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: patient recorded as having no known allergies to drugs attending: chief complaint: change in mental status, hematemesis major surgical or invasive procedure: egd central line history of present illness: ms. is a 78 year-old woman with a history of a recent left-sided stroke with subsequent left carotid stenting and initiation of warfarin therapy for atrial fibrillation who was brought in from rehab today for deteriorating mental status. she is intubated and sedated, and thus unable to provide her own history. per ems records, she was noted by staff this morning to be unresponsive around 8am this morning. she had a fsbg that was >600 at that time, and other labs were significant for a hematocrit of 19.6 from a baseline of 27, a creatinine of 3.8 and pt of 23.6. she was noted at that time to be responsive only to painful stimuli with a pinpoint right pupil (midline, reactive left pupil) and left facial droop. when her labs returned to, ems was called. when ems attempted intubation, she had a gag reflex and vomitted a small amount of coffe ground material. . upon arrival to the ed, her heart rate was in teh 80s with a bp of 100/60 and an o2 sat of 100%. she was intubated for airway protection and, per the ed resident, the patient had a difficult intubation in that she had episodes of bradycardia requiring atropine. gi was called and a gastric lavage via her peg revealed coffe ground material without any fresh blood. she received 2 units of fresh frozen plasma, 4 units of prbcs, and 10 mg of sc phytonadione. a femoral line was placed for emergent iv access. she was also given ampicillin/sulbactam for a dirty urinalysis. . of note, during her recent hospitalization, she was noted to drop her hematocrit from 32.8 on admission down to a nadir of 24.1; this responded to 29.3 with 2 units of prbcs on . two days later, her hematocrit had drifted down to 26.9 and she was given an additional 2 units of prbcs with a response up to 35.0. by the time of discharge, her hematocrit was back down to 27.2, though stable. . . review of systems: unable to obtain from patient due to sedation/intubation; per son, no , hematochezia, fevers past medical history: - hypertension - recent left mca stroke - left ica stent placed - operative peg placement following failure of swallow eval - paroxysmal atrial fibrillation, recently started on warfarin - reported copd; no pfts in records - chronic renal failure, baseline creatinine approx 2.6 with secondary hyperparathyroidism - chronic diastolic chf - hyperlipidemia - type 2 diabetes mellitus - depression - morbid obesity social history: up until her recent hospitalization, ms. lived with her son for several decades; upon discharge from last week, she was sent to rehab. she is a former smoker with a ~50 pack-year history; she quit approximately 10 years ago. she has a history of rare alcohol use without any active use at this time. family history: one sister died of heart disease at age ; another sister has heart disease. her brother died of colon cancer at age 68. three of her four children have died, one from aids, one from drowning and one from ?choking. physical exam: t 97.7 bp 156/68 hr 83 rr 22 sat 100% vent: ac vt 450cc rr 16 peep 5 fio2 0.50 general: sedated, grimacing to pain, resisting opening of her eyelids heent: perrl, no icterus, (+) ett neck: obese, supple, no lymphadenopathy detected chest: clear to auscultation throughout, no w/r/r cv: rrr, nl s1s2, no murmurs abdomen: obese, (+) peg, nondistended, no hsm extremities: 1+ edema to mid-shins, 1+ dp pulses, right femoral line neuro: sedated, perrl (5mm -> 3mm), grimacing and gagging to suctioning, moving all four extremities and wthdrawing to pain, opening eyes slightly to verbal command, 1+ patellar reflexes, plantar response equivocal bilaterally pertinent results: ecg (): normal sinus rhythm at 91 bpm, normal axis, normal intervals, no obvious st segment changes, though unsteady baseline may be obscuring subtle st segment changes. . head ct w/o contrast (): no evidence of intracranial hemorrhage. marked mucosal thickening within the nasal cavity and ethmoid air cells without fluid levels to suggest the presence of acute sinusitis. small-vessel angiopathy as described. . cxr (): the lung volumes are diminished. no focal consolidation, pneumothorax or pleural effusion is detected. the cardiomediastinal contour is within normal limits. et tube terminates 1.5 cm above the carina. ng tube enters the stomach. the tip has been excluded. . egd: impression: normal mucosa in the esophagus blood in the fundus there was some superficial ulceration with a small amount of oozing from around the g tube. no other bleeding site seen. patent rotated for maximum visability given presence of large clot. normal mucosa in the duodenum otherwise normal egd to second part of the duodenum . recommendations: serial hematocrits proton pump inhibitor repeat egd if acutely rebleeds ap chest 10:05 p.m, history: increased wheezing, crackles and dyspnea, assess