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: no known allergies / adverse drug reactions attending: chief complaint: frequent suctioning major surgical or invasive procedure: none history of present illness: 88 year old female with recent acute on chronic left sdh, recent sah s/p coiling of right pca artery aneurysm, hydrocephalus with vp shunt, acute respiratory failure secondary to large thoracic mass (benign thyroid nodule) requiring trach, severe dysphagia with peg placement, ?gi bleed, dvt with ivc filter placement transferred from osh for anemia and admitted to micu for increasing respiratory secretions. . patient had been at prior to transfer and per report patient noted to have hct 23.8 and concern for gi bleed and was sent to osh for blood transfusion. there vs: 100.4 114/66 80 94% ra. there was question of allergic rxn (?seizures) to blood in the past so ohs transferred her to . prior to transfer patient had cxr with concern for a rll pneumonia. given 750mg of levoquin. . in the ed, initial vs were 100 98 106/54 26 94%. 18g and 20g were placed for access. exam notable for rectal exam: no stool in the vault, very trace guiac + effluent. pulmonary exam with coarse breath sounds bilaterally, scattered rhonchi, pink secretions from trache collar. patient received pr tylenol for temp of 100.8. abx were not continued as suspicion for pna low. . on arrival to the micu, patient comfortable without complaint with cough, sob, cp. . of note, anemnia/dark tarry stools has been chronic issue and per previous dc summaries patient with recent egd and c-scope wnl. previously, initial positive guaiac tests thought secondary due to manipulation of her peg tube, . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: subarachnoid hemorrhage s/p coiling of r pca aneurysm hydrocephalus s/p vp shunt respiratory failure requiring trach placement thoracic mass: biopsied - benign thyroid nodule hyperthyroidism with goiter anemia - prior black stools with no source found from egd/c-scope deep vein thrombosis s/p ivc filter hypertension atrial fibrillation social history: originally from republic, spanish-speaking. prior to her prolonged hospitalization in she was living with her daughter and granddaughter and was very independent. currently she is at . she walks with a cane or walker at baseline. no history of tobacco or alcohol use. family history: cad physical exam: admission physical: general: alert, oriented, no acute distress, comfortable, pleasant, breathing comfortably on trach mask heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: rhonchorus breath sounds bilaterally, no wheezes, rales abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: non-focal, moving all four extremities with sensation intact pertinent results: labs: admission labs: 12:55am blood wbc-8.0# rbc-2.80* hgb-8.7* hct-25.4* mcv-91 mch-31.2 mchc-34.5 rdw-16.2* plt ct-475* 12:55am blood neuts-77.2* lymphs-11.9* monos-5.8 eos-4.6* baso-0.4 12:55am blood pt-12.4 ptt-30.5 inr(pt)-1.1 12:55am blood ret aut-3.9* 12:55am blood glucose-119* urean-25* creat-1.0 na-139 k-4.6 cl-102 hco3-28 angap-14 12:55am blood alt-12 ast-15 ld(ldh)-147 alkphos-77 totbili-0.3 06:42am blood calcium-9.2 phos-4.0 mg-1.8 iron-15* 12:55am blood hapto-330* 06:42am blood caltibc-250* ferritn-41 trf-192* discharge labs: thyroid function tests: 06:40am blood t3-65* free t4-1.5 06:40am blood tsh-0.34 micro: urine culture-final negative mrsa screen-final negative blood culture, routine-pending emergency blood culture, routine-pending studies: cxr : impression: 1. grossly stable thyroid goiter causing widening of the right paratracheal stripe. 2. unchanged elevation of the right hemidiaphragm and bibasilar atelectasis. 3. no evidence of pneumonia or acute pulmonary edema. brief hospital course: 88 year old female with recent acute on chronic left sdh, recent sah s/p coiling of right pca artery aneurysm, hydrocephalus with vp shunt, acute respiratory failure secondary to large thoracic mass (benign thyroid nodule) requiring trach, severe dysphagia with peg placement, ?gi bleed transferred from osh for anemia and admitted to initially to the micu for increasing respiratory secretions. she was stable for transfer to the medicine floor within one day. active issues by problem: # respiratory secretions: on arrival to micu, patient's secretions were minimal and she had no signs of respiratory distress. initial concern for ?pna vs tracheitis however patient without leukocytosis or fevers (except initial temp of 100, no recurrence). cxr without focal