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: fever, hypotension major surgical or invasive procedure: egd peg placement picc placement history of present illness: hpi: 63 male with a history of end-stage liver disease secondary to non-alcoholic steatohepatitis, seizure disorder, type 2 diabetes, hypothyroidism presents with fevers and hypotension and profound dehydration from . per their records, he had been having fevers for several days. it was considered that he could have a nasal source from chronic dobhoff. ceftaz was started, and then was changed to meropenem several days prior to admission. he has continued to spike through that and motrin. . he has poor baseline functional status, and is not able to relate any complaints. comparing records, his mental status appears to be better on admission than it had been since his discharge. he had some green diarrhea on the day prior to presentation and his blood sugars had been very high for the past several days (300's). . of note, patient was recently discharged from on after prolonged admission since , originally admitted for convulsive status epilepticus. he was treated for his seizures, which were felt secondary to his elevated ammonia level. he also developed sepsis and was started on cvvh. his blood cultures at that time had coag negative staph and vanco-sensitive enterococcus. he also had an episode of vt and an echo at the time revealed a decreased ef of approximately 40%. . ed course: he was hypotensive to 60s on arrival. he was given aggressive fluid resuscitation. he was in in acute renal failure. a subclavian line was placed. past medical history: pmhx: - nash cirrhosis, on transplant list - hcc - diabetes mellitus hypertension - seizure disorder - hypothyroidism - gerd - chf, tte in demonstrated lvef 40% with regional lv wall motion abnormalities, which was new as compared to (ef at that time was >55%. - cad, s/p cardiac cath in for planned ptca of rca which failed secondary to occlusion and dissection; followed by - hyperlipidemia - ugib s/p tips social history: remote smoking history, married. currently lives at . family history: nc physical exam: physical exam on admission: physical examination: vs tm 101.2 tc 97.4 98/52 78 28 100% on 35% trach mask general: elderly, ill appearing male, lying in bed, nad heent: mmdry, white film on tongue, poor dentition, perrl neck: supple, no lad, trach in place, jvp flat lungs: coarse bs bilaterally cardiac: regular, ii/vi hsm at apex, no s3 or s4 abdomen: obese, sl distended, nt, pos bs gu: no scrotal edema extr: trace le swelling. upper extremities with 2+ pitting edema in the forearms. skin: stage 2 coccyx ulcer. neuro: arousable, followed simple commands like open mouth or eyes. can barely move hands, and is not able to move toes. pertinent results: ekg: nsr 78 bpm, nl axis, nl intervals, deep q in ii, iii, avf. good rwp. consistent with prior from . . imaging: . cxr: persistent atelectasis within the right perihilar region and left lung base. tip of right subclavian central venous catheter overlie the proximal right atrium. recommend partially withdrawing. . abd u/s findings: there is no ascites identified in the abdomen. no new liver masses are identified, and there is no biliary dilatation identified. doppler examination of the tips shunt demonstrate flow within the shunt which is wall- to-wall, however, the distal portion of the shunt shows some narrowing. velocities within the tips shunt are 30, 96, and 282 in the proximal, mid and distal portions respectively. elevated velocities within the distal portion are concerning for a distal stenosis. flow in the main portal vein is hepatopetal and is 44 cm/sec. some flow away from the tips shunt is identified within the anterior right portal vein. flow within the left portal vein is still demonstrated towards the tips shunt on this exam. brief hospital course: a/p : 63m h/o esld nash, hcc, seizure disorder, dm2, hypothyroidism, poor baseline mental status (unable to speak, unable to move extremities at baseline per wife), admitted from rehab via with fevers, hypotension, profound dehydration, and electrolyte derangements, now with improved mental status after rehydration. . # fevers/hypotension: his initial presentation was felt to be concerning for sepsis in light of fevers prior to admission. patient was determined to be severely hypovolemic in the ed, and was given 7 liters of normal saline. his bp improved and has since remained stable. the possible sources of infection were felt to include decubitus ulcer, gi/diarrhea, uti, pulmonary. he was initially covered with linezolid with history of vre, which was switched to daptomycin, piperacillin/tazobactam, and metronidazole for broad coverage. his chest x-ray showed no pneumonia. he had no recurrent fevers and blood and urine cultures and stool c. diff were negative. his antibiotics were subsequently removed and his vitals remained stable. given this clinical picture, hypovolemia from dehydration rather than sepsis was considered the most likely cause of hypotension. . # seizures: patient had a recent prolonged admission with refractory seizures, necessitating pentobarbital coma at one point. seizures during his prior admission were primarily absence in nature, as he would stare off and become non-responsive, but no rhythmic motions were noted. the epilepsy service was consulted to assist with management of his several anti-epileptics. given