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 / aspirin / lipitor / glucophage attending: chief complaint: gi bleeding major surgical or invasive procedure: none history of present illness: 54 year old female with hx gib from upper gi avm's (stomach, duodenum, jejunum), on coumadin for extensive dvt s/p ivc filter, dm, asthma, and osa who presents with 2 days of dark stools and lightheadedness. the patient reports that she has had dark, non-bloody stools for two days associated with lower quadrant cramping. she also reports lightheadeness on standing for the past week, no syncope. she denies any vomiting, nausea or hematemasis. she went to her pcp today who recommended that she go the ed. at her pcp's office, she was found to have a bp 110/60 sitting, tenderness in abd in lower midline, hemoccult + stools. at her pcp's office, labs were done which showed a hb 7.3 and inr 2.5. of note, she had a ferillicit infusion on for chronic anemia likely slow gib. in the ed: triage vs 97.2 66 130/66 15 97%. she was found to have lower abd discomfort, guiac positive brown stool w/o any overt melena. her hct was found to be down 27 from 31 at the end of , but up from 25 during presumed gib in . ng lavage was negative. she received ffp 2 units, vit k 10mg iv, protonix 80mg iv and ivf. she had a type and screen sent. ct abd was performed for abdominal pain which showed no acute process. most recent vitals: 69 144/65 14 100%2l nc. currently she feels well, with some nausea but no vomiting recently. denies fever but has had some chills. feels fatigued and weak. mild abdominal pain. denied cough, shortness of breath or chest pain past medical history: -gi hx as of : nine upper endoscopies, two small bowel enteroscopies, five colonoscopies and one sigmoidoscopy over the last six years. multiple avms have been found and treated in her duodenum and jejunum. her most recent scopes were last , when 2 angioectasias in the stomach, one in the jejunum, one in the descending colon were found. -poorly controlled dmii -hypertension -asthma -anemia - profound iron deficiency gastric and duodenal av malformations as above, transfusion dependent, hct baseline around 22-29 -depression -migraines -obesity -chronic abdominal pain -delayed gastric emptying -diverticulosis -extensive dvt s/p thrombectomy, ivc filter placement, common and external iliac vein stenting on coumadin/plavix -osa, on home bipap vs cpap -? meningioma (lesion identified by ct on in left perimesencephalic region, being followed) -s/p appendectomy -s/p bilateral oophorectomy and hysterectomy -gout social history: negative for etoh, very remote marijuana use (30 yrs ago). positive tobacco use. currently smokes 3 cigarettes/ day, 20 pack-year history. formerly worked as a special needs counselor. currently lives alone in an apartment in the in the . has a son and grandchildren she sees frequently. family history: colon ca in mother and grandmother both in 70s, htn in mother, diabetes in grandfather. family hx of thrombophilia. son has recurrent epistaxis. physical exam: vitals: t: 98.7 p: 70 bp: 142/90 r: 11 sao2: 100% 2l nc general: obese aaf in nad. heent: nc/at, perrl, eomi without nystagmus, no scleral icterus noted, no lesions noted in op but dry mm. neck: supple, obese, difficult to assess jvp pulmonary: lungs cta bilaterally cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: obese, surgiclaly scarred, diffusely ttp, no peritoneal signs. extremities: wwp. no c/c/e bilaterally, 2+ dp pulses b/l. skin: no rashes or lesions noted pertinent results: radiologic data: capsule endoscopy: 1. coffee grounds in the stomach 2. delay in gastric emptying 3.angioectasia in the proximal jejunum 4. angioectasia in the ileum . egd's: 11 egd's since , some with agioectasias,last egd erythema in the antrum compatible with mild gastritis a small bowel enteroscope was passed to what appeared to be the mid jejunum. no avms or other abnormalities were