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: penicillins attending: chief complaint: ercp, management of a complicated patient major surgical or invasive procedure: 1. ercp with stent placement 2. bone marrow biopsy history of present illness: mr. is an 86-year-old man with history of cad s/p mi, a fib, aaa, who is transferred from hospital for ercp. he initially presented to hospital on for shortness of breath and drop in hematocrit. the patient notes that he developed progressive sob and doe over the past few weeks prior to admission, to the point that he would have to rest after walking 20 feet. denies fevers, chills, cough, chest pain. of note, he was seen by an outside dermatologist recently for chronic urticaria and pruritis, felt to be related to his anemia. on admission to , he was noted to have a hct of 19.6 from a baseline of 30. mcv was 111. he received a total of 4 packed red blood cell transfusions with an appropriate hematocrit bump to 30. upper endoscopy and colonoscopy were performed at the outside hospital showing mild gastritis, duodenitis, sigmoid-predominant diverticulosis, and internal hemorrhoids, but no evidence of active or recent bleeding. ct abdomen/pelvis yesterday revealed a 1.4cm gall stone obstructing the distal common bile duct with 1.4 cm dilation of the common bile duct as well as mild intrahepatic ductal dilatation, cirrhotic appearing liver with a ~1cm hypodense lesion, extensive abdominal aortic aneurysm, and sigmoid diverticulosis. he was reportedly seen by hematology with plan for possible bone marrow biopsy as an outpatient. the morning of transfer, the patient became hypotensive to the 70-80s systolic. reportedly asymptomatic. his heart rate was 55-65. he was given a 250cc ns bolus followed by maintenance fluids and his systolic blood pressure improved to 90. blood and urine cultures were sent and he received one dose of levofloxacin 250mg iv. he was transferred to for further management. past medical history: hypertension coronary artery disease s/p inferior myocardial infarction in stage ii chronic kidney disease, baseline 1.4 as of atrial fibrillation-- off of anticoagulation s/p upper gastrointestinal bleed 1.5 yrs ago history of duodenal ulcer with bleed 1.5 yrs ago chronic anemia (baseline hct 30) pending heme w/u mds atrial septal defect pulmonary hypertension mitral regurgitation tricuspid valve disease carotid stenosis- totally occluded r ica abdominal aortic aneurysm history of transient ischemic attack seizure disorder diverticulosis hearing loss choledocholithisis/cholelithisis diagnosed this admission social history: lives with his 82-year-old wife in . married x 45 years. independent of adls, does his own yard work. formerly worked as an advertising salesman for the gazette for 35 years. smoked up to 3 ppd since age 13, quit 4 years ago. drinks 2 vodka martinis daily. has one son who lives in , ak, and one daughter who lives in . family history: noncontributory physical exam: vitals: t: 96.3, bp: 111/60, p: 77, r: 18, o2: 100% ra general: alert, oriented, pleasant elderly male in no acute distress heent: mildly icteric sclera, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no ascites ext: warm, well perfused, 1+ distal pulses, no clubbing, cyanosis or edema skin: no spider angiomata, no palmar erythema pertinent results: outside hospital labs: hct trend: 19.6 () --> 21.4 ()--> 30.5 () wbc: 11.7 () --> 6.6 (), 79% pmn, 8 bands, 9 lymphs mcv: 111 (prior to rbc transfusion) inr: 1.3 () tibc 211, iron 90, ferritin >1500, b12 1205, folate 14.2, transferrin 151 na 132, k 4.2, cl 102, co2 20, gun 57, cr 3.0, gluc 145 t bili 2.6, d bili 1.7, ast 111, alt 213, alk phos 455 cr 3.6, t bili 1.7, direct bili 1.0, ast 70, alt 152, alk phos 350, ldh 129, dilantin 4.6 . images: ct abd/pelvis: 1. findings are consistent with choledocholithiasis and associated biliary obstruction. suggestion of mild intrahepatic biliary ductal dilatation. there is dilation of the extrahepatic portion of the cbd which measures 1.4 cm. within the distal cbd right at the level of the ampulla there is an obstructing gall stone measuring 1.3 x 1.4 x 1.4 cm. 2. cirrhotic appearance to the liver with the presence of a subtle hypodense focus within the left lobe (0.8 x 1.1 x 1.3cm). the possibility of a neoplastic focus needs to be excluded. 3. bilateral atrophic kidneys. 4. extensive abdominal aortic vascular disease involving the mesenteric vessels, renal arteries, and iliac arteries which are aneurysmally dilated. evaluation limited by non-contrast scan. 5. coronary artery disease. 