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: cipro / doxycycline / paxil / quinine / compazine / levaquin / lithium attending: chief complaint: altered mental status/somnolence . pcp: . in hepatologist: dr. major surgical or invasive procedure: transjugular liver biopsy history of present illness: (adapted from micu admission note): . 55y/o f with sarcoidosis, copd, idiopathic cardiomyopathy with ef 40% and diastolic dysfunction, varices s/p tips and hypothyroidism presenting today with confusion. she has had multiple recent hospital admissions (4 in the last few weeks) for similar symptoms that required intubation and resolved with lactulose therapy. she was last d/c on and was in her usoh at home per her husband and compliant with her medications. she did have one episode over the weekend where she was nauseous and had nbnb emesis x1. other than this she has been taking po and without complaint. she reportedly was taking her lactulose and had 5bm prior to her evening dose which she then skipped. on admission, she was difficult to arouse and he called 911 and had her taken to hospital. there, she remained difficult to arouse and received 1 dose of lactulose after a ngt was placed. her glucose level was in the 60s so she also received glucagon and d5 containing ivf. the husband denies any antecedent fevers, chills, sob, chest pain, abdominal pain, brbpr, melena, hematemesis, dizziness, loc, falls, paresthesias, or weakness. he claims that she is taking her lactulose as directed and that he administers the doses to her and watches her take them. the patient concurs that she adheres strictly to her medical regimen. prior to her episodes of ams, she reports increased fatigue, but no other symptoms. . her liver disease is thought to be sarcoidosis, although per review of path slides "the granulomas do not contain polarizable foreign material. possible etiologies for the granulomas include drug reactions, sarcoidosis, crohn's disease, infections, and primary biliary cirrhosis." repeat biopsy showed findings consistent with prior sarcoid and now with nodular regenerative hyperplasia. the patient has had multiple admissions for encephalopathy believed to be medication non-compliance as hard stools observed on rectal exam at admission. she has grade ii varices with h/o bleeding and recurrent transfusions and gastric and colonic avm w/ h/o bleed. also severe portal hypertensive gastropathy and grade 3 esophagitis seen on egd. she is s/p tips 12/. . in our ed, she was felt to be protecting her airway though she was not following commands or opening her eyes. she received pr lactulose concerns that she would aspirate any ngt meds. she remained hemodynamically stable and her labs were significant only for thrombocytopenia (lower than her baseline) and mild lft abnormalities that are in line with her previous values. . in the icu, she was seen to be opening her eyes to voice and vocalizing (though inappropriately). she was started on lactulose and . although she did not have significant stool output her mental status improved significantly. . on transfer to the floor the patient reports feeling back to her baseline but does feel slightly constipated. she denies any dizzyness, fevers/chills, weight loss or weight gain, shortness of breath, cough, abdominal pain, hematemesis, hematochezia, melena, chest pain or palpitations. she reports a good appetite. past medical history: past medical history: #. ?hepatic sarcoid #. s/p tips #. severe portal hypertensive gastropathy #. grade 3 esophagitis #. idiopathic cardiomyopathy: -echo demonstrating an ef of 15-20% (no report, ?osh) and a p-mibi that confirmed an ef of 23% with no ischemic changes--> improving to ef 40-45%, mild-to-moderate global left ventricular hypokinesis -cardiac cath : no angiographically apparent flow-limiting lesions, mild mitral regurgitation, and severe systolic ventricular dysfunction with a left ventricular ejection fraction of 20%. -right heart cath: : normal right sided filling pressures. mild pulmonary artery hypertension. preserved cardiac index. #. copd, followed by , pfts wnl #. hx of sah s/p coiling, 2 new aneurysms seen on angio #. grade ii esophageal varices #. colonic avm and diverticulum #. evidence of