seen. otherwise normal egd to middle jejunum . colonoscopies: 5 coloscopies since , last polyp in the proximal ascending colon (polypectomy) internal hemorrhoids angioectasia in the descending colon otherwise normal colonoscopy to cecum . small bowel enteroscopy: angioectasia in the upper third of the stomach angioectasia in the proximal to mid jejunum otherwise normal egd to third part of the duodenum . ct abd/pelvis: prelim no acute intra-abdominal process to explain pain . mra brain: impression: marked degradation of image quality by patient motion. there is no definite evidence of a high flow malformation, although given both patient motion and the extent of the imaging excursion, a cta of the head would be far more sensitive for evaluation and would be less prone to motion artifact. 08:18pm wbc-5.3 rbc-3.39* hgb-6.8* hct-23.1* mcv-68* mch-20.1* mchc-29.6* rdw-20.7* 08:18pm plt count-403 08:18pm pt-17.5* ptt-24.6 inr(pt)-1.6* 12:30pm pt-25.9* ptt-26.2 inr(pt)-2.5* 12:15pm glucose-108* urea n-12 creat-1.0 sodium-142 potassium-4.2 chloride-104 total co2-27 anion gap-15 12:15pm wbc-5.5 rbc-3.90* hgb-7.8* hct-27.4* mcv-70* mch-20.1* mchc-28.6* rdw-19.1* 06:35am blood wbc-5.9 rbc-4.13* hgb-8.8* hct-29.6* mcv-72* mch-21.4* mchc-29.9* rdw-21.2* plt ct-388 08:50am blood wbc-9.2# rbc-4.58 hgb-9.8* hct-33.9* mcv-74* mch-21.3* mchc-28.8* rdw-20.5* plt ct-455* 04:20am blood wbc-5.1 rbc-4.17* hgb-8.8* hct-30.6* mcv-74* mch-21.2* mchc-28.8* rdw-20.2* plt ct-397 07:44pm blood hct-28.5* 03:47am blood wbc-5.3 rbc-4.03* hgb-8.5* hct-29.5*# mcv-73* mch-21.1* mchc-28.8* rdw-20.2* plt ct-387 08:18pm blood wbc-5.3 rbc-3.39* hgb-6.8* hct-23.1* mcv-68* mch-20.1* mchc-29.6* rdw-20.7* plt ct-403 10:40am blood wbc-5.9 rbc-3.89* hgb-7.9* hct-27.8* mcv-72* mch-20.2* mchc-28.2* rdw-20.2* plt ct-503* 06:35am blood pt-12.6 ptt-22.8 inr(pt)-1.1 03:47am blood pt-15.1* ptt-22.8 inr(pt)-1.3* 08:50am blood glucose-85 urean-8 creat-1.1 na-143 k-4.2 cl-101 hco3-29 angap-17 04:20am blood glucose-160* urean-8 creat-0.8 na-139 k-3.8 cl-103 hco3-25 angap-15 03:47am blood glucose-162* urean-11 creat-0.9 na-140 k-3.8 cl-103 hco3-28 angap-13 12:15pm blood glucose-108* urean-12 creat-1.0 na-142 k-4.2 cl-104 hco3-27 angap-15 04:20am blood calcium-8.5 phos-3.7 mg-2.0 brief hospital course: ms. is a 54 year old female with a history of multiple upper gi bleeds from arteriovenous malformations who was admitted to the icu for several episodes of melena and decreased hct. . 1. acute blood loss anemia/gi bleed- patient has a history of multiple upper gi bleeds due to avms. there is concern for hereditary telangectasia disorders such as osler--rendu. she was hemodynamically stable on arrival to the icu, after receiving one unit of ffp and 10mg vitamin k in the emergency department to reverse her therepeutic inr. in the icu, she was transfused 2units of packed rbcs for a hematocrit of 23.1, with an appropriate increase in her hematocrit to 29.5. thereafter, the patient's hematocrit remained stable. the patient was called out to the medical floor on . she underwent mra of the brain, which although markedly limited by motion, showed no obvious intracranial avm. her hct remained stable on the floor and she was instructed to follow-up with her pcp . . this plan, along with her plan to continue low dose coumadin, was discussed with dr. prior to discharge, and the pt will be expected in her clinic on . pt and her daughter understand her ongoing risk for further bleeding in the setting of anticoagulation, and as below, elected to continue with coumadin given her significant dvt. . 2. hypertension, benging: the patient's home lasix, metoprolol, lisinoprl, and isosorbide were initially held due to concerns for hemodynamic instability in the setting of active gi bleed. these were restarted on . her bp remained stable thereafter . 