infiltrate. previous sputum cultures have grown pseudomonas; however this likely represents colonization rather than infection, so it was felt that repeat sputum cultures would not be helpful in this clinical setting. antibiotics were not started. secretions appear to be coming from both oropharyngeal and pulmonary sources, however they are clear and she is able to expectorate them extremely well on her own. she was seen by the interventional pulmonary team, who had no further recommendations or plans for interventions at this time. pt was continued on trach mask and required suctioning every 6-8 hours. guaifenesin and saline nebs were initiated to help break up the thickened sputum. this regimen, along with albuterol, should be continued at her rehab facility. # normocytic anemia: likely due to a very slow lower gi bleed. admission hct 25.4, with baseline hct ~28-30. exam in ed guaiac + but without overt melena or brbpr. previous gi work-up with unrevealing egd (documented in operative note) and reportedly normal colonoscopy at in . peg lavage on arrival to the micu guaiac negative. previous vitamin b12, folate wnl. iron studies suggested iron deficiency anemia, for which she was continued on her iron supplementation. she was transfused one unit prbc's for hct 22 with appropriate response to 25. after transfer to the medicine floor, hct continued to remain stable. she did have more dark brown guaiac positive stools. it is likely that she has a very slow gi bleed that is causing her anemia, more likely lower rather than upper gi given the guaiac negative peg lavage. as this appears to be a chronic issue that is relatively stable, it is recommended that she continue to have her hemoglobin/hematocrit followed and could have a repeat colonoscopy for further work up, however will defer to her pcp or the rehab medical director for further management. # dysphagia: secondary to esophageal narrowing by large thyroid mass and difficulty swallowing (noted to have likely aspirations in the past). peg tube in place. initially held tube feeds in the setting of possible gi bleed, however these were restarted on hospital day 2 with no issues. speech and swallow consult was obtained, however they deferred further evaluation to her speech therapist at , as they have been working with her for 3 months now on this issue. she remained npo and on tube feeds for her stay in the hospital. # substernal goiter, hyperthyroidism: tfts sent while inpatient, which appear improved (however less reliable in acute illness): tsh 0.34, freet4 1.5, and t3 65. ent team was notified of her admission and requested an appointment be made for her with dr. for evaluation for resection of thyroid mass. this appointment will be on ###, after which the ent, ip, neurology, and endocrine teams will need to decide on the best future course of action. chronic inactive issues: # dvt s/p filter placement: placed on heparin sc # seizure disorder: continued keppra, with prn ativan. # hyperthyroidism: continued methimazole. # history of atrial fibrillation. chads 2. anticoagulated with asa. transition of care issues: - resp secretions: will need suctioning at least every hours, continue with saline nebs, albuterol/ipratropium nebs, and guaifenesin - goiter, hyperthyroidism: appears to be in euthyroid state now, may now be a surgical candidate. has ent appt with dr. for surgical eval, after which ent, ip, neurology, and endocrine teams will decide on the best future course of action for removal of thyroid mass - anemia: slow gi bleed most likely, should have hemoglobin/hematocrit checked 2x/weekly. transfuse for hct <21, hemodynamic instability, or symptoms. - dysphagia: should continue to work with speech/swallow therapist at to determine when it may be safe to try po nutrition again. - full code this admission medications on admission: 1. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 2. levetiracetam 750 mg tablet : two (2) tablet po twice a day. 3. lorazepam 0.5 mg tablet : 0.5 tablet po q6h (every 6 hours) as needed for mouth movements. 4. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po bid (2 times a day). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath, wheezing. 6. methimazole 10 mg tablet : one (1) tablet po bid (2 times a day). 7. senna 8.8 mg/5 ml syrup : one (1) tablet po bid (2 times a day) as needed for constipation . 8. acetaminophen 500 mg tablet : two (2) tablet po every six (6) hours as needed for pain. 9. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection three times a day: for dvt prophylaxis. 