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: aspirin attending: chief complaint: brbpr major surgical or invasive procedure: examine under anesthesia with anoscopy colonoscopy egd history of present illness: this is a 77-year-old spanish-speaking jehovah's witness with multiple medical comorbidities (htn, hyperlipidemia, diabetes, anxiety/depression, parkinson's and dementia) who underwent hemorrhoidal surgery on , developed brbpr 2 days later and was found to have hct of 24 and inr on 10 (not on coumadin), stabilized in micu and now transferred to the floor for further w/u of anemia. . the patient had outpatient hemorrhoidectomy without complications on under the care of dr. here at for chronic symptomatic hemorrhoids. per op note, there were large partially prolapsing hemorrhoids with a significant external component in the right posterior and left lateral position which were removed with a electrocautery and ligasure and a small right anterior hemorrhoid which was electrocoagulated because it was internal. three days afer the surgery, she began to develop brbpr and rectal pain and presented to the ed for this on . . on arrival to the ed, vs were t98.2 hr87 bp137/56 rr13 99%. her inr was found to be 9.9 although the patient reports to never having been on coumadin and was not taking any herbal medications or rat poison. she was given 10 mg po vitamin k. hct on arrival was 33.9 (baseline ~39) after passing ~250cc brbpr, dropped to 25 prompting transfer to icu. on transfer, patient was asymptomatic (hr 80s, sbp 130s). . in the icu, patient was seen by heme/onc, colorectal surgery, and gi. heme-onc felt that her presentation and labs were consistent with ingestion of vitamin-k antagonist (found that factors 2,7,10 were low, 5,8,9, normal). mixing studies were negative. she was taken to the or on for with anoscopy where her hemorrhoids were noted to appear clean, although melena was found and her rectum was packed with surgicell. gi felt that her brbpr was likely lower gi but recommended endoscopy and colonoscopy to look for origin. endoscopy was unremarkable other than a polyp in the stomach and colonoscopy was remarkable for diverticulosis of the whole colon, several small (2-5 mm) polyps and ulceration in the rectum, the latter of which was thought to be the source of the patient's recent bleeding. her hct on transfer from the micu was 21.9 and the patient remained asymptomatic throughout. . on arrival to the floor, patient continues to feel well though complains of rectal pain. past medical history: - type 2 diabetes mellitus, diet controlled - hypertension - hyperlipidemia - osteoarthritis - chronic low back pain - somatoform disorder - depression/anxiety - dementia - parkinsonism, tremor - glaucoma - gerd - s/p appendectomy - s/p total knee replacement x 2 - s/p post left wrist spur removal - cesarean section x 3 - history of back surgery: --l4-s1 decompression and fusion --removal of broken hardware at s1 with a revision arthrodesis --repeat ct scan shows pseudoarthrosis at l5-s1, with decompression down s2, and l3-l4 arthropathy --l4-s1 anterior lumbar interbody fusion followed by posterior stabilization --revision decompression with iliac screws - right humerous fracture social history: home: lives alone in . family: originally from d.r. divorced. 3+ children, closest == son (visits ~/wk). is pt's hcp. : retired housekeeper. functional: pt requires help with iadls and bathing but independent in other adls. son visits /wk, son's girlfriend calls to check daily. tob: never smoked etoh: none illicits: denies family history: sister with breast cancer. (+) hx depression, (-) hx diabetes. physical exam: admission: vitals: t 98.9| bp 142/55| hr 77| rr 18| satting 98% on ra abdominal pain. general: tearful, complaining of abdominal pain. heent: perrl, eomi. left eye with medial plaque. neck: no carotid bruits, jvd lungs: ctab heart: rrr, normal s1 s2, no mrg abdomen: soft, ttp without rebound, worse in epigastric/ruq region, nabs, no organomegaly. nbs. negative /cullen sign extremities: no c/c/e neurologic: a+ox3. mae. no cn deficits. discharge: vitals: tc:98.4, bp:130/64, p:80, rr:18, o2:93%ra general: elderly woman lying in bed in nad heent: bilateral conjunctival pallor, skin normal tone per patient neck: supple, jvd flat, no lad lungs: ctab, no murmur/rubs/gallops cv: not tachy, holosystolic murmur in lusb abdomen: soft, non-distended, diffusely tender to palpation ext: 2+ dp pulses, feet are