for aspiration or pneumonia. impression: ap chest compared to : lung volumes are very low, and the anatomic detail in the lungs is obscured by respiratory motion, but there appears to be new consolidation in the right mid and upper lung consistent with pneumonia due to aspiration. moderate cardiomegaly has increased also and there is no mediastinal vascular engorgement suggesting cardiac decompensation, though i doubt that edema is present. pleural effusion if any is small, decreased since . no pneumothorax. discharge labs 06:48am blood wbc-9.6 rbc-3.13* hgb-9.4* hct-29.0* mcv-93 mch-29.9 mchc-32.3 rdw-15.6* plt ct-285 06:48am blood neuts-77.8* lymphs-15.6* monos-4.4 eos-2.1 baso-0.2 06:48am blood plt ct-285 06:48am blood pt-13.0 inr(pt)-1.1 06:48am blood glucose-144* urean-109* creat-2.7* na-150* k-4.2 cl-115* hco3-26 angap-13 06:48am blood mg-2.1 brief hospital course: ms. is a 78 year-old woman with a recent left-sided ischemic stroke and subsequent left internal carotid stenting who presents with altered mental status following a large gi bleed in the setting of recent initiation of aspirin, clopidogrel, and warfarin. . ## acute blood loss anemia secondary to gi blood loss: hct on admission was as low as 15. she was admitted to the micu and monitored with serial hcts. she received 4 units of prbcs intially with hct rise to 29. she received an egd which showed blood in the fundus and superficial ulceration surrounding the g tube but no active bleeding. she was continued on ppi. her aspirin, plavix, and coumadin were initially held. the following day her plavix and aspirin were restarted. aspirin was decreased to 81 mg. her coumadin was held and should likely not be restarted in the future given multiple episodes of significant gi bleeds. following her egd, her hct continued to slowly trend down to 25 and she received another unit of prbcs with appropriate response to 30. upon transfer to the floor her vital signs were stable and her hematocrit remained between 28-30. she was scheduled follow up with dr. of gi on and neurology to decide on restarting coumadin weighing the risks of gib and recurrent stroke. . ## altered mental status: unclear cause. had evidence of uti on admission. also potentially secondary to hypoperfusion in the setting of profound anemia. also possible contribution of uremia given concurrent renal failure. head ct without any acute change. toxicology screen negative. her baseline prior to last discharge was reportedly interactive. however, after discussions with physicians at her rehab, it seems that her baseline there upon arrival was minimally verbal and minimally interactive. her mental status improved with blood transfusions and improvement in her renal failure. her mental status at discharge was occasional one word answers and nodding yes or no. acoording to her son and hcp this has been her baseline since she suffered the cva in of this year. . # respiratory failure: she was intubated for airway protection in the setting of hematemesis and altered mental status. she was quickly weaned from the vent and was extubated without complication. her mental status remained poor following extubation and there was concern for her respiratory status in this setting but her abgs continued to be excellent not requiring further intervention. on the medical floors her oxygen ranged from 84-93 on room air, she was discharged on 1 liter nc saturating at 92-94 percent. her oxygen requirements decreased with the addition of furosemide to her regimen which had been held during her icu course. she had a chest x-ray on which was consistent with volume overload and possible aspiration. she was not treated for aspiration pneumonia given she remained afebrile and wbc count was normal, her oxygen requirements also decreased with addition of furosemide. . ## urinary tract infection: evidence of uti on u/a and received unasyn in ed. on her recent hospitalization, she had a urine culture that grew our enterococcus which was senstive to both vancomycin and ampicillin. she was started empirically on ampicillin and cipro. unfortunately, urine culture was not sent prior to antibiotic administration and repeat urine culture grew only yeast. she was changed from ampicillin/cipro to augmentin. her renal function and leukocytosis improved over the course of admission. she completed a course of augmentin which was stopped upon transfer to the floor. . ## acute on chronic renal insufficiency: acute exacerbation is most likely due to prerenal azotemia in the setting of massive gi blood loss. her baseline cr was ~2.3-2.7. on admission, cr 3.8 and bun significantly elevated to 168 from her last value prior to discharge of 68. urine lytes were consistent with prerenal etiology. she was volume resuscitated with ns and renal function improved. unclear if followed by renal as an outpatient. will need to be seen by renal if not already seen by a nephrologist. at discharge her creatinint was back at baseline of 2.7. . ## hypernatremia: treated with free water through peg tube, discharged