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: demerol / actos attending: chief complaint: elevated lfts major surgical or invasive procedure: aicd cardioversion on history of present illness: 72-year-old gentleman with a past medical history significant for vf arrest s/p aicd placement in , chf with ef of 15-20%, afib, dm, copd, htn, ischemic hepatitis, and recent admissions to icu first for syncope in setting of afib with rvr in then for altered mental status in early (d/c ), now tranfered from rehab because feeling ill for the past few weeks found to have ast 1733, alt 1164 in the ed without obstructive picture on lfts. . pt reports he has not felt well over the past few weeks. in particular, he reports he went to rehab 4 weeks ago from his last stay at . he says he was regaining strength for the first two weeks but then in the last two weeks has lost all that strength again and feels like he is back to when he was admitted to rehab. he says his weakness is particularly prominent in his legs. he reports occasional sob when walking that has also worsened somewhat in the last 2 weeks. he denies chest pain, diaphoresis, or nausea this these sx. he started having a prominent itching sensation around the time he was admitted to rehab, mostly on his arms. he has been itching his arms a lot in the last 4 weeks and has created multiple scabs on his arms from the itching. he denies thinking that his skin is more yellow. he denies nausea although told ed he had some. he says he hasn't had much of an appetitie recently and hasn't eaten anything by mouth but also reports he has been feed daily through his g-tube while at rehab. he is not able to clearly articulate why he has a g-tube. he isn't sure why the rehab sent him to the hospital today, but is able to articulate that they found his liver to be inflammed on the labs from the ed here. . in the ed, initial vs: 98.1 90 102/67 25 96% ra. ast/alt markedly elevated with only mild ap elevation and normal tbili but with significantly elevated inr. wbc wnl and ruq u/s showed mild abnormalities but no evidence of cholecystitis. surgery was consulted re gallbladder and said no evidence of cholecystitis or surgical need. cxr showed "stable" r pleural efffusion with no evidence of pna. ed concerned that ua consistent with a uti. pt was given iv cipro/flagyl as well as zofran. having intermittent nose bleeds in ed. gtube patent. pt with episodic desats to 80s but o2 sat probe unreliable. most recent vitals: 2235: t 97.7 hr 92 bp 92/53 rr 20. past medical history: - schf- tte 15-20%, dry weight 198 lbs. - paroxysmal atrial fibrillation - on coumadin - cad - cath showed showed single vessel lcx disease (70% occlusion distally and the om branch had 90% at mid vessel) - acid after vf arrest in , vr 7232cx - diabetes (last a1c 8.5 ) - dyslipidemia - hypertension - copd - barrett's esophagus with high grade dysplasia - right sided pleural effusion which had been present on chest x rays since - post-cryotherapy x 3, barrx - s/p gi bleed- ugib from a gastric ulcer - s/p appendectomy - s/p bone tumor excision from shoulder - portal vein thrombosis - g-tube social history: occupation: retired from police force and security service at hospital housing: lives independently at blakes estate senior center (a retirement community), but found to be in squalor in . family: closest family is cousin ), lives down the street from him. hcp is . adopted. never married, no children. tobacco: 45 year 1-2ppd history, quit 11 years ago. alcohol: none drugs: none family history: adopted. does not know his family history. physical exam: admission exam: vs - temp 96.3 f, bp 96/64, hr 71, r 22, o2-sat 98% ra general - sick appearing m with thin ext, difficult to tell if mild yellowish tinge to face is baseline skin color heent - perrla, eomi, sclerae anicteric but very pale, mmm, op clear but with poor dentention neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - decreased breath sounds halfway up on r, otherwise clear heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - distended, no fluid wave, no hsm, nt to palp, norm bs, tube in place in epigastrium is normal appearing without surround swelling, erythema, or discharge extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps), pt with multiple ue excoriations and scabs at various stages of healing (some appear to be fairly recent), none on legs skin: scratch lesions on arms as noted above, no spider angiomas or palmar erythema, no prominent skin yellowing except for question of this vs baseline color on face lymph - no cervical lad neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, no asterixis discharge exam: vs: 97.6, 110/58, 59, 18, 98ra