warm, trace edema and varicose veins bilaterally pertinent results: admission labs: 09:10pm blood wbc-9.3 rbc-3.73* hgb-11.4* hct-33.9* mcv-91 mch-30.5 mchc-33.6 rdw-13.4 plt ct-234 09:10pm blood neuts-45.0* lymphs-48.3* monos-4.4 eos-1.7 baso-0.6 09:10pm blood pt-96.4* ptt-55.9* inr(pt)-9.9* 01:31am blood d-dimer-1104* 05:48pm blood pt-19.6* ptt-40.3* inr(pt)-1.9* anemia workup: 06:35pm blood fibrino-264 thrombn-15.2 06:35pm blood fact ii-32* fact v-79 factvii-36* facviii-115 fact ix-58 fact x-30* 04:10am blood ret aut-1.8 05:53am blood ret aut-2.4 06:35pm blood inh scr-neg 06:35pm blood caltibc-250* vitb12-303 ferritn-30 trf-192* 06:35pm blood homocys-4.1 h. pylori negative kub: no evidence of obstruction or free air. kub: no evidence of sbo, volvulus, or pneumoperitoneum. ruq u/s: 1. echogenic liver consistent with fatty infiltration. other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. no gallstones and no biliary dilatation. 3. bilateral simple renal cysts. colonoscopy: findings: mucosa: localized ulceration including 1 large ulcer was noted in the rectum in the area of recent hemorrhoidectomy. protruding lesions several 2-5mm small polyps were noted throughout the colon, excavated lesions multiple small diverticula were seen throughout the colon. diverticulosis appeared to be of mild severity. other no fresh or old blood seen in the colon. impression: ulceration in the rectum, which is likely the source of the patient's recent bleeding. small 2-5mm polyps in the colon diverticulosis of the whole colon no fresh or old blood seen in the colon. egd: esophagus: normal esophagus. stomach: protruding lesions a single polyp of benign appearance was found in the stomach. duodenum: normal duodenum. impression: polyp in the stomach otherwise normal colonoscopy to third part of the duodenum brief hospital course: 77-year-old spanish-speaking jehovah's witness with multiple medical comorbidities (htn, hyperlipidemia, diabetes, anxiety/depression, parkinson's and dementia) who underwent hemorrhoidal surgery on , developed brbpr 2 days later and was found to have hct of 24 and inr on 10 (not on coumadin), stabilized in micu then transferred to the floor for further w/u of anemia and management of rectal and abdominal pain. . acute issues # brbpr: patient presented to the ed with several days of brbpr. in the ed, she had a further episode of bleeding leading to hct drop to 25 prompting transfer to the micu. with anoscopy showed "absolutely no evidence of bleeding at any of the sites." egd was unremarkable with the exception of a polyp in the stomach. however, colonoscopy was remarkable for diverticulosis of the whole colon, several small (2-5 mm) polyps and ulceration in the rectum, the latter thought to be the most likely cause of the patient's bleeding, although it is unclear why did not mention the rectal ulcers. patient is a jehovah's witness thus wishes to not receive any blood products. throughout her stay, she had 2 peripheral ivs, was on continuous telemetry and we checked hct, which remained in the low 20s. she never developed any symptoms of hemodynamic instability (hr 80s, sbps 120s-130s) although did feel quite fatigued. we gave her senna, colace, miralax and an xxx enema to help her to continue having bowel movemenents. she had several bms during her time on the medical floor, none of which were bloody. she will follow-up with gi as an outpatient regarding further management of her rectal ulcers. we explained to her the importance of eating fiber and staying hydrated to prevent constipation leading to the development of more hemorrhoids or of anal fissures. . # rectal pain: the patient developed severe rectal pain after her colonoscopy and anoscopy such that she had difficulty sitting and going to the bathroom. she was already on oxycodone and morphine for back pain, which we continued. we also started her on lidocaine and hydrocortisone cream, with minimal effect. the colorectal team performed a rectal exam which was unremarkable and suggested giving her low dose gabapentin. on discharge, her rectal pain had improved slightly. . # coagulopathy: on admission, the patient's inr was 9.9. etiology was unclear as the patient denied taking warfarin, any herbal medications or ingesting rat poison. factor deficiencies (2, 7, 10 low) and correction of inr with vitamin k were consistent with ingestion of vitamin-k antagonist. her son brought in all of her medications, none of which included warfarin. we