3. history of dvt - prior to admission, the patient was on chronic anticoagulation with coumadin for history of left lower extremity dvt in . several outpatient providers have recommended she go off anticoagulation given multiple gi bleeds but patient has been reluctant to do so. the patient's coumadin was discontinued on admission, and her anticoagulation was reversed. past notes indicate that her goal inr should be 1.6-2.5. her coumadin was restarted on cautiously at a dose of 2.5mg po qdaily (baseline 5-7.5mg), as the patient strongly preferred to continue coumadin, despite a frank discussion of the risks. after discussion with her pcp, agreed to discharge the patient on low dose coumadin, she will have her inr checked on , and again during her visit with her pcp in her clinic, at which time a repeat hct will be checked also. . 4. asthma - stable, continued albuterol and flovent. . 5. obstructive sleep apnea - continued cpap with o2 2l/min per home settings. . 6. diabetes mellitus type 2, poorly controlled with complications - the patient was treated with glargine twice daily, plus a humalog sliding scale. . 7. neuropathy - continued gabapentin, oxycodone, and cymbalta. . 8. chronic pain: continued opiates per home regimen medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs every 4-6 hours as needed butalbital-acetaminophen-caff - 50 mg-325 mg-40 mg tablet - 1 (one) tablet(s) by mouth every six (6) hours as needed for headache duloxetine - 30 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth once a day fabricate - new channels in new shoes for existing klenzak brace - - use as directed as needed fluticasone - 50 mcg spray, suspension - 2 sprays in each nostril twice a day fluticasone - 110 mcg/actuation aerosol - 2 puffs twice a day furosemide - 20 mg tablet - 1 tablet(s) by mouth once a day if gain 2 pounds or more in one day. if you gain over 4 pounds in a day call the health center gabapentin - 800 mg tablet - 1 tablet(s) by mouth three times a day hydrocortisone acetate - 25 mg suppository - 1 per rectum rectally once per day after bm as needed insulin glargine - 100 unit/ml cartridge - 75 units at noon and at bedtime sq daily insulin lispro - 100 unit/ml solution - according to sliding scale administer twice a day - no substitution insulin syringes - ultra comfort 28 - - use as directed isosorbide mononitrate - 30 mg tablet sustained release 24 hr - 1 tablet(s) by mouth once a day lisinopril - 40 mg tablet - 1 tablet(s) by mouth once a day metoclopramide - 10 mg tablet - 1 tablet(s) by mouth four times a day before meals and at bedtime metoprolol tartrate - 100 mg tablet - take one tablet by mouth twice a day mupirocin calcium - 2 % cream - apply to each naris with cotton swab twice a day olopatadine - 0.1 % drops - 1 gtt ou twice a day oxycodone - 15 mg tablet sustained release 12 hr - 1 tablet(s) by mouth twice a day oxycodone-acetaminophen - 5 mg-325 mg tablet - 1 to 2 tablet(s) by mouth q 6 h pantoprazole - 40 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth twice a day pt would like it delivered to her at her daughter's house at . apt#3, . simvastatin - 40 mg tablet - 1 tablet(s) by mouth once a day urea - 40 % cream - apply to both feet twice a day as needed for thickened and dry skin warfarin - 5 mg tablet - 1 tablet(s) by mouth once a day except on thursday and sunday, take 1 1/2 tablets by mouth zolpidem - 10 mg tablet - 1 tablet(s) by mouth at bedtime as needed docusate sodium - 100 mg capsule - 1 capsule(s) by mouth twice a day loratadine - 10 mg tablet - 1 tablet(s) by mouth once a day nicotine - 7 mg/24 hour patch 24 hr - apply 1 patch once a day senna - 8.6 mg tablet - 1 tablet(s) by mouth twice a day discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po q6h (every 6 hours) as needed for headache. 3. duloxetine 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation daily (daily). 5. gabapentin 400 mg capsule sig: two (2) capsule po q8h (every 8 hours). 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily): or if you gain more than 2 pounds. 7. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal daily (daily). 8. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 9. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 10. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 11. metoclopramide 10 mg tablet sig: one (1) tablet po four times a day: with meals. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for breakthough pain: do not use with alcohol or driving. limit 4 grams tylenol total per day. 14. naphazoline-pheniramine 0.025-0.3 % drops sig: one (1) drop ophthalmic (2 times a day). 15. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 16. oxycodone 15 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po twice a day: do not use with alcohol or driving. 17. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constip. 19. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime) as needed for insomnia. 20. insulin glargine 100 unit/ml solution sig: seventy five (75) units subcutaneous twice a day: qmorning, qhs. 21. insulin lispro 100 unit/ml solution sig: 1-20 units subcutaneous qachs: according to your home sliding scale. 22. warfarin 1 mg tablet sig: 2.5 tablets po once a day: goal inr 1.6-2.5, follow your inr closely and re-dose accordingly. discharge disposition: home discharge diagnosis: acute blood loss anemia/gi bleed dvt, chronic asthma hypertension, benign type 2 diabetes mellitus, poorly controlled no complications discharge condition: good discharge instructions: you were admitted with recurrence of your gi bleeding. this was likely due to your avms (venous malformations) plus your blood thinning from your coumadin. with supportive care and blood transfusion your bleeding stopped. please resume your coumadin with caution and have your inr closely monitored. please follow up with your gastroenterologist, pcp, hematologist. . you inr level is still subtherapeutic. you preferred to remain on coumadin, although you should discuss discontinuing this with your primary care doctor. you will need to have your inr and hct checked with your pcp . you should see your pcp in her clinic by 8:30am on , this plan was discussed with your pcp, . , who is expecting you. . thye following changes were made to your medication regimen: 1. your coumadin dose was decreased to 2.5mg po qdaily. . please resume all previous medications as before. return to the hospital with fevers, chills, recurrence bloody or black stool, or other concerning symptoms. followup instructions: please the clinic on with your pcp, . , she asks that you arrive prior to 8:30am, and is expecting you. please call your pcp: , . , if you are unable to make this appointment. . provider: lab phone: date/time: 10:00 provider: , md phone: date/time: 10:30 provider: fitting technician phone: date/time: 11:40 procedure: venous catheterization, not elsewhere classified transfusion of packed cells transfusion of other serum diagnoses: obstructive sleep apnea (adult)(pediatric) other chronic pain abdominal pain, unspecified site abnormal coagulation profile unspecified essential hypertension acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled iron deficiency anemia secondary to blood loss (chronic) asthma, unspecified type, unspecified depressive disorder, not elsewhere classified personal history of venous thrombosis and embolism other postprocedural status obesity, unspecified angiodysplasia of intestine with hemorrhage anticoagulants causing adverse effects in therapeutic use migraine, unspecified, without mention of intractable migraine without mention of status migrainosus mononeuritis of unspecified site diverticulosis of colon (without mention of hemorrhage) internal hemorrhoids without mention of complication angiodysplasia of stomach and duodenum with hemorrhage family history of malignant neoplasm of gastrointestinal tract dyspepsia and other specified disorders of function of stomach 

Answer: The patient is high likely exposed to