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: iodine / gluten attending: chief complaint: shortness of breath, weakness, malaise major surgical or invasive procedure: arterial line placement aortic valvuloplasty flexible sigmoidoscopy history of present illness: ms. is an 87 year old female who presented to this morning with complaint of dyspnea going on for several days, gradual in onset. she has a h/o critical as, is being considered for an avr. she presents with increasing shortness of breath and generalized weakness. additionally she had an episode of vomiting last night. does not know if she had any hematemesis or coffee-ground emesis . she reports that she has chronically black stools due to iron supplementation. noted to be hypoxic on arrival. her ros at was notably positive for orthopnea, cough, n/v, dysuria, and negative for chills/fever, abd pain, diarrhea. cxr was thought to be consistent with chf. her hct was found to be 22 down from a previous value of 27, with guaiac positive stools, and inr found to be 5. she was given vitamin k 10mg iv, 1 unit prbcs, lasix 10mg iv. hct bumped to 30 after 1 unit prbcs, and inr decreased to 3.9 after vit k. she was then transferred to for further management. ekg: rate: 63 bpm. axis left axis deviationst/t non-specific st changes rhythm: paced on arrival to our ed, initial vs were: 96.5 78 158/79 20 98% 6l nasal cannula, she eventually required nrb and desatted when weaning was attempted. protonix bolus + gtt was started; she was type and crossed, given 2 units ffp, given lasix 10mg iv. ekg was noted as vpaced rhythm. gi consulted but have not seen her yet. on arrival to the micu, patient's vs. t97.4 hr 75 bp 151/44 rr 21 sao2 87% on 100% nrb review of systems: unable to obtain patient's respiratory status and confusion. past medical history: 1. critical aortic stenosis, awaiting valve replacement in . 2. diastolic dysfunction, normal ef. 3. mild ar and moderate mr. 4. paroxysmal atrial fibrillation on coumadin. 5. status post permanent pacemaker. 6. tia in and left occipital stroke in . 7. status post right carotid endarterectomy in . 8. chronic kidney disease, stage 4, baseline creatinine around 2.2-2.4. 9. hypertension. 10. duodenal diverticulum and diverticulosis. 11. history of celiac disease. 12. history of chronic pancreatitis likely related to celiac disease. 13. status post cholecystectomy. 14. gerd. 15. bilateral renal artery stenosis. 16. history of acute renal failure during diuresis. 17. history of hyponatremia in the setting of chf. 18. status post total abdominal hysterectomy. 19. anemia of chronic disease, baseline hematocrit around 28-30. 20. hyperlipidemia. social history: mostly independent with adls. she was a l&d nurse for 40 years. no reports of alcohol, drugs or tobacco abuse. lives alone, independent adls. retired l&d nurse. family history: father with cardiac disease, otherwise non-contributory physical exam: admission exam: vitals: t97.4 hr 75 bp 151/44 rr 21 sao2 87% on 100% nrb general: in acute respiratory distress, somnolent, can state name and location but not year/date neck: jvd elevated 3cm above clavicle cv: difficult to auscultate, normal rate, loud systolic murmur lungs: diffuse crackles throughout all lung fields abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding ext: no apparent edema. warm, well perfused, 2+ pulses, no clubbing, cyanosis. neuro: oriented x2, somnolent skin: stage 2 on coccyx . discharge exam: general: intermittently confused, delerious neck: jvd elevated 3cm above clavicle cv: difficult to auscultate, normal rate, loud systolic murmur lungs: diffuse crackles throughout all lung fields abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding ext: no apparent edema. warm, well perfused, 2+ pulses, no clubbing, cyanosis. neuro: oriented x2, somnolent skin: stage 2 on coccyx pertinent results: admission labs: 03:15pm blood wbc-15.9* rbc-3.23* hgb-11.0* hct-30.9* mcv-96 mch-34.2* mchc-35.7* rdw-15.0 plt ct-248 03:15pm blood neuts-81.9* lymphs-11.5* monos-6.3 eos-0.2 baso-0.1 03:15pm blood pt-39.4* ptt-49.8* inr(pt)-3.9* 08:11pm blood fibrino-470* 08:11pm blood glucose-128* urean-63* creat-2.6* na-123* k-4.2 cl-83* hco3-22 angap-22* 08:11pm blood alt-25 ast-43* ck(cpk)-135 alkphos-103 totbili-1.3 08:11pm blood lipase-212* 03:15pm blood ck-mb-5 03:15pm blood ctropnt-0.27* 08:11pm blood albumin-4.3 calcium-9.1 phos-5.3* mg-2.6 08:11pm blood osmolal-275 08:11pm blood digoxin-2.2* 08:00pm blood type-art po2-61* pco2-45 ph-7.35 caltco2-26 base xs-0 08:00pm blood lactate-1.8 08:15pm urine color-yellow appear-clear sp -1.009 