his low albumin, corrected phenytoin levels (goal 20-30) and free phenytoin levels (goal 2-2.5) were followed. his phenytoin dose was slightly decreased. continuous eeg monitoring x 2 days demonstrated slow background but no rhythmic epileptiform activities, ruling out subclinical seizures. he was continued on his prior regimen of phenytoin (at a lower dose), zonismaide, levetiracetam, and topiramate. he was also placed on lorazepam 0.75 mg tid for seizure prophylaxis in the setting of lowered seizure threshold. his phenytoin dose was further decreased to 150mg per peg tid after his free phenytoin level returned elevated at 2.9. he should have a free phenytoin level checked on and again on , and the results should be communicated to dr. at . she will determine any further dose adjustments. he should also continue on his current dose of lorazepam until , when it should be decreased to 0.5mg iv q8h. he was discharged on these medications with follow up with dr. . please contact her at the above number for any questions regarding his antiepileptic medication regimen. . # ams: although patient is minimally responsive to commands, this current mental status and functional status (rigidity and limited ability to move extremities) is his new baseline. wife stated patient is the "best" he has been since . he had periods of increased lucidity with orientation to person and place. his ammonia was followed and was found to be higher than previous levels. he was maintained on lactulose and his rifaximin was increased. antiepileptic management as above. he remained at his baseline mental status for the remainder of his stay. . # ugib: on , patient had coffee-ground emesis. his dobhoff was removed and tube feedings were held. noticed some brown mucous at trach site. ng lavage showed coffee grounds but no bright red blood. his hct was stable from prior days at 24.9. he received 3 u prbcs with an increase in his hct to 30.9. his aspirin and sc heparin were held, and he was placed on a ppi . egd on showed small hiatal hernia and grade b esophagitis with contact bleeding in the lower third of the esophagus. peg tube was placed on and he has been tolerating tube feeds. his hematocrit has remained stable at 29. his sc heparin was restarted. consider holding aspirin for 2 weeks (to restart on ) to allow mucosa to heal, in light of risk of recurrent life-threatening gi bleeding. he was maintained on a ppi. . # hypernatremia: hypernatremia to 166 on admission was considered most likley due to hypovolemia given his clinical exam and improvement with replacement of his 8l free water deficit. he also received free water boluses via peg tube. his sodium level remained stable. . # cad: patient has history of cad, and had elevated troponin on admission, but was unable to give a history of chest pain. acute renal failure was considered a possible contributor to elevated troponin levels, and his ck trended downwards. his beta blocker and ace-inhibitor were initially held in the setting of hypotension. his aspirin was held in the setting of an upper gi bleed as above. his home beta blocker and ace-inhibitor were restarted after he remained stable after gi bleed. his blood pressure has remained stable. . # decubitus ulcer / heel blisters: pt was admitted with stage 2 ulcer on coccyx and pressure blisters on heels. wound care and plastic surgery consults were obtained and recommendations followed. a rectal tube was placed for hygiene and he may need fecal diversion in the future. patient will need follow up with plastic surgery post-discharge. . # esld/cirrhosis: he has a history of hcc and nash cirrhosis, and is s/p tips after a gi bleed. he was previously considered for liver transplant but has been delisted due to his baseline mental status. a ruq us was performed on admission with some concern for tips stenosis. ir assessed the tips under fluoroscopy and found mild narrowing but no hemodynamically significant stenosis. his ammonia level was found to be elevated from baseline as above, although his mental status remained at baseline. he was maintained on lactulose and his rifaximin was increased. . # pancytopenia: patient was found to be pancytopenic (but not neutropenic) on admission, with low platelets and leukopenia thought likely secondary to chronic liver disease/sequestration, and low hematocrit thought likely secondary to anemia of chronic disease. his wbc and platelet counts remained stable. his hematocrit was stable after resuscitation from gi bleed as above. further workup was deferred to the outpatient setting. . # arf: creatinine was 1.9 on admission (greatly increased from baseline of 0.5), considered likely prerenal given hypovolemia. it improved greatly with fluid resuscitation and has remained stable at 0.4-0.5. . # dm2 uncontrolled with complications: prior to admission, fingersticks had been trending upwards at rehab. nph and riss titrated to maintain fs <150. on ace-inhibitor as above. . # hypothyroidism: continued home regimen of levothyroxine 200mcg daily. . # respiratory failure s/p tracheostomy: no respiratory difficulties during this admission with stable oxygen saturation on baseline 35% trach mask. speech and swallow service was consulted, and patient was fitted for passy-muir valve. . # fen: patient has tolerated tube feeds via peg tube at goal rate. hypovolemia on admission was corrected with aggressive fluid resuscitation. patient subsequently developed anasarca due to low albumin state, although respiratory status was not compromised. he was given occasional doses of iv furosemide for gentle diuresis. hypernatremia as above. . # ppx: pneumoboots for dvt prophylaxis was maintained. sc heparin was also administered, with temporary hold in setting of gi bleed. on ppi. . # communication: wife . # access: picc placed. . # full code . # dispo: patient was determined medically stable and was discharged to rehab. . medications on admission: - meropenem - dilantin 300 tid - keppra 2250 - topiramate 200 - zonisamide 700 qd - asa - metoprolol 12.5 - lisinopril 2.5 qd - lactulose - rifaxamin - aldactone 100 qd - lasix 140 qd - insulin nph 20 - synthroid 200 qd - fragmin discharge medications: 1. levetiracetam 500 mg tablet : 4.5 tablets po bid (2 times a day). 