cva/tia #. hypothyroidism #. anemia #. s/p hysterectomy #. s/p cholecystecomy #. s/p appendectomy #. reflex sympathetic dystrophy s/p fall, on disability, now resolved social history: married, lives in , has 2 sons and 5 grandchildren, 36 pack-year smoking hx quit 2 years ago, does not drink etoh and denies former abuse, no h/o illicits or ivdu, does not work disability for rsd. family history: mi physical exam: admission h&p to micu: pe: 98.5, 144/65, 70, 16, 98% ra gen: lying at ~ 30 degree angle in bed, ngt in place, opening eyes and tracking to voice heent: no icteric sclera, no cervical lad cv: rrr, 2/6 sem at rusb w/out radiation lungs: scattered bilateral crackles but poor inspiratory effort abd: previous midline surgical scar, non-tender, + caput medusa, no obvious ascites, mildly distended ext: trace le edema bilaterally neuro: opening eyes and orienting to voice, responds " hospital" to all questions, moving all extremities spontaneously, not following commands to squeeze hands skin: no rash . vs: tm 97.7 tc96.9 bp 95-132/40s-80s hr 60-90 rr 13-18 98-100%ra +700cc since admission gen: well-appearing, comfortable, no distress heent: nc/at, eomi, conjunctivae pink, sclera anicteric, op clear, dentures in place, mmm skin: no rashes, +spider angiomas, purplish finger tips with brittle nails and healing wounds but no e/o infection, no jaundice ln: no /poster/pre-auricular/submandibu/supraclavic ln cv: distant heart sounds, crescendo/decrescendo murmur at apex, +s1/s2, no rubs or gallops, no extra heart sounds, no heaves pul: ctab but with soft bibasilar crackles and decreased breath sounds right base : slightly distended, +caput medusae, +bs (?hyperactive), palpable spleen, nml liver span, no tympany, non-tender ext: thin, 2+radial, 2+dp l, trace dp r, no clubbing, slight cyanosis of bilat finger tips, no edema neuro: alert and oriented, answers questions appropriately, no asterixis pertinent results: admission labs: u/a: 250 glucose, otherwise negative . lactate 3.1 . ammonia: 177 . 144 109 22 ------------< 243 4.4 23 1.1 . ca: 8.3 mg: 2.2 . alt: 34 ap: 151 tbili: 1.1 alb: 3.0 ast: 50 : 82 lip: 85 . mcv 92 4.8 d > 38.5 < 64 n:77.3 band:0 l:15.5 m:4.1 e:2.7 bas:0.5 anisocy: 1+ poiklo: 1+ macrocy: occasional ovalocy: 1+ plt-est: very low . transfer labs: 141 109 16 ---------------< 106 3.2 26 1.1 . ca 7.7 ; mg 1.7; phos 3.5 . cbc: 3.9 > 26.4 < 65 . studies: cxr : since the prior examination, the patient has been extubated. a nasogastric tube remains in place with the distal tip off the inferior edge of the radiograph below the diaphragm. the lungs are well expanded; however, there is minimal bibasilar atelectasis evident. the mediastinum is unremarkable. the cardiac silhouette is stable, accounting for patient and technical factors. no effusion or pneumothorax is evident. the visualized osseous structures are unremarkable. . u/s findings: this was a limited doppler evaluation of the tips stent. again demonstrated in the right hepatic lobe is a tips stent catheter, which appears unchanged in position. color doppler evaluation shows wall-to-wall color doppler signal within the tips stent. flow velocities within the tips stent in the proximal, mid, and distal portions are 127, 173, and 175 cm/sec respectively. overall, these are in similar range to the prior studies of and . there is appropriate hepatopetal blood flow in the main portal vein. as before, no definite flow is identified within the left portal vein. impression: patent tips stent with flow velocities within similar range to recent evaluations. . small bowel follow-through : no evidence of mechanical obstruction. fecalization of the small bowel consistent with slowly resolving small bowel obstruction. small bowel fold thickening likely related to resolving obstruction and chronic liver disease. r heart cath : 1. normal right sided filling pressures. 2. mild pulmonary artery hypertension. 3. preservec cardiac index. . echo : the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild to moderate global left ventricular hypokinesis. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. ef 40-45%, diastolic dysfunction. . eeg : markedly abnormal portable eeg due to the low voltage slow and disorganized background and bursts of generalized slowing. these findings indicate a moderately severe encephalopathic condition affecting both cortical and subcortical functions. medications, metabolic disturbances, and infection are among the most common causes. there were no areas of prominent focal abnormalities, and there were no epileptiform features. . egd varices at the lower third of the esophagus grade 3 esophagitis in the gastroesophageal junction (biopsy) food in the whole stomach granularity, congestion and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy . liver biopsy: 1. focal, mild portal and minimal lobular, predominantly mononuclear inflammation with admixed eosinophils and a rare neutrophil. 2. a rare portal, non-necrotizing granuloma identified. 3. bile ducts with no diagnostic abnormalities recognized. 4. no steatosis or intracytoplasmic hyalin. 5. mild increased portal fibrosis with foci of sinusoidal fibrosis on trichrome stain (interpreted as stage 1 fibrosis). 6. no iron deposition on iron stain. note: the features are consistent with involvement by the patient's previously diagnosed hepatic sarcoidosis. the presence of focal sinusoidal fibrosis raises the possibility of a prior toxic/metabolic injury. a reticulin stain will be performed and the results reported in an addendum. . brief hospital course: ms. is a 55f w/ esld most likely from sarcoid s/p tips, severe portal gastropathy, grade ii esoph varices, cardiomyopathy w/ ef 40% and diastolic dysfunction admitted to micu for ams likely hepatic encephalopathy and possible med non-compliance, treated with lactulose with marked improvement. 1) altered mental status: extensive possible differential diagnosis but most likely etiology is continued suboptimal lactulose compliance vs subtherapeutic lactulose dose at home and resulting hepatic encephalopathy. this is especially likely given her improving mental status after only 2 doses of lactulose. cxr w/o pathology, pt remained afebrile with mild left shift, u/a without e/o infection. sbp unlikely given no abdominal symptoms and minimal ascites. recurrent hospitalizations after her tips procedure also indicate tips may be cause of her worsening encephalopathy. she was evaluated by interventional radiology for a tips reduction however the procedure was not completed as there was good portal flow across the liver. she did have a transjugular liver biopsy by ir, results were pending at time of discharge. she will follow up with dr. in clinic. 2) anemia: baseline hct low 30s. she has significant bleeding risks from varices, gastropathy and colonic/gastric avms and is likely slowly oozing. she has required transfusions in past however did not require transfusion during this admission. guaiac negative stools in-house, no e/o hematemesis or hematochezia at this time. she was continued on nadolol and lactulose. hematocrit was 32.2 on discharge. 3) sarcoidosis: liver and pulmonary involvement resulting in pulmonary hypertension and varices. complicated by several variceal bleeds resulting in tips placement. she was continued on her home prednisone dosage. 4) portal hypertension and gastropathy: secondary to sarcoidosis as above and resulting in tips placement. she continued her ppi and nadolol. 5)partial small-bowel obstruction: pt with normal small bowel follow-through and had several episodes of vomiting and abdominal x-ray showed evidence of small-bowel obstruction which resolved with bowel regimen. she continued to take po's without problem and was having bowel movements per day and was free of abdominal pain/nausea on discharge. she was given a rx for enemas which she can use if she is constipated despite taking lactulose as this worked well for her during her hospitalization. 6) chf: chronic stable moderate systolic and diastolic dysfunction non-ischemic cardiomyopathy thought to be related to her sarcoidosis. no current signs of fluid overload on exam as basilar crackles likely atelectasis. 7) copd: pfts stable over past 2 years and not requiring home oxygen therapy. she received prn nebulizer treatments. 8) hypothyroidism: continue synthroid 9) h/o rsd s/p fall: now resolved, on gabapentin and amitriptylene 10)code status - full medications on admission: 1. omeprazole 40 mg 2. prednisone 10 mg daily 3. nadolol 40 mg daily 4. levothyroxine 88 mcg daily 5. diltiazem 30 mg 6. folic acid 1 mg daily 7. ursodiol 300 mg tid 8. 