08:15pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-sm 08:15pm urine rbc->182* wbc-2 bacteri-few yeast-none epi-<1 transe-<1 08:15pm urine mucous-rare 08:15pm urine hours-random creat-18 na-54 k-48 cl-64 08:15pm urine osmolal-315 other pertinent labs: 03:15pm blood ctropnt-0.27* 08:11pm blood ck-mb-5 ctropnt-0.30* probnp-* 03:40am blood ck-mb-4 ctropnt-0.25* microbiology: blood culture : negative blood culture : negative urine legionella antigen : negative urine culture : negative imaging: cxr : worsening right lower lobe pneumonia and mild pulmonary edema tte : the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. there is critical aortic valve stenosis (valve area <0.8cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the velocities across the aortic valve have increased slightly. the severity of aortic stenosis remains critical. the other findings are similar. brief hospital course: 87 year old female with critical as presenting with gradual-onset dyspnea and weakness, found to have anemia with guaiac positive stools, as well as new hypoxia and leukocytosis with likely pneumonia and acute congestive heart failure exacerbation. # goals of care: when the patient initially presented, she was considered a candidate for possible percutaneous aortic valve replacement (core valve). however given her tenous fluid status, refractory gi bleeding on anticoagulation and delerium, she was no longer considered a candidate. several family meetings were convened to assess her goals of therapy and care, and it was decided by all including her son and daughter , and the care team that further interventions would not be of benefit. she was discharged to a skilled nursing facility with the understanding that care will be aimed at maintaining her comfort and with the expectation that her condition will worsen in the near future and further hospitalization are not indicated. this was discussed with her health care proxy, her son, on : , and he agreed with this assesment. #perineal irritation: to gi bleed and constant oozing she has significant perineal pain. she requires frequent perineal cleanings and aquafor cream applications. topical lidocaine and prn 1mg dilaudid were also helpful for pain control. she has not required dilaudid since . # critical as: thought to be very likely to be contributing to her dyspnea and hypoxia. her cardiologists were contact and as she was being considered for aortic valve replacement in the near future, she was transferred to the ccu for evalution for prompt replacement vs. valvuloplasty on this admission. she went for valvuloplasty on during which time the initial gradient was a mean of 72 mm hg and this decreased to 20 mm hg translating into a valve area increase from 0.4 cm2 to 1.06 cm2 post-valvuloplasty. she is maintained on metoprolol and amlodipine predominantly to maintain a low heart rate and reduce her symptoms in the setting of atrial fibrillation. # acute hypoxemic respiratory failure: patient presented with dyspnea, orthopnea, and hypoxia, with worsening of hypoxia after receiving transfusion 1 unit prbcs and 2 units ffp for anemia and supratherapeutic inr. patient started on non-rebreather in ed, and on arrival to icu had o2 sats in mid-high 80s on nrb with 95% fio2 plus 6l nc. abg 7.35/45/61. differential diagnosis included pneumonia (leukocytosis, cough, rll infiltrate on cxr), acute pulmonary edema/chf exacerbation in setting of critical as and recent transfusions (diffuse crackles on exam, pulm edema on cxr, bnp ), possible flash pulmonary edema from htn, possible cardiac event (elevated troponins, normal ck mb), or trali. given concern for hcap (recent hospitalization), blood cultures were sent and patient was started on vanc/cefepime. she was cautiously diuresed with lasix boluses (10mg iv x2, followed by 20 mg iv x1), with 1.8l uop. given significant hypoxemia, was started on nippv overnight for 5 hours, with improvement in sats to mid-high 90s. a-line placed for repeated abgs and close monitoring. repeat abg 7.42/36/76. she was transitioned back to high flow face mask, and maintained sats in 90s overnight. a tte performed on showed worsening aortic stenosis. on , the patient was transferred to ccu, with plans for potential aortic valve replacement the following week, pending improvement in general clinical status. diuresis was continued in the ccu, and she continued to respond to iv lasix with improvement in her respiratory status. she remained on high-flow o2 face mask, and on , we began to wean the o2. her oxygen requirement decreased over her hospital course and on discharge her o2 sat was 