10. aspirin 325 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po once a day: please do not start taking until . . 11. ferrous sulfate 300mg po bid 12. latanoprost 0.005% 1drop each eye qhs 13. solumedrol iv 40mg q12hr (never received at , not continued during this hospitalizations) discharge medications: 1. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 2. lorazepam 0.5 mg tablet : one (1) tablet po every six (6) hours as needed for for mouth movements. 3. docusate sodium 50 mg/5 ml liquid : one hundred (100) mg po bid (2 times a day). 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation inhalation q6h (every 6 hours) as needed for sob, wheezing. 5. methimazole 10 mg tablet : one (1) tablet po bid (2 times a day). 6. senna 8.8 mg/5 ml syrup : five (5) ml po twice a day as needed for constipation. 7. acetaminophen 500 mg tablet : two (2) tablet po every six (6) hours as needed for pain. 8. aspirin 325 mg tablet : one (1) tablet po daily (daily). 9. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : three hundred (300) mg po bid (2 times a day). 10. latanoprost 0.005 % drops : one (1) drop(s) each eye ophthalmic hs (at bedtime). 11. levetiracetam 100 mg/ml solution : 1500 (1500) mg po bid (2 times a day). 12. guaifenesin 100 mg/5 ml syrup : ten (10) ml po q6h (every 6 hours). 13. sodium chloride 3 % solution for nebulization : fifteen (15) ml(s) (1 nebulization) inhalation q6h (every 6 hours). 14. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours) as needed for sob, wheezing . 15. heparin (porcine) 5,000 unit/ml solution : one (1) injection (5000 units) injection three times a day: can discontinue if patient is able to ambulate 3x daily. discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses: chronic respiratory failure dysphagia anemia likely secondary to slow gastrointestinal bleed substernal goiter hyperthyroidism secondary diagnoses: deep vein thrombosis seizure disorder atrial fibrillation 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 ms. , you were admitted to the hospital for increased respiratory secretions and low blood counts. we did blood tests and xrays, and we do not believe that you have have a lung infection. the increased secretion is partly due to the benign thyroid mass and difficulty swallowing. your low blood counts are likely coming from a very small and very slow bleed in your intestines. you got 1 unit of blood and your blood counts have been very stable. your doctor may decided if you should have a colonoscopy as an outpatient for further evaluation. changes made to your medications: start guaifenesin 10 ml every 6 hours start saline nebulizations every 6 hours start ipratropium nebulizations every 6 hours as needed for shortness of breath or wheezing it was a pleasure to take care of you at ! followup instructions: name: , m location: greater family health center address: , , phone: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. we are working on a follow up appointment in otolaryngology with for your hospitalization. you must follow up within 1 week of discharge. the office will contact you at the facility with the appointment information. if you have not heard within 2 business days please call the office at . department: radiology when: thursday at 2:00 pm with: cat scan building: cc clinical center campus: west best parking: garage department: neurosurgery when: thursday at 2:45 pm with: , md building: lm campus: west best parking: garage department: neurology when: wednesday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: interventional pulmonary when: tuesday at 9:00 am with: building: de building ( complex), campus: west best parking: garage department: endocrinology when: tuesday at 11:20 am with: , md building: sc clinical ctr campus: east best parking: garage procedure: enteral infusion of concentrated nutritional substances diagnoses: obstructive hydrocephalus unspecified essential hypertension acute posthemorrhagic anemia atrial fibrillation thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm long-term (current) use of anticoagulants epilepsy, unspecified, without mention of intractable epilepsy fever, unspecified personal history of venous thrombosis and embolism personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits heart valve replaced by transplant hemorrhage of gastrointestinal tract, unspecified gastrostomy status chronic respiratory failure tracheostomy status presence of cerebrospinal fluid drainage device goiter, unspecified dysphagia, unspecified 

Answer: The patient is high likely exposed to