have sent for a lab test to look for warfarin in her initial blood samples, resuls pending. . # anemia: the patient's hct hovered in low 20s, lowest was 19.9. as described above, she remained largely asympomatic. of note, she appears to have a baseline anemia with low/normal rbcs (mid-low 30s over past 10 years). we thought her anemia was likely multifactorial in cause, include brbpr and coagulopathy as described previously. her mcv was 94 but rdw was elevated, suggesting a combination of iron-deficiency from bleeding (though transferrin and were tibc low, perhaps because there was not enough time to equilibrate) with macrocytic anemia. she was found to have an innappropriately low reticulocyte count, although platelet and wbc count were normal thus not pancytopenic. we explored several causes of normocytic hypoproliferative anemia including endocrine disorders (hypo/ hyperthyroidism, panhypopituitarism, hyperpth all associated with mild proliferative anemia. the patient never had elevated calcium and we checked her tsh which was normal. heme-onc thought the most likely cause was nutrition deficiency thus she was started on folate and b12 supplementation. we gave her 2 doses of po iron after which she developed nausea and vomiting thus we switched this to iv iron, which the patient tolerated well. on discharge, her hct was 22.3. she should have retic count rechecked as outpatient once stable and consider heme/onc referral if persistently low. . # systolic murmur: patient has a holosystolic in lusb, newly heard during this admission. likely flow murmur due to anemia, but would recommend oupatient f/u for tte . # abdominal pain: the patient had abdominal pain and abdominal exam was remarkable for diffuse tenderness without any peritoneal signs. had kub x 2 since admission which showed no evidence of obstruction. labs were notable for slightly elevated ast, alt, alk-phos, ggt which did not provide a clear picture of the etiology bilirubin was normal). of note, she had an abdominal ct in which was normal (but did not have elevated lfts then). on this admission, she underwent a ruq u/s which showed no stones in the gallbladder but was remarkable for fatty infiltration of the liver. she is at risk for nafld given several risk factors (dm, htn, hld). we also sent an h. pylori which was negative. on discharge, abdominal pain was improved and lfts were normal with the exception of slightly elevated alk phos at 118. she will have outpatient gi follow-up. . # genital herpes: on the last day of your admission, you pointed out several small erythematous papules near your vagina, which appeared to be genital herpes. these lesions were causing you minimal pain but were quite itchy and bothersome. you told us that you had these lesions in the past inside of your vagina but had never been treated for them. we prescribed you with 3 days of valtrex for treatment of your genital herpes. . chronic issues . #diabetes mellitus: diet controlled. . #hld: continued on simvastatin 10 mg qhs . #parkinsonism: continued on pramipexole . transitional issues: 1) will f/u with colorectal, gi, pcp and (for monthly iv iron infusions) 2) please f/u warfarin levels medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from webomr. 1. amlodipine 5 mg po daily start: in am hold for sbp<100 2. atenolol 25 mg po bid hold for sbp<100/hr<60 3. famotidine 20 mg po daily 4. mirtazapine 30 mg po hs 5. morphine sr (ms contin) 15 mg po q12h 6. omeprazole 20 mg po bid 7. oxycodone (immediate release) 5 mg po q6h:prn breakthrough pain hold for sedation/rr<10 8. pramipexole *nf* 0.75 mg oral 9. simvastatin 10 mg po qhs 10. zolpidem *nf* 6.25 mg oral qhs extended release multiphase tablet po at bedtime 11. bisacodyl 10 mg po/pr daily:prn constipation 12. caltrate 600 + d *nf* (calcium carbonate-vitamin d3) 600 mg(1,500mg) -400 unit oral qday 13. hydrocortisone (rectal) 2.5% cream 1 appl pr tid for rectal pain 14. biotene oralbalance *nf* (lactoperoxi-gluc oxid-pot thio;<br>saliva stimulant agents comb.2) 30 cc mucous membrane qid swish and spit 15. senna 1 tab po bid:prn constipation 16. simethicone 80 mg po qid:prn gas/bloating 17. lidocaine-diphenhyd--mag- *nf* 200-25-400-40 mg/30 ml mucous membrane qid prn mouth pain swish and spit discharge medications: 1. amlodipine 5 mg po daily hold for sbp<100 2. hydrocortisone (rectal) 2.5% cream 1 appl pr tid for rectal pain 3. morphine sr (ms contin) 15 mg po q12h 4. oxycodone (immediate release) 5 mg po q6h:prn