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: sigmoidoscopy history of present illness: ms. is a 44 y/o female with a hx of ugib duodenal ulcers and etoh liver disease who was transferred from hosptial due to altered mental status. . as per her sister, she was recently admitted to hospital for an upper gi bleed. she was discharged to detox facility for a couple of days. when she came home from detox, she was mildly confused. over the next few she become progressively more confused and had significant decrease in her functional status. also having frequent diarrhea. her sister took her to her pcp who promptly sent her to the ed. in the ed at (per report) it was thought her mental status may be related to her liver disease and she was transferred to . . in the ed, initial vs: 98.0 90 113/50 18 98%. she had a head ct which was negative for an acute process. there was no ascitic fluid that was visulized therefore could not perform a diagnostic tap. she was given lactulose and ceftriaxone. ? given narcan with improvement of mental status. . overnight, cr was found to be 5.1 with bun of 15. wbc 22. u/a suggestive of uti. she was given 100g albumin for hrs and ceftriaxone for uti, ? sbp. this morning on rounds, she was thought to be acutely confused, and transfer to the micu transfer was requested for altered mental status and possible endoscopy. on evaluation this morning, she was confused and unable to give a history. she denied having any discomfort. she oriented to self but not to place and time. . review of systems: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: alcohol abuse social history: lives with his eldest of 2 sons. lots of family support (mother, sisters, ) - requires 24 hour care at home. not currently employed, on ssi. - smoking: quit > 16 yrs ago, 25 pack year history - etoh: history of abuse, last drink > 22 yrs ago - drugs: history of polysubstance abuse including cocaine, crack, barbiturates, amphetamines, and marijuana. none for 20 years. family history: no pertinent family history, including psc, liver disease, or other gastrointestinal disease. (has identical twin brother without above conditions). grandfather with diabetes. physical exam: admission physical exam: vs - 98.1 132/74 96 20 99/ra general - nad, drowsy, confused heent - scleral icterus neck - supple, no thyromegaly, no jvd lungs - cta bilat, no r/rh/wh, good air movement, mild expiratory wheezing, resp unlabored, no accessory muscle use heart - rrr, no mrg, nl s1-s2 abdomen - nabs, distended but soft/nt, no masses or hsm, no rebound/guarding extremities - several punctures in volar arms with surround erythmea, ? injection drug sites vs. prior ivs. bilateral le 3+ edema neuro - aaox1, mild left facial droop, speech fluent, no pronator drift . discharge exam: afebrile, hd stable, on ra general: well appearing 51yo m. comfortable, appropriate and in good humor. mildly jaundiced. heent: sclera icteric though improved. perrl, eomi. neck: supple with low jvp cardiac: rrr, iii/vi systolic murmur with best heard at lusb. lungs: resp were unlabored, no accessory muscle use, moving air well and symmetrically. ctab, no crackles, wheezes or rhonchi. abdomen: normoactive bs. distended but soft, non-tender to palpation, tympanic to percussion, no hsm or tenderness. extremities: wwp, trace lle (reduced from baseline). neuro: a and o x 3; approrpiately mentating; motor and sensory grossly intact pertinent results: admission labs: 05:40pm blood wbc-22.4* rbc-3.18* hgb-10.4* hct-33.0* mcv-104* mch-32.9* mchc-31.7 rdw-19.2* plt ct-387 05:40pm blood neuts-74* bands-0 lymphs-16* monos-5 eos-0 baso-0 atyps-2* metas-2* myelos-1* 05:40pm blood pt-19.3* ptt-44.8* inr(pt)-1.8* 05:40pm blood glucose-81 urean-15 creat-5.2* na-131* k-3.2* cl-97 hco3-16* angap-21* 05:40pm blood alt-52* ast-150* alkphos-265* totbili-4.8* dirbili-4.0* indbili-0.8 05:40pm blood lipase-23 05:40pm blood albumin-2.3* calcium-8.5 phos-3.6 mg-2.2 02:37pm blood ammonia-147* 06:20am blood osmolal-288 06:20am blood hbsab-negative hbcab-negative 05:40pm blood hcg-<5 05:40pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 06:20am blood hcv ab-negative 03:06am blood type-art po2-90 pco2-26* ph-7.42 caltco2-17* base xs--5 intubat-not intuba 05:51pm blood glucose-77 lactate-1.7 na-132* k-3.2* 03:06am blood hgb-10.2* calchct-31 o2 sat-96 cohgb-1 methgb-0 03:06am blood freeca-1.14 . discharge labs: 07:15am blood wbc-26.7* rbc-2.46* hgb-7.8* hct-25.5* mcv-104* mch-31.6 mchc-30.6* rdw-18.4* plt ct-490* 07:15am blood