97% on room air. she may require gentle diuresis with furosemide if she develops further pulmonary edema if she complains of shortness of breath. # rll pna: patient presented with dyspnea, cough, leukocytosis, and worsening rll infiltrate on cxr. blood culture sent, and patient started on empiric antibiotics with vanc/cefepime to cover potential hcap, given recent hospitalization. urine legionella antigen negative. patient remained afebrile, she completed an 8 day course of antibiotics and her sob resolved. # gib: h/h significantly decreased from most recent value on of 10.0/27.4, with baseline hcts over last couple of months between 25-28. likely slow gib given occult positive stool and h/o emesis (though no clear history of hematemesis or coffee ground emesis). of note also has recent history of hemorrhoidal bleeding. gi consulted and patient started on pantroprazole drip. given supratherapeutic inr, received 10mg iv vit k, rec'd 2 units ffp. warfarin was held. patient's hct bumped following transfusion 1 unit prbcs at , though trended down over next day back to 24. had 2 piv, and was typed and crossed for 4 units. in the setting of the patient's respiratory distress, gi decided to treat conservatively for gib given there are no signs of active bleeding. in the ccu, her hct was trended and stabilized between 23-25 on . gi was consulted and was performed which showed multiple gastric ulcers with no active bleeding. flex sig significant for internal hemorrhoids with no active bleeding. after discussing goals of care with mrs. family, it was decided to discontinue phlebotomy. in addition, heparin was discontinued continued gib and melanotic stools accepting the risk of cva. her last hct on was 24.7. she continues to have melanotic stools and requires frequent cleaning of her perineum. # leukocytosis: likely secondary to pneumonia given her cxr findings. ua not suggestive of uti, urine culture pending. blood cultures sent before intiation of antibiotics on the day of admission. vancomycin and cefepime were started on the day of admission for presumed hcap in the setting of her recent hospitalization at . lipase was checked in the setting of her chronic pancreatitis with concern for an acute-on-chronic picture; however, this was in the 200s and did not represent a change from her many recent values. her last wbc count was 12.6 on and her c-diff pcr was negative. there was no further workup performed as her goals of care shifted towards comfort measures. she was treated for a total of 8 days for hcap. # troponinemia: troponins were elevated to 0.24 at and rose to 0.27 in our ed. she did not have chest pain, and only nonsepcific st/t changes on ekg which are not significantly changed from prior. she had a recent cath showing no significant cad. on her third set trop rose to 0.3, but was decreased back to 0.25 the next morning. she was thought to be unable to clear troponin in the setting of her acute-on-chronic renal insufficiency. mb has been flat. there was a question of demand ischemia in setting of anemia. in the setting of this as well as her critical as, she was transferred to the ccu. it was felt this was likely demand ischemia and no further workup was performed. # hyponatremia: hyponatremic to 120 on admission which seemed to be at least partly chronic with na 124-128 since . she appeared volume up on lung exam, however did not have peripheral edema so there was thought to be less of an element of right heart failure. with high suspicion of volume overload in the setting of her additional hypoxia, she was diuresed with several doses of lasix and her sodium improved to 125 the next morning, which is at her recent baseline. her sodium improved to 135 and was 148 on , no further workup was performed given her shift in goals of care. . # acute on chronic kidney disease: h/o chronic kidney disease, stage 4 with baseline creat 2.2-2.4, up to 2.7 on admission. bun/cr ratio was 21, suggesting pre-renal etiology of acute-on-chronic picture in the setting of likely poor forward flow given her as. it was also thought her bun was possibly elevated due to gib. no acute interventions were taken for the and her creatinine was stable at 2.6 the following day. it bumped as high as 3.3 during the ccu stay, but came down to 2.9 prior to discharge. . # afib: she has sick sinus syndrome with ventricular pacer, and is additionally rate controlled on digoxin, metoprolol, amlodipine at home; these were held on admission. given her likely gib and elevated inr, warfarin was held. she received vitamin k and ffp with inr coming down to 1.3 on the day following