general: cachectic, ill appearing male. aaox2, tachypnic with accessory muscle. comfortable appearing heent:area of right neck with subcutaneous echymosis. no pulsatile mass, small excoriation of the right lateral area underneath the dressing. cardiac: rr, holosystolic mumur heard best at the llsb and in the apex, no appreciable s3 or s4. lungs: moving air bilaterally in upper lung fields. small crackles in the r anterior chest. abdomen: thin, soft, ntnd. no hsm or tenderness. extremities: cool lower extremities- cyanotic, but able to move them, slowed capillary refill biltarelly. no pitting edema. skin: no peripehral edema pertinent results: liver ultrasound son images of the right upper quadrant demonstrate normal liver echogenicity, without focal lesions. the midline structures including the pancreas are not well seen due to overlying gastrostomy tube. normal hepatopetal flow is seen within the main portal vein. there are pleural effusions, right greater than left, a small amount of perihepatic ascites. the gallbladder is collapsed with an abnormally thickened wall - likely reflecting liver disease. there is no pericholecystic fluid. the common bile duct is normal in caliber measuring 4 mm. impression: 1. decompressed gallbladder with thick wall, likely reflecting liver disease. 2. bilateral pleural effusions, right greater than left with small amount of perihepatic ascites. echo the left and right atria are moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated with severe global hypokinesis (lvef = 20 %). systolic function of apical segments is relatively preserved. no masses or thrombi are seen in the left ventricle. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. there is abnormal septal motion/position. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension.there is no pericardial effusion. impression: biventricular cavity enlargement with severe global left ventricular hyopkinesis and right ventricular free wall hypokinesis. moderate to severe tricuspid regurgitation. mild-moderate mitral regurgitation. pulmonary artery hypertension. admission labs 05:12pm blood wbc-10.2 rbc-3.58* hgb-7.5* hct-25.6* mcv-72* mch-21.0* mchc-29.4* rdw-17.4* plt ct-363# 05:12pm blood pt-36.7* ptt-37.2* inr(pt)-3.7* 05:12pm blood glucose-318* urean-82* creat-1.0 na-129* k-4.4 cl-88* hco3-30 angap-15 05:12pm blood alt-1164* ast-1733* ld(ldh)-954* ck(cpk)-41* alkphos-233* totbili-1.3 05:12pm blood totprot-6.6 albumin-3.5 globuln-3.1 calcium-9.2 phos-2.2* mg-2.2 08:11pm blood lactate-2.0 discharge labs: 07:55am blood wbc-8.4 rbc-4.00* hgb-8.1* hct-29.7* mcv-74* mch-20.2* mchc-27.2* rdw-18.1* plt ct-293 07:55am blood pt-37.9* ptt-39.1* inr(pt)-3.7* 07:55am blood glucose-218* urean-73* creat-1.6* na-136 k-5.1 cl-95* hco3-33* angap-13 07:55am blood alt-192* ast-75* alkphos-224* totbili-1.4 07:55am blood calcium-8.5 phos-3.9 mg-2.9* 04:18am urine color-straw appear-clear sp -1.007 04:18am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 4:18 am urine culture (final ): no growth. brief hospital course: micu course: 72 year old male transferred from rehba to the micu for congestive hepatopathy and encephalopathy due to afib with rvr whose heart condition continued to decompensate and it was determined that given his poor perfusion and recent studies that he has end stage heart dieseae and changed his goals of care to comfort measures only. # goals of care: goals of care discussion occured on this admission with both mr. and with the 2 healthcare proxys. decision was made to be cmo, focus on comfort. pt was given morphine elixir as needed for sob. he may also get lasix 40-80mg iv prn for sob. he is on lactulose for bowel movements, but has not had a bm in a few days. this should continue to be address at his rehab. hcp and pt request that patient is not re-hospitalized. pt is eating and ice cream by mouth and is aware of aspiration risks. his icd was turned off prior to discharge. # acute hepatitis- patient was originally admitted with transaminitits and this was felt to be int he setting of poor forward flow of the heart given his afib with rvr. his workup for other causes was negative. his lfts continued to downtrend after his heart rate improved. # a. fib with rvr: pt with a known history of atrial fibrillation with biv icd. it was unclear if this was actually pacing him at the time that he came in. the icd was used to cardiovert him into regular rate. he then went into afib to the 130s on additional occasion however responded well to metoprolol. his pacer was interogated and felt to be working properly. his warfarin was d/c'd due to his changes in goals of care to cmo. # end stage heart failure- patient has history of both