breakthrough pain hold for sedation/rr<10 5. pramipexole *nf* 0.75 mg oral 6. senna 1 tab po bid:prn constipation 7. simethicone 80 mg po qid:prn gas/bloating 8. simvastatin 10 mg po qhs 9. cyanocobalamin 1000 mcg po daily rx *cyanocobalamin (vitamin b-12) 1,000 mcg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 10. folic acid 1 mg po daily rx *folic acid 1 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 11. gabapentin 300 mg po hs rx *gabapentin 300 mg 1 capsule(s) by mouth daily disp #*30 capsule refills:*0 12. iron dextran 1000 mg iv once duration: 1 doses 13. lidocaine 5% ointment 1 appl tp prn rectal pain rx *lidocaine hcl 3 % please apply around rectal area prn disp #*1 tube refills:*0 14. atenolol 25 mg po bid hold for sbp<100/hr<60 15. bisacodyl 10 mg po/pr daily:prn constipation 16. caltrate 600 + d *nf* (calcium carbonate-vitamin d3) 600 mg(1,500mg) -400 unit oral qday 17. famotidine 20 mg po daily 18. lidocaine-diphenhyd--mag- *nf* 200-25-400-40 mg/30 ml mucous membrane qid prn mouth pain swish and spit 19. mirtazapine 30 mg po hs 20. omeprazole 20 mg po bid 21. zolpidem *nf* 6.25 mg oral qhs extended release multiphase tablet po at bedtime 22. valacyclovir 500 mg po q12h duration: 5 days day 1 = rx *valacyclovir 500 mg 1 tablet(s) by mouth twice per day disp #*6 tablet refills:*0 discharge disposition: home discharge diagnosis: rectal ulcer anemia, acute blood loss iron deficiency coagulopathy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , it was a pleasure taking care of you during your recent admission at . you came to the hospital several days after having hemorrhoid surgery because you were bleeding from your rectum. several hours after arriving to the emergency room, you passed more blood from your rectum and your hematocrit dropped to a very low level, prompting your transfer to the medical intensive care unit. your inr, which is a measure of the clotting function of your blood, was very high, although you were not taking any anti-coagulants. we remain unclear of exactly why this happened. you had an exam under anesthesia with anoscopy which showed that the sites of the excised hemorrhoids were not bleeding. an esophagogastroduodenoscopy (egd) was unremarkable, however a colonoscopy showed that you had a rectal ulcer, which we thought was the source of your bleeding. you were transferred to the general medical floor about 1 week into your hospitalization where we continued to manage your anemia and also tried to help you with your rectal and abdominal pain. for your anemia, you were started on b12, folate and iron supplementation. we did a right upper quadrant ultrasound for your abdominal pain, which showed some changes in your liver (fatty infiltration) that we recommend you follow-up as an outpatient. for your rectal pain, we gave you lidocaine and steroid cream and also started you on gabapentin. upon discharge, you were having less pain in your rectum and abdomen. medication changes 1) please start taking 300 mg gabapentin daily for your rectal pain 2) please use lidocaine and hydrocortisone cream as needed for your rectal pain 3) please continue to get monthly iv infusions of iron for your anemia. this will be done at the hematology/oncology clinic. 4) please start taking b12 and folate supplementation for your anemia follow-up appointments: please see below followup instructions: department: gastroenterology when: 1:00 with: , md, where: ra (/ complex), department: when: thursday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 10:30 am with: , md building: sc clinical ctr campus: east best parking: garage department: surgical specialties when: tuesday at 1 pm with: , np building: sc clinical ctr campus: east best parking: garage procedure: other endoscopy of small intestine colonoscopy anoscopy diagnoses: unspecified essential hypertension acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled dysthymic disorder other and unspecified hyperlipidemia paralysis agitans osteoarthrosis, unspecified whether generalized or localized, site unspecified do not resuscitate status lumbago benign neoplasm of colon other and unspecified coagulation defects diverticulosis of colon (without mention of hemorrhage) undiagnosed cardiac murmurs unspecified deficiency anemia hemorrhage of rectum and anus ulcer of anus and rectum benign neoplasm of stomach other genital herpes dementia, unspecified, without behavioral disturbance 

Answer: The patient is high likely exposed to