pt-22.1* inr(pt)-2.1* 07:15am blood glucose-92 urean-36* creat-1.3* na-136 k-4.3 cl-105 hco3-17* angap-18 07:15am blood alt-25 ast-88* alkphos-151* totbili-3.5* 07:15am blood albumin-2.7* calcium-8.1* phos-5.5* mg-1.7 . micro: bcx negative x4 ucx negative x2 c.diff negative . imaging: ct head technique: axial mdct images were acquired of the head without contrast and reformatted into coronal and sagittal planes. findings: the exam is somewhat limited by patient motion, although repeat scans were performed. there is no intracranial hemorrhage, extra-axial collection, or mass effect. the ventricles and sulci are normal in size and configuration. matter/white matter differentiation is preserved. the orbits are normal appearing. the soft tissues are unremarkable. there is an air-fluid level within the left maxillary sinus, and mucosal thickening of ethmoid air cells. the frontal sinuses are clear. an air-fluid level is seen in the sphenoid sinus with aerosolized debris. the mastoid air cells and middle ear cavities are clear. there is no osseous abnormality. impression: 1. no acute intracranial process. 2. air-fluid levels in multiple paranasal sinuses. . liver ultrasound: findings: the liver is diffusely coarse and echogenic consistent with history of liver disease. no focal lesions are seen. the gallbladder appears normal. the common bile duct is mildly dilated measuring up to 8 mm. no definite stone is seen within the common bile duct. to and fro flow is seen within the main portal vein. there is no ascites. the right kidney measures 13.9 cm in the long axis and is normal in appearance without hydronephrosis or stones. impression: 1. diffusely echogenic liver consistent with history of alcoholic hepatitis. 2. to and fro flow within the main portal vein without portal vein thrombosis. 3. common bile duct measures up to 8 mm and is thus dilated. mrcp/ercp could better evaluate for an obstructing cause. . renal ultrasound: the right kidney measures 12.1 cm. the left kidney measures 12.5 cm. there is no hydronephrosis, stones or masses. the bladder is only minimally distended and cannot be assessed. small portion of a urinary catheter is seen. impression: normal renal son . hida scan: radiopharmaceutical data: 4.2 mci tc-m disida (); history: common duct dilation, leukocytosis, and right upper quadrant pain. evaluate for biliary pathology. methods: following the intravenous injection of tracer, serial one-minute images of tracer uptake into the hepatobiliary system were obtained for 75 minutes. a delayed static image was obtained at 5.5 hours. images of the injection site were also acquired. interpretation: serial images over the abdomen show poor uptake of tracer into the hepatic parenchyma in a homogeneous pattern. at 15 minutes, the small bowel is visualized, although no tracer uptake is seen within the gallbladder throughout the first 75 minutes. the patient returned to the nuclear medicine suite after 5.5 hours for additional imaging, which revealed tracer activity within the gallbladder. impression: 1. diffusely poor tracer uptake throughout the liver is consistent with poor hepatocellular function. 2. tracer activity within the gallbladder on delayed images excludes the diagnosis of acute cholecystitis. 2. excretion of tracer into the small bowel excludes the diagnosis of complete biliary obstruction. . cxr history: alcoholic hepatitis. aspiration event. impression: ap chest compared to : consolidation in the perihilar left lung and in the right upper lung extending to the apex is readily explained by massive aspiration. a smaller region of consolidation may be present in the right lung projecting behind the lower pole of the right hilus. mild cardiomegaly and mediastinal vascular engorgement have increased suggesting cardiac decompensation. dr. was paged. . cxr bilateral upper lobe consolidation is slightly more pronounced today than yesterday. whether this is due to progression of pneumonia or deposition of early edema in a region of pre-existing pneumonia is difficult to say since the mediastinal veins are dilated in the supine position. heart size is top normal, and there may be mild pulmonary vascular engorgement, but no clear edema elsewhere. there is no appreciable pleural effusion. nasogastric tube passes into the stomach and out of view . sigmoidoscopy - polyp at 8cm in the rectum - polyps at the ranging distance from 18 cm to 28 cm in the distal sigmoid colon - grade 2 internal hemorrhoids - otherwise normal sigmoidoscopy to splenic flexure - recommendations: patient will need colonoscopy for removal of polyps when her alcoholic hepatitis improves and her inr is less than 1.5. brief hospital course: ms. is a 44 year old female with a history of upper gi bleed (ugib) secondary to duodenal ulcers and alcoholic liver disease who was transferred from hospital due to altered mental status. . active problems by issues: . # alcoholic hepatitis: hepatic encephalopathy, jaundice, lfts with alcoholic picture, viral studies were negative. she has signficant synthetic dysfunction as well with a discriminant function of 51 on admission. steroids were deferred initially for possible acute hepatitis since her lfts and bilirubin were improving in the micu with fluids. hepatitis b and c virus serologies negative. on floor tube feeds were started to augment nutrition and improve hepatitis. ngt was accidentally self removed. nutrition reconsulted and felt she could take adequate caloric intake to treat alcoholic hepatitis and so ngt was not replaced. discriminant function 36 on discharge but patient clinically much improved, walking around floor, jaundice improving, poing well with downtrending t.bili <4 on discharge. patient discharged in improved condition agreement with plan to abstain from alcohol completely. she was discharged home with outpatient alcohol rehabilitation. . # encephalopathy: the patient was transferred to the micu for altered mental status (ams); likely due to hepatic encephalopathy. a lumbar puncture was attempted, but unsuccessful. she received narcan in the ed to which there was a questionable improvement in her mental status. she was given lactulose and rifaxamin, aiming for 4 bowel movements/day and was also started on empiric antibiotic coverage since she had a leukocytosis with the ams including acyclovir, vancomycin, ampillicin, and ceftriaxone. the patient then had a right upper quadrant ultrasound that showed dilated common bile duct, so she underwent a hida scan which ruled out cholangitis as a cause of her ams and leukocytosis. at that point, ampicillin was discontinued and the patient was continued on vanc/acyclovir, flagyl/ceftriaxone was added for intra abdominal pathology. antibiotics were changed to vanc/zosyn after she developed pna. the patient also has a drinking history and was started on thiamine. as the patient's mental status slowly improved, the acyclovir was stopped, as the concern for encephalitis lessened. on arrival to the floor her mental status continued to improve with lactulose and rifaximin. he encephalopathy was attributed to alcoholic hepatitis and continued to improve throughot duration of stay. . # acute renal failure: the patient was found to be in arf (baseline creatinine is around 0.9) and presented with creat 5.2. fena of 0.22 consistent with prerenal etiology and muddy brown casts were found in the urine sediment suggesting acute tubular necrosis (atn). with significant liver dysfunction hepatorenal syndrome (hrs) was of concern. renal consulted but thought that the etiology was pure atn. she underwent a renal ultrasound which was normal and an albumin challenge which ruled out hepatorenal syndrome. creatinine continued to improve after albumin was given and with improvement in hepatitis. . # aspiration pneumonia: she developed aspiration pneumonia on with a rising leukocytosis. she was fed with a -gastric tube and continued on vanc/zosyn. she completed an hcap course with vanc/zosyn and she remained on ra throughout duration of floor stay. . # leukoctosis: patient with profound leukocytosis which uptrended initially and remained elevated. initial concern was for hcap which was adequately treated. c.diff returned negative multiple times. leukocytosis remained elevated despite hcap treatment and so wbcs thought most likely related to alcoholic hepatitis rather than infectious etiology. cultures negative otherwise in work up. . # upper gi bleed (ugib): presented with bright red blood per rectum (brbpr), and a hematocrit trending down 33 -> 30. upon further questioning, she reported that she was having her menses. her hematocrit remained stable and she did not recieve any blood transfusions. this was initially stable until 2 days prior to discharged when on the floor she began having gib. patient again felt this was menses though rectal exam with internal hemorrhoids. flex sig was completed given concern for rectal bleed which showed grade 2 hemorrhoids and multiple recto-sigmoid polyps. polyps were not removed because of elevated inr and tenuous alc hep. repeat colonoscopy