrhage cardiac pacemaker in situ other and unspecified nonspecific immunological findings 

Answer: The patient is high likely exposed to