on 400cc q4h until hypernatremia resolves. will need daily electrolytes until this resolves. . ## recent left-sided ischemic stroke; s/ stenting. her aspirin was decreased to 81 mg but she was otherwise continued on both aspirin and plavix. . ## chronic diastolic chf: her metoprolol and lasix were initially held. with stability following her egd, her metoprolol was restarted and uptitrated. her lasix was held in the setting of her arf and restarted upon transfer to medical floor. she was discharged on furosemide 60mg , this will need to be titrated up to dose of 100mg which she was on as outpatient. she needs close i/o and daily weights to determine her volume status. . ## atrial fibrillation: remained in in sinus rhythm. recently started on warfarin for her atrial fibrillation which was discontinued in the setting of her gi bleed. her beta blocker was initially held but was quickly restarted. decision to restart coumadin will be made by gi, neurology, and her pcp. up within the next few weeks was arranged with all three. . ## type 2 diabetes mellitus, uncontrolled with complication. she had significantly elevated fsbgs while in house despite holding her tube feeds. her glargine was titrated and she was continued on insulin sliding scale. will need to increase glargine and adjust sliding scale as indicated. . ## hypertension: antihypertensives intially held given significant bleeding but then restarted as above. titrate up metoprolol as needed for hypertension. need addition of another , consider ace inhibitor if creatinine allows given her diabetes. . ## hyperlipidemia: continued on statin . ## depression: continued on citalopram . ## fen: tfs were restarted following egd and extubation. tfs residuals were >100 on day prior to discharge, this resolved with as needed reglan. continue with as needed prokinetic to keep gut motility adequate. . ## dvt prophylaxis: pneumoboots . ## communication: son ( who is hcp . ## code: full, per son who is hcp. medications on admission: (per discharge summary from ; patient and son unable to verify) citalopram 20 mg daily atorvastatin 80 mg daily nitroglyerin patch q6h ipratropium nebulizer q4h prn albuterol nebulizer q4h prn clopidogrel 75 mg daily aspirin 81 mg daily ferrous sulfate 325 mg daily calcitriol 0.25 mcg daily lansoprazole 30 mg daily furosemide 100 mg docusate 100 mg daily metoprolol 50 mg tid insulin glargine 14 units qhs insulin lispro sliding scale warfarin 2 mg qhs bisacodyl prn acetaminophen prn ondansetron prn discharge medications: 1. atorvastatin 80 mg tablet : one (1) tablet po daily (daily). 2. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po daily (daily). 3. calcitriol 0.25 mcg capsule : one (1) capsule po daily (daily). 4. citalopram 20 mg tablet : one (1) tablet po daily (daily). 5. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) inhalation q4h (every 4 hours) as needed. 6. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 7. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 8. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 9. metoprolol tartrate 50 mg tablet : one (1) tablet po tid (3 times a day). 10. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours). 11. insulin glargine 100 unit/ml cartridge : twenty two (22) units subcutaneous at bedtime: titrate as blood sugars indicate. 12. humalog 100 unit/ml cartridge : one (1) subcutaneous four times a day: sliding scale as directed. 13. furosemide 80 mg tablet : 1 and tablet po once a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary: gastrointestinal bleed secondary: heart failure h/o cva diabetes type ii atrial fibrillation hypernatremia acute renal failure copd uti discharge condition: stable, hematocrits stable>96 hours, mental status at baseline discharge instructions: you were admitted for a bleed likely originating from your stomach. this was likely caused by a combination of gastritis along with being on several blood thinner medications. your blood counts stabilized. . followup instructions: provider: , md phone: date/time: 1:00 provider: , md, mph: date/time: 11:30 provider: , md phone: date/time: 2:30 provider: , md phone: date/time: 11:00 md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified other endoscopy of small intestine insertion of endotracheal tube enteral infusion of concentrated nutritional substances diagnoses: urinary tract infection, site not specified congestive heart failure, unspecified acute posthemorrhagic anemia acute kidney failure, unspecified chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation depressive disorder, not elsewhere classified chronic kidney disease, unspecified other and unspecified hyperlipidemia acute respiratory failure morbid obesity long-term (current) use of anticoagulants secondary hyperparathyroidism (of renal origin) diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled hemorrhage of gastrointestinal tract, unspecified hyperosmolality and/or hypernatremia chronic diastolic heart failure gastrostomy status 

Answer: The patient is high likely exposed to