400 mg tid 9. thiamine 100 mg daily 10. ferrous 325 mg 11. sucralfate 1 g qid 12. lactulose 30 ml tid 13. amitriptyline 50 mg daily 14. albuterol 90 mcg prn 15. gabapentin 300 mg discharge medications: 1. nadolol 20 mg tablet sig: two (2) tablet po daily (daily). 2. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 3. diltiazem hcl 30 mg tablet sig: one (1) tablet po bid (2 times a day). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). 6. 200 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 7. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po bid (2 times a day). 9. amitriptyline 50 mg tablet sig: one (1) tablet po hs (at bedtime). 10. gabapentin 300 mg capsule sig: one (1) capsule po q12h (every 12 hours). 11. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical x1 prn. 12. lactulose 10 gram/15 ml syrup sig: 30-45 mls po q4h (every 4 hours): to ensure bowel movements/day. disp:*qs ml(s)* refills:*2* 13. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 14. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 15. albuterol 90 mcg/actuation aerosol sig: two (2) puffs inhalation every four (4) hours as needed for shortness of breath or wheezing. 16. sucralfate 1 gram tablet sig: one (1) tablet po four times a day: do not take within 2 hours of taking your thyroid hormone medication. 17. fleets enema please use up to once daily if you are not having a bowel movement despite taking lactulose as directed. discharge disposition: home discharge diagnosis: liver disease from ?sarcoidosis . secondary diagnoses: #. ?hepatic sarcoid #. s/p tips #. severe portal hypertensive gastropathy #. grade 3 esophagitis #. idiopathic cardiomyopathy, ef 40% #. copd, followed by , pfts wnl #. hx of sah s/p coiling, 2 new aneurysms seen on angio #. grade ii esophageal varices #. colonic avm and diverticulum #. evidence of cva/tia #. hypothyroidism #. anemia #. s/p hysterectomy #. s/p cholecystecomy #. s/p appendectomy #. reflex sympathetic dystrophy s/p fall, on disability, now resolved discharge condition: stable discharge instructions: you were admitted with altered mental status that was believed to be from encephalopathy secondary to your liver disease. you were started on lactulose therapy and . you also had a liver biopsy while you were in the hospital. the results of the biopsy were still pending at the time of your discharge. you can follow up with dr. to obtain these results. . you had an episode of vomiting and an x-ray showed evidence of a small bowel obstruction but you did not require any further management. you were tolerating food and passing gas and stool. . please take all medications as prescribed. you must take lactulose therapy four times a day to ensure at least 3 bowel movements a day. you were also given a prescription for fleets enemas, which you should use if you are not having at least 3 bowel movements per day. . take all medications as directed, you were given a prescription for rifaxamin which you should take every day. please call your physician or proceed to the emergency department if you develop any concerning symptoms such as persistent fevers, worsening abdominal pain or fluid, persistent vomiting, shortness of breath, confusion or chest pain. call your doctor if you are not having at least three bowel movements per day. followup instructions: please call and an appointment to follow up with dr. , the phone number is . please call your primary care doctor an appointment to follow up within one to two weeks of discharge from the hospital. md procedure: transjugular liver biopsy diagnoses: other primary cardiomyopathies anemia, unspecified esophageal reflux congestive heart failure, unspecified portal hypertension unspecified acquired hypothyroidism sarcoidosis other sequelae of chronic liver disease hepatic encephalopathy esophageal varices in diseases classified elsewhere, without mention of bleeding other specified disorders of stomach and duodenum lung involvement in other diseases classified elsewhere chronic combined systolic and diastolic heart failure 

Answer: The patient is high likely exposed to