6. mitral valve calcifications. 7. cholelithiasis. 8. sigmoid diverticulosis without evidence for diverticulitis. 9. degenerative changes in the lumbar spine. . cxr: there is calcified granuloma in the right lower chest peripherally unchanged. minimal atelectasis is seen at the left lateral sulcus, this may reflect an element of scarring as it is similar to that seen previously. the left hemidiaphragm is slightly elevated. the right lung is otherwise clear. the heart is upper normal in size. there is no chf. labs at : 01:30pm blood wbc-4.5 rbc-3.08* hgb-10.2* hct-30.1* mcv-98 mch-33.0* mchc-33.8 rdw-20.5* plt ct-230 01:30pm blood plt ct-230 07:00am blood fibrino-471* 01:32pm blood ret aut-0.8* 01:30pm blood glucose-143* urean-27* creat-1.8* na-136 k-4.5 cl-104 hco3-22 angap-15 01:30pm blood alt-41* ast-25 ck(cpk)-26* alkphos-314* totbili-1.8* 04:00am blood alt-111* ast-45* ld(ldh)-138 alkphos-303* totbili-1.2 dirbili-0.9* indbili-0.3 04:48pm blood ck-mb-4 ctropnt-0.10* 12:30am blood ck-mb-4 ctropnt-0.10* 01:30pm blood ck-mb-4 ctropnt-0.07* 01:30pm blood calcium-8.7 phos-2.1* mg-1.8 04:00am blood caltibc-124* vitb12-820 folate-13.6 ferritn-greater th trf-95* 08:02pm blood tsh-1.5 07:00am blood pth-49 08:02pm blood hbsag-negative hbsab-negative hbcab-negative 08:02pm blood afp-<1.0 04:00am blood phenyto-3.9* 08:02pm blood hcv ab-negative 04:00am blood pep-no specific abnormality echo : the left atrium is mildly dilated. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. lv systolic function appears globally depressed (ejection fraction approximately 30 percent), with regional variation (the posterior and lateral walls contract better than the rest of the ventricle). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. the right ventricular cavity is dilated with depressed free wall contractility. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. at least moderate (2+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the tricuspid valve leaflets are mildly thickened. the supporting structures of the tricuspid valve are thickened/fibrotic. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. the main pulmonary artery is dilated. the branch pulmonary arteries are dilated. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is further decreased, and the mitral and tricuspid regurgitation are significantly increased ercp : cannulation of the biliary duct was successful and deep with a clever cut sphincterotome using a free-hand technique. a single 15mm filling defect consistent with a calcified round stone that was causing partial obstruction was seen at the lower of the common bile duct. there was post-obstructive dilation. a biliary sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. a 10fr by 7cm cotton biliary stent was placed successfully. diverticulum in the distal duodenal bulb ecg: atrial fibrillation. leftward axis. intraventricular conduction delay. inferior myocardial infarction, age undetermined. t wave inversions in leads i, avl, as well as leads v2-v6 may be due to left ventricular hypertrophy, although the contour also is consistent with coronary ischemia and should be considered strongly. clinical correlation is suggested. compared to the previous tracing of repolarization abnormalities are new and the rate has increased. intervals axes rate pr qrs qt/qtc p qrs t 68 0 128 472/486 0 -26 173 brief hospital course: mr. is an 86 year old gentleman with coronary artery disease, atrial fibrillation, congested heart failure, and multiple other problems transferred from hospital for choledocholithiasis, hypotension and acute renal failure, had a brief stay at the icu before transferred to the general medicine unit. while at the icu, mr. was started on flagyl 500 mg iv q8h and ciprofloxacin 500 mg po q24h for 24 hours. he was given a total of 4500cc iv fluid during his ed and icu stay. the icu team decided to postpone on mr. ercp until monday () because he was afebrile and hemodynamically stable without leukocytosis. on , patient was seen by hematology/oncology consultants who performed bone marrow biopsy to work up his acute on chronic anemia. given chronic elevated mcv in the setting of normal folate and b12, differentials then include alcohol, myelodysplastic syndrome, liver disease, reticulocytosis, or medications such as anti-metabolites. in mr. case, the first two causes were highest on the differential. over the course of his