admission. given that her chads2 score is 5, she does need anticoagulation but in the setting of gib this was not started initally. in the ccu, heparin was started and was continued even when her inr was no longer supra-therapuetic as we did not want to restart warfarin in the setting of possible cardiac catheterization. however, warfarin was restarted 24hr after the procedure at a lower dose of 3mg given her elevated inr on admission. warfarin was discontinued in the setting her her gib which is currenlty more symptomatic for ms , it is hoped that stopping anticoagulation may decrease the severity of her gib. (oozing from her gi tract is causing her much pain) given the change in goals of care, anticoagulation is no longer indicated. . # mental status: ms was delerious in the ccu and cleared some what after transfer to the floor. this was felt to her lack of sleep for several days while in the unit. it is hoped that transfer to a will improve her mental status. she was provided trazodone and seroquel for sleep during her stay at . transitional issues: # code status: comfort measures only medications on admission: preadmission medications listed are correct and complete. information was obtained from family/caregiver. 1. atorvastatin 20 mg po daily 2. amlodipine 5 mg po daily 3. digoxin 0.125 mg po every other day 4. magnesium oxide 400 mg po once duration: 1 doses 5. aspirin 81 mg po daily 6. gemfibrozil 600 mg po bid 7. creon 12 3 cap po tid w/meals 8. ferrous sulfate 325 mg po tid 9. metoprolol succinate xl 200 mg po daily 10. warfarin 2 mg po daily16 11. calcitriol 0.25 mcg po daily 12. cyanocobalamin 500 mcg po daily 13. calcium carbonate 600 mg po daily 14. vitamin d 1000 unit po daily 15. ascorbic acid 1000 mg po daily 16. omeprazole 20 mg po bid 17. furosemide 20 mg po daily discharge medications: 1. lidocaine jelly 2% 1 appl tp once duration: 1 doses 1 tube 2. amlodipine 5 mg po daily 3. ferrous sulfate 325 mg po tid 4. metoprolol succinate xl 200 mg po daily 5. acetaminophen 1000 mg po tid 6. aquaphor ointment 1 appl tp tid:prn sores 7. hydromorphone (dilaudid) 1 mg po q4h:prn pain hold for sedation, rr<10 8. ondansetron 4-8 mg iv q8h:prn nausea 9. simethicone 40-80 mg po qid:prn gas 10. trazodone 25 mg po hs:prn insomnia 11. omeprazole 20 mg po bid discharge disposition: extended care facility: healthcare & rehabilitation center - discharge diagnosis: critical aortic stenosis acute on chronic diastolic congestive heart failure lobar pneumonia acute on chronic renal failure anemia gastrointestinal bleed acute respiratory failure discharge condition: mental status: confused, waxing and mental status. paranoid. activity: requires assistance. discharge instructions: ms. , you were admitted to the hospital with a pneumonia and bleeding from your gi tract. your pneumonia was treated with antibiotics. the gi doctors performed (camera down into the stomach) which showed ulcers which are the likely source of the bleeding. you also had an aortic valvuloplasty (procedure to temporarily open up the aortic valve). you continue to have bleeding in your stool. because of all of your medical illnesses, you and your family have decided to focus on comfort. most of your medications were stopped and we stopped checking labs. you will be discharged to a skilled nursing facility where you can eventually get hospice services. you will not be hospitalized should you continue to get sicker. followup instructions: the nurses and doctors at the nursing home will be taking care of you. procedure: combined right and left heart cardiac catheterization other endoscopy of small intestine flexible sigmoidoscopy percutaneous balloon valvuloplasty diagnoses: pneumonia, organism unspecified acidosis esophageal reflux congestive heart failure, unspecified acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) hyposmolality and/or hyponatremia chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation acute on chronic diastolic heart failure aortic valve disorders other and unspecified hyperlipidemia acute respiratory failure cardiogenic shock long-term (current) use of anticoagulants chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction cardiac pacemaker in situ personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits awaiting organ transplant status chronic pancreatitis delirium due to conditions classified elsewhere epistaxis internal hemorrhoids without mention of complication external hemorrhoids without mention of complication candidal esophagitis contact dermatitis and other eczema, unspecified cause 

Answer: The patient is high likely exposed to