systolic and diastolic heart failure with an ef of 15-20%. a repeat tte did not demonstrate any significant changes. the patient originally required dobutamine in the icu. his medical management was optimized however due to his low blood presures and ef. it was then felt that his heart failure with worsening renal function was end stage, and his goals of care were changed to cmo. . # acute renal failure- patient had intermittently elevated cr in the setting of oliguria likely due to decreased perfusion of his kidneys from his poor cardiac output. . #cystitis: patient had a positive urine culture for e. coli. patient was given 3 days of ceftriaxone. no associated complications. transitional issues: patient was discharged to rehab for palliative care/hospice care, with the goal to not be rehospitalized. his icd was turned off prior to being discharged. medications on admission: - levofloxacin 750mg qd day 1 - metronidazole 500mg tid day 1 - digoxin 0.125 mg eod - metoprolol 6.25 mg - aldactone 12.5 mg qd - lasix 40mg - metolazone 5mg qd - asa 81mg qd - lantus 15units and iss - vit d + calcium - ranitidine 150mg - tylenol prn - ducolax prn - miralax prn - warfarin discharge medications: 1. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). tablet(s) 2. metoprolol tartrate 25 mg tablet sig: 0.25 tablet po tid (3 times a day). 3. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 4. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: one (1) po q1h (every hour) as needed for shortness of breath or wheezing. 5. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 6. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 7. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed for itching. 8. insulin glargine 100 unit/ml solution sig: fifteen (15) units subcutaneous qam. 9. insulin lispro 100 unit/ml solution sig: as directed subcutaneous four times a day: per sliding scale. discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: primary diagnoses end stage heart failure acute renal failure congestive hepatopathy atrial fibrillation with rapid ventricular rate secondary diagnoses: insulin dependent type ii diabetes discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking care of you while you were here at . you were brought to the hospital from rehab because you weren't feeling well and blood tests from rehab showed that your liver wasn't working properly. from testing performed here, it was determined that this was due to your heart not pumping properly and had bakced up the blood in the liver. because your heart wasn't pumping very well you were in the icu and on iv medications to keep your blood pressure up for a short time. after they put your heart back a slower speed (by using your aicd to shock the heart), you were transfered out of the icu to the cardiology floor. your heart continued to not pump very well despite giving you medications to try to help it pump better. we discussed with you and your health care proxy that the long term prognosis for the heart not pumping well were not good, and that you have end stage heart failure. during these discussions you decided to focus your care on comfort, and we will be transferring you back to a rehab facility with this goal of making you comfortable. transitional issues: you are being transfered to rehab for palliative care. followup instructions: you should follow-up with your primary care doctor procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances other electric countershock of heart diagnoses: other primary cardiomyopathies acidosis other iatrogenic hypotension abnormal coagulation profile coronary atherosclerosis of native coronary artery unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver chronic airway obstruction, not elsewhere classified atrial fibrillation personal history of tobacco use paroxysmal ventricular tachycardia other and unspecified hyperlipidemia long-term (current) use of insulin pressure ulcer, lower back automatic implantable cardiac defibrillator in situ altered mental status encounter for palliative care do not resuscitate status anticoagulants causing adverse effects in therapeutic use hepatic encephalopathy acute on chronic systolic heart failure diseases of tricuspid valve barrett's esophagus pressure ulcer, stage ii nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] attention to gastrostomy personal history of sudden cardiac arrest portal vein thrombosis other and unspecified escherichia coli [e. coli] chronic passive congestion of liver acute kidney failure with other specified pathological lesion in kidney other specified pruritic conditions cystitis, unspecified 

Answer: The patient is high likely exposed to