deferred to outpatient after improvement in hepatitis and coagulopathy. . # anion gap acidosis: she is noted to have a gap of 18 upon admission labs. her lactate was within normal limits, no osmolar gap. given bun unlikely to be uremia, but possible contribution of acute renal failure. also possible alcoholic/starvation ketosis. gap closed and remained stable after transfer to floor from micu. . # sodium imbalance: she likely had hypervolemic hyponatremia due to liver dysfunction. she was maintained on a fluid restricted diet. she later developed hypernatremia while she was on tube feeds only for aspiration. this was treated with free water flushes through the ng tube. after hepatitis and hcap improved/resolved her na remained stable requiring no further intervention. . # macrocytic anemia: with significant alcohol use she is likely either folate or b12 deficient. . # peptic ulcer disease (pud): she has a history of duodenal ulcers and was continued on pantoprazole. . transitional issues: - colonoscopy needs to be completed as an outpatient with removal of colonic polyps after inr improves - patient counseled extensively on the importance of alcohol abstainence and she is agreeable with plan. should continue reinforcing abstinence - consider baclofen for alcohol abuse prophylaxis medications on admission: oxycodone 5mg vitamin b12 ondansetron 4mg pantoprazole 40mg daily discharge medications: 1. cyanocobalamin (vitamin b-12) 100 mcg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. rifaximin 550 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 4. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 5. hydrocortisone 2.5 % cream sig: one (1) appl rectal prn (as needed) as needed for rectal irritation. disp:*1 tube* refills:*0* 6. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po twice a day. disp:*1800 ml(s)* refills:*1* 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 9. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every twelve (12) hours as needed for nausea. discharge disposition: home discharge diagnosis: primary diagnosis: hepatic encephalopathy acute kidney injury discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , . you were admitted to the hospital because you were more confused than your baseline and there was concern that you had bleeding from your intestines. we did not find that there was any significant bleeding in your intestines and the levels of your blood stayed steady. you do have a hemorrhoid which bleeds a little bit when you have bowel movements. flex sigmoidoscopy performed showed polyps in your sigmoid colon which should be followed up after you are discharged. . for your confusion, we think that it relates to your liver disease. when your liver disease progresses, a condition called cirrhosis, your body builds up toxic substances. you were treated with lactulose to make you have bowel movements which will remove these toxic substances. . finally, you developed a pneumonia because when you swallow the food sometimes goes into your lungs. this is called aspiration. you have to eat very slowly to help the food go into your stomach not your lungs. . the following changes were made to your medications: - start folic acid 1mg daily - start thiamine 100 mg daily - start vitamin d 400 unit daily - start hydrocortisone cream: apply rectally as needed for irritation - continue pantoprazole - start lactulose 30 ml twice daily - start rifaximin 550 mg twice daily . it is also very important that you keep all of the follow-up appointments listed below. . it is also very important that you have a colonoscopy to evaluate polyps in your colon. . it was a pleasure taking care of you in the hospital! followup instructions: name: , md address: ,ste 8a, , phone: appointment: wednesday 10:45am md procedure: enteral infusion of concentrated nutritional substances flexible sigmoidoscopy diagnoses: acidosis anemia, unspecified acute kidney failure with lesion of tubular necrosis hyposmolality and/or hyponatremia hypopotassemia chronic kidney disease, unspecified other b-complex deficiencies pneumonitis due to inhalation of food or vomitus disorders of phosphorus metabolism blood in stool hepatic encephalopathy hyperosmolality and/or hypernatremia other and unspecified alcohol dependence, continuous internal hemorrhoids without mention of complication acute alcoholic hepatitis peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction benign neoplasm of rectum and anal canal 

Answer: The patient is high likely exposed to