stay, mr. hematocrit stayed around 25 (from a baseline of 31). he subsequently received two units of red blood cell transfusion, one in the evening of , and one in the early morning of , with subsequent hematocrit at 31. on monday , mr. ercp for extraction of his common bile duct stone. the procedure had no complication. sphinterotomy was performed, and a single 15mm filling defect consistent with a calcified round stone that was causing partial obstruction was seen at the lower of the common bile duct. there was post-obstructive dilation. the stone was not able to be extrated at the time because of its size and calcification. a 10 french 7cm stent was placed to enable drainage of the bile. patient was told to return for a repeat ercp in six weeks () for re-evaluation. a routine ekg done after ercp showed diffuse t wave inversion with asymmetrical t waves. ck levels over the next 24 hours remained around 25, and troponin t was 0.1->0.1->0.07. patient was asymptomatic throughout the episode. no pre-ercp ekg was available for comparison, and cardiology consult felt that these changes were unlikely ischemic because the non-territorial nature of t wave inversion, and that similar inversions were noted in selected lead ii in telemetry from hospital. it is possible that the patient had a demand ischemic event in recent past, but in the setting of recent acute kidney injury and anemia, had a mild elevation of cardiac enzymes that persisted. he was started on aspirin, metoprolol, and statin. heparin was not initiated because of the lack of symptoms, unclear timing and onset for the elevated troponin, and the past history of upper gi bleed. echocardiography on (one day after the ekg change) showed ejection fraction of 30%, a reduction from 40% in . it also showed diffusely depressed left ventricular wall motion. his primary care physician, . , was informed of these findings, and a stress test had been scheduled within a week of discharge at hospital with his cardiologist, dr. . he will continue to take aspirin, statin, lisinopril and beta blocker (his heart rate was 75 with metoprolol). given that he had not previously been on statin, his liver function test should be checked on an outpatient basis, and this had been communicated to his primary care physician. mr. also had acute kidney injury when he initially presented to us. fena was borderline (1.9%) but of uncertain value because patient was receiving iv bolus of lasix prior to transfer at osh. this acute on chronic renal failure was likely secondary to hypoperfusion of the kidney, as the patient's blood pressure was in the 70s/40s prior to transfer. his creatinine gradually improved throughout his stay here, coming down from 3.1 to 1.8 (with his baseline at 1.4). his urine output was adequate, and renal ultrasound was unremarkable. he was also hyponatremic on presentation, but the level improved after fluid restriction. mr. also had a history of alcohol abuse, and throughout this hospitalization he was given daily thiamine, multivitamin, and folate. his ct at hospital showed a cirrhotic liver with a hypodense lesion in the left liver lobe, and the team recommended that this be followed up on an outpatient basis, along with education on alcohol cessation. this had also been communicated to the primary care physician. medications on admission: medications at home: iron sulfate 325mg po bid hctz 25mg po daily kcl 20 meq po daily lisinopril 10mg po daily prilosec 20mg po daily dilantin 300mg po qhs spectrovite 1 tab po daily . medications on transfer: levofloxacin 250mg iv x 1 protonix 40mg po daily dilantin 300mg po qhs k clor con 20 meq po qod ferrous sulfate 325mg po bid lisinopril 10mg po daily hctz 25mg po daily spectrovite 1 tab po daily procrit 10,000 units sq x 1 today discharge medications: 1. phenytoin sodium extended 100 mg capsule sig: three (3) capsule po hs (at bedtime). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po twice a day. 5. multivitamin tablet sig: one (1) tablet po once a day. 6. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day. 7. toprol xl 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*60 tablet sustained release 24 hr(s)* refills:*2* 8. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 12. outpatient lab work please measure na, k, cl, hco3, bun, cr on and have the results faxed to your primary care doctor's office. discharge disposition: home with service facility: discharge diagnosis: choledocholithiasis, hypotension, acute kidney injury anemia coronary artery disease discharge condition: stable discharge instructions: you originally presented to hospital on with low blood pressure, acute kidney injury, and were found to have a stone in your common bile duct. you were treated with fluid and antibiotics for presumed abdominal infection, and you were transferred to the , first in the intensive care unit, and then here on the general medicine floor. your kidney function appears to be recovering now, but your anemia is still being worked up. the hematology oncology team here performed a bone marrow biopsy, and the result will be communicated to your primary care physician, this can be followed up on an outpatient basis. you also esophageal retrograde cholangiopancreatography (ercp) to evaluate your common bile duct stone. the stone was calcified, and its large size and integration into the common bile duct wall prevented a safe and swift removal with the ercp. consequently, a metal stent of 10 french diameter was placed to allow normal bile flow. after ercp, your routine electrocardiogram showed new changes that were concerning for cardiac ischemia. we therefore a series of blood test to assess whether your heart was sufferring from an acute injury. over the next 24 hours, your cardiac enzymes, although slightly elevated, did not increase, and we concluded that the elevated level might be secondary to your suboptimal kidney function, rather than as a result of cardiac injury. you also echocardiography as part of this evaluation, and it did not show any new cardiac wall motion abnormality suggesting heart muscle injury from ischemia; nor was there evidence of any acute cardiac event. lastly, during your stay at the , a ct scan of your abdomen showed a cirrhotic appearing liver with a ~1cm hypodense lesion. this needs to be followed up with your primary care physician as an outpatient issue. you will have a repeat ercp here at in one month to re-evaluate your common bile duct stone and the newly placed stent. given the change in your cardiac status, we decided to add several medications. you should continue to take metoprolol, aspirin, and atorvastatin. please speak with your primary care physician as to whether you should continue these medications. if you remain on atorvastatin you will need to have your liver enzymes monitored. in addition, you will need to have a stress test within one week of discharge from the hospital. this may be arranged by your primary care doctor. your lisinopril and hydrochlorothiazide were being held because of the decreased kidney function. your lisinopril was restarted at half your normal dose on the day of discharge. you will need to meet with your primary care doctor to decide whether you can restart the hydrochlorothiazide, and whether he wants to increase the lisinopril to your normal dose. please contact your physician or return to the emergency room if you experience severe abdominal pain, chest pain, acute shortness of breath, fever, sudden dizziness or weakness, or any worsening signs and symptoms. followup instructions: 1. please follow up with your primary care physician . () within one week regarding your anemia (bone marrow biopsy) workup, your liver cirrhosis (based on the recent ct finding), your kidney function, and management of your coronary artery disease. 2. repeat ercp appointment: ercp 2 (st-4) gi rooms date/time: 9:00 provider: , md phone: date/time: 9:00 procedure: endoscopic sphincterotomy and papillotomy biopsy of bone marrow endoscopic insertion of stent (tube) into bile duct diagnoses: acidosis coronary atherosclerosis of native coronary artery congestive heart failure, unspecified cirrhosis of liver without mention of alcohol acute kidney failure, unspecified hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation other chronic pulmonary heart diseases personal history of tobacco use hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) occlusion and stenosis of carotid artery without mention of cerebral infarction chronic kidney disease, stage iii (moderate) hypotension, unspecified ostium secundum type atrial septal defect old myocardial infarction epilepsy, unspecified, without mention of intractable epilepsy personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits abdominal aneurysm without mention of rupture other and unspecified coagulation defects unspecified deficiency anemia calculus of bile duct without mention of cholecystitis, with obstruction 

Answer: The patient is high likely exposed to