2. topiramate 100 mg tablet : two (2) tablet po bid (2 times a day). 3. zonisamide 100 mg capsule : seven (7) capsule po daily (daily). 4. levothyroxine 100 mcg tablet : two (2) tablet po daily (daily). 5. lactulose 10 gram/15 ml syrup : thirty (30) ml po tid (3 times a day). 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 7. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 8. lisinopril 5 mg tablet : 0.5 tablet po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 10. lorazepam 2 mg/ml syringe : 0.75 mg injection q 8h (every 8 hours). 11. rifaximin 200 mg tablet : two (2) tablet po tid (3 times a day). 12. nystatin 100,000 unit/g cream : one (1) appl topical (2 times a day). 13. heparin lock flush (porcine) 100 unit/ml syringe : two (2) mg intravenous daily (daily) as needed. 14. albuterol sulfate 0.083 % (0.83 mg/ml) solution : one (1) nebulizer inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 15. ipratropium bromide 0.02 % solution : one (1) nebulizer inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 16. insulin nph human recomb 100 unit/ml suspension : as directed units subcutaneous twice a day: administer 28 units every morning and 32 units every evening. 17. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day) for 3 days. 18. zinc sulfate 220 (50) mg capsule : one (1) capsule po daily (daily) for 3 days. 19. phenytoin 100 mg/4 ml suspension : one y (150) mg po tid (3 times a day). 20. outpatient lab work please check free phenytoin level (goal 2.0-2.5) on and . please communicate results to dr. . 21. insulin lispro 100 unit/ml solution : as directed units subcutaneous four times a day: please see sliding scale. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: hypernatremia hypovolemia upper gi bleed sacral decubitus ulcer secondary: epilepsy cad chf discharge condition: stable, mental status at baseline, bp stable, electrolytes within normal limits discharge instructions: you were admitted to the hospital with fever, low blood pressure, and a very high sodium level. you were initially treated with antibiotics. no source of infection was discovered despite extensive testing and your fever never recurred, so you were taken off antibiotics. your blood pressure improved with iv fluids. your sodium level also improved with fluids. you were followed by the neurology-epilepsy service during your stay, and they recommended adjustments to your anti-seizure medications. you had continuous eeg monitoring that did not show any evidence of seizure activity. you had some bleeding from your stomach which was thought to be secondary to irritation of the stomach lining. your aspirin was held and you were starting on an anti-acid medication. you were also followed by the wound care service for your sacral decubitus ulcer. you were given a few doses of iv furosemide for edema in your arms and legs. a picc line was placed. a feeding tube was placed in your stomach. your respiratory status was stable. . please take all of your medications as prescribed. please attend all of your follow up appointments. . if you experience low blood pressure, fever, blood in vomit or stool, seizure activity, change in mental status from your baseline, or other concerning symptoms, please call your doctor or go to the er. followup instructions: 1) epilepsy: , md phone: date/time: 9:00am 2) plastic surgery: please follow-up in clinic for yoursacral decubitus ulcer. call ( to make an appointment. 3) please call your primary care doctor, dr. , to schedule a follow up appointment. procedure: venous catheterization, not elsewhere classified other endoscopy of small intestine enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] transfusion of packed cells phlebography of the portal venous system using contrast material diagnoses: coronary atherosclerosis of native coronary artery congestive heart failure, unspecified unspecified essential hypertension cirrhosis of liver without mention of alcohol acute kidney failure, unspecified unspecified septicemia unspecified protein-calorie malnutrition severe sepsis diaphragmatic hernia without mention of obstruction or gangrene other and unspecified hyperlipidemia other shock without mention of trauma pressure ulcer, lower back diarrhea malignant neoplasm of liver, primary diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled esophagitis, unspecified hypovolemia hyperosmolality and/or hypernatremia acute on chronic systolic heart failure generalized nonconvulsive epilepsy, with intractable epilepsy chronic respiratory failure esophageal hemorrhage tracheostomy status 

Answer: The patient is high likely exposed to