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 / hydrochlorothiazide / ibuprofen / zosyn attending: chief complaint: brbpr major surgical or invasive procedure: none history of present illness: 79f with pmh of afib on coumadin, htn, dm2, cad, chf, previous mca stroke, and hemorrhoids, who presents with brbpr of one day duration. patient first noted blood-streaked stool after a large bowel movement this morning. the patient has a hx of hemorrhoids and noted that her stool this morning was very hard ,as she had been constipated for the past week. patient denies chronic constipation; although she does take oxycodone/oxycontin for claudication pain, she is also on standing docusate. with her bleed this morning, she had no abdominal pain, lightheadedness, dizziness, nausea or vomiting. no chest pain or shortness of breath. her daughter did notice a small, slow trickle of blood from her rectum after the bowel movement. later in the day, patient showed up for episodic visit to surgery and was noted to have blood stains on her pants but no acute bleeding. she was referred to a covering pcp at for evaluation, where she was found to have large amounts of bright red blood in her diaper and continued to bleed from her rectum. she continued to deny dizziness, confusion, abdominal pain, nausea/vomiting. she was referred to the ed. of note, patient denies any hx of black stools or bleeding with wiping. her last colonoscopy was in , and was significant for diverticulosis of the entire colon with moderate to large openings. in the ed, initial vs were: t 98.3 hr 52 bp 132/72 rr 16 o2 sat 100% ra. exam revealed a small, non-bleeding rectal hemorrhoid and a trickle of blood from the rectum. her hct of 33.5 which appears to be her baseline, and her inr was 2.7. she was also noted to have bun 56 with cr 1.3. she has a hx of difficult iv access, and after multiple attempts, only has a single 20g piv. she was transferred to the icu for further management. past medical history: - cva with left mca infarct , now mostly aphasic, right sided weakness in arm and leg - coronary artery disease and infranodal heart block; stress mibi showed a reversible, medium sized, moderate severity perfusion defect involving the lad territory which was new and a reversible, large, moderate severity perfusion defect involving the lcx territory, pt did not want intervention, started on imdur - chf diastolic (lvef 55-60% in ) - moderate mitral regurgitation - hypertension - diabetes mellitus type 2 - hyperlipidemia - h/o dvt , bilateral dvt - pancreatitis - hemorrhoids - h/o recurrent c. diff colitis - peripheral disease - chronic ulcer on left toe - long term foley placement - atrial fibrillation - ivc filter placement for dvt despite adequate anticoagulation - left common femoral thromboendarterectomy with left common iliac stent and left profunda stent placement - r cea (unknown date) - cystoscopy social history: she is a widow. lives in same building as her daughter (different floors), who is her primary caretaker. an aide come to the house on weekday mornings. former smoker with 40 pack-years; quit 20 years ago. denies etoh. denies recreational drug use. live in . family history: mother with cad. both parents with htn. physical exam: admission physical exam: vitals: t: 95 bp: 153/69 p: 57 rr: 18 spo2: 99% on ra general: alert, no acute distress, unable to assess orientation secondary to dysphasia heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: ctab, no wheezes, rales, ronchi cv: bradycardia, regular, normal s1 + s2, no murmurs abdomen: +bs, soft, non-tender, non-distended, gu: no foley ext: warm, well perfused, 1+ edema . transfer physical exam: . discharge physical exam: . pertinent results: admission labs: 06:53pm wbc-6.2 rbc-4.01* hgb-10.5* hct-33.5* mcv-84 mch-26.1* mchc-31.2 rdw-18.2* 06:53pm neuts-70.8* lymphs-21.7 monos-4.3 eos-2.2 basos-0.9 06:53pm pt-27.7* ptt-37.2* inr(pt)-2.7* 06:53pm glucose-149* urea n-56* creat-1.3* sodium-137 potassium-4.2 chloride-101 total co2-24 anion gap-16 07:00pm glucose-133* lactate-1.9 k+-4.4 . microbiology: none . imaging: kub (): impression: no evidence of obstruction. (): findings: protruding lesions grade 2 internal hemorrhoids were noted. excavated lesions multiple diverticula were seen in the whole colon. other no active bleeding at time of procedure. impression: grade 2 internal hemorrhoids diverticulosis of the whole colon no active bleeding at time of procedure. otherwise normal colonoscopy to cecum . colonoscopy (): procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. the efficiency of a colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions can be missed with the test. a physical exam was performed. the patient was administered mac anesthesia. the physical exam was performed prior to administering anesthesia. supplemental oxygen was used. the patient was placed in the left lateral decubitus position.the digital exam was normal. the colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. the appendiceal orifice and ileo-cecal valve were identified. careful visualization of the colon was performed as the colonoscope was withdrawn. the colonoscope was retroflexed within the rectum. the procedure was not difficult. the quality of the preparation was good. the patient tolerated the procedure well. there were no complications. findings: protruding lesions grade 2 internal hemorrhoids were noted. excavated lesions multiple diverticula were seen in the whole colon. other no active bleeding at time of procedure. impression: grade 2 internal hemorrhoids diverticulosis of the whole colon no active bleeding at time of procedure. otherwise normal colonoscopy to cecum . discharge labs: 04:20am blood wbc-6.2 rbc-3.07* hgb-8.7* hct-27.4* mcv-89 mch-28.4 mchc-31.8 rdw-20.4* plt ct-220 04:20am blood pt-20.3* inr(pt)-1.9* 12:30am blood calcium-9.2 mg-2.0 12:30am blood glucose-91 urean-21* creat-1.0 na-140 k-4.2 cl-107 hco3-21* angap-16 brief hospital course: 81 y/o with extensive cardiovasular and peripheral disease, a-fib on coumadin, and external hemorrhoids, initially admitted to the medical icuwith brbpr and persistent trickling of blood and blood clots from rectum. . # gi bleed: on admission, the patient had slow active gib with bright red blood and clots at the rectum. she was on coumadin with therapeutic inr. she has a history of external hemmorhoid, but on exam this was not the source of bleeding. she received 1 unit of prbcs on in response to a hct drop from 33.5 to 24.0. she responded well with a stable hct in the 29s. a previous colonoscopy done in showed diverticulosis throughout the entire colon, which was not known to have bled previously. gastroenterology was consulted and was concerned that a colonoscopy would be unrevealing of a different source and could be traumatic. as her bleeding stopped and her hct was stable, they decided not to pursue the study initially. she was transferred out of the icu to the floor for further management. on the medical floor, she was started on a heparin drip for anticoagulation as well as coumadin. she initially did well. however on , she had recurrent rectal bleeding. the heparin drip was stopped as was her coumadin. her hematocrit remained stable. she was reprepped for colonosocpy, which was performed on . this revealed diverticulosis throughout the colon but no source of active bleeding. the thought was that her bleed was likely diverticular in origin. the plan was to be more ginger with adding back on her anticoagulation/antiplatelet agents. the plan was to start coumadin without a heparin bridge. once her inr was therapeutic and her hematocrit remained stable, the plan was to add back on plavix and then, if her hematocrit is stable, to add aspirin. her diet was advanced and she was tolerating a normal diet at the time of discharge with no bleeding. . # afib: the patient has a high risk for clot with chads2 score of 6. she is chronically anticoagulated with coumadin. see above re: her coumadin was held and then restarted, which led to recurrent bleeding. it was ultimately restarted again prior to discharge. notably, this clinical situation is difficult such that being off of anticoagulation is risky with respect to possible subsequent event. however, being on the anticoagulation has led to recurrent bleeding. she was in bradycardia and a fib throughout her stay, but was asymptomatic. . # chf: the patient reportedly has diastolic chf with ef 55-60% in 4/. through her stay she had mild b/l pitting edema of the lower extremities without any signs of dyspnea or rales on lung exam. her home statin was continued. her lasix was held in the setting of her gib and concern for loss of volume. it was restarted prior to discharge. . # hemoptysis: patient had one small episode of hemoptysis on , with no associated dyspnea, chest pain, or hypoxia. no further episodes occurred subsequently despite continuation of coumadin. patient has been closely followed by pulmonology for this over the past two years with no clear etiology. further evaluation deferred to the outpatient setting. . # cad: she has extensive cardiac and peripheral disease history, normally treated with asa 81mg, plavix, and warfarin. cardiac enzymes and an ekg were checked to rule out ischemic event; these were normal. given her gib, the difficulty of the situation was discussed in detail with the patient, her daughter and her primary care physician. above plan was formulated (starting coumadin without a bridge --> adding plavix --> adding aspirin). . # ckd: cr 1.3 on admission, with bun of 56. the ratio would normally be concerning for prerenal arf, but given the acute bleed, bun is likely not reflective of gfr. her renal function was monitored and by the time of transfer out of the icu improved to 1.0 and remained stable thereafter. . # pain control: has chronic pain, neuropathic per daughter, controlled with oxycontin/oxycodone (total daily dose 30mg) and gabapentin. has been constipated during the past week, but has not increased her narcotic dose. her home medications were continued. . # bradycardia: pt has chronic asymptomatic bradycardia, and per discharge summary from hospitalization, she regularly dipped below 35 and sometimes as low as upper 20s, but remained asymptomatic. cardiology follows her for this rhythm and has determined a pacemaker is not indicated given she is asymptomatic. cardiology notes also mention that the patient is reluctant to pursue a pacemaker at this time. review of her ekg reveals a periodic junctional bradycardia between periods of afib. . # dm: on metformin as outpatient, transferred to iss during her stay . # htn: during her stay she was oaccasionally hypertensive to 150s/80s. her home lasix was held as per above. . # hyperlipidemia: her home statin was continued. . # iron deficiency anemia: fe 12 in , with tibc 316 and ferritin 76,suggestive of fe deficiency anemia. mcv at the time was 86 with an elevated rdw. has been on supplementation as outpatient. iron supplements were continued. . # gerd: home ppi continued . medications on admission: - atorvastatin 80 mg po daily - clopidogrel 75 mg po daily - warfarin 5 mg po dailu - aspirin 81 mg daily - isosorbide mononitrate 30 mg daily - furosemide 80 mg po daily - metformin 500 mg po bid - omeprazole 20 mg po daily - oxycodone 10 mg po q12h prn pain - oxycodone 5 mg/5 ml po q6h prn pain - gabapentin 250 mg qam and qhs - docusate sodium 50 mg po bid - iron 325 mg po daily - thiamine hcl 100 mg po daily - mvi - lactobacillus probiotic discharge medications: 1. atorvastatin 80 mg tablet : one (1) tablet po daily (daily). 2. oxycodone 10 mg tablet extended release 12 hr : one (1) tablet extended release 12 hr po q12h (every 12 hours). 3. oxycodone 5 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain. 4. gabapentin 400 mg capsule : one (1) capsule po hs (at bedtime). 5. gabapentin 300 mg capsule : one (1) capsule po qam (once a day (in the morning)). 6. ferrous sulfate 300 mg (60 mg iron) tablet : one (1) tablet po daily (daily). 7. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 8. isosorbide mononitrate 30 mg tablet extended release 24 hr : one (1) tablet extended release 24 hr po daily (daily). 9. warfarin 5 mg tablet : one (1) tablet po once daily at 4 pm. 10. metformin 500 mg tablet : one (1) tablet po twice a day. 11. omeprazole 20 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po once a day. 12. furosemide 40 mg tablet : two (2) tablet po daily (daily). 13. miralax 17 gram/dose powder : seventeen (17) g po once a day as needed for constipation. disp:*qs * refills:*0* discharge disposition: home with service facility: of discharge diagnosis: gi bleeding, acute bradycardia cad pvd a fib chronic, diastolic chf dm2 uncontrolled with pvd comps chronic pain discharge condition: level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). aphasic discharge instructions: you were admitted with a gi bleed. your coumadin was stopped and you were taken off of your aspirin and plavix and your bleeding stopped. you were started on a heparin drip and your bleeding restarted. you had a colonoscopy which was negative for bleeding (at that point you had stopped bleeding again). you were started back on your coumadin. you will need to follow-up with to have your blood count checked. at that time, if you are stable, they may decide to add on your plavix. you will then need to follow-up again to have your aspirin added back on. . please weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: when: thursday at 1:50 pm with: , md. post clinic building: sc clinical ctr campus: east best parking: garage *this appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. this visit, you will see your regular primary care doctor in follow up. department: when: tuesday at 10:20 am with: , m.d. building: campus: east best parking: garage department: surgery when: thursday at 12:15 pm with: , md building: lm bldg () campus: west best parking: garage procedure: colonoscopy central venous catheter placement with guidance diagnoses: coronary atherosclerosis of native coronary artery esophageal reflux congestive heart failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation chronic kidney disease, unspecified other specified cardiac dysrhythmias long-term (current) use of insulin other late effects of cerebrovascular disease long-term (current) use of anticoagulants iron deficiency anemia, unspecified atherosclerosis of native arteries of the extremities with gangrene diverticulosis of colon with hemorrhage late effects of cerebrovascular disease, aphasia chronic diastolic heart failure internal hemorrhoids without mention of complication other musculoskeletal symptoms referable to limbs diabetes with peripheral circulatory disorders, type ii or unspecified type, uncontrolled 

Answer: The patient is high likely exposed to