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: tetracyclines / penicillins / neomycin attending: chief complaint: bright red blood per rectum major surgical or invasive procedure: thoracentesis x 3 angiography of lower extremeties history of present illness: the patient is a year old woman with pmhx of cad s/p stent x 4, htn, and afib on coumadin who presented from rehab with 2 episodes of dark brbr starting the night prior to presentation and then 4 episodes on the day of admission since 8am soaking through 4 chucks/pads. at rehab, her hematocrit went from 28 -> 25 overnight. bp at ed at presentation was 70/40, hr 110 -> 150/p, hr 92 with 600 ns. upper lavage of 500 cc was clear with out any coffee grounds or bright red blood. in the ed, the patient was noted to have a large dark clot at anus - about one cup; she received 3-4 units of ffp, 2 units of prbcs and 40 of iv lasix, 10 sub q vitamin k. hematocrit was 23.1 (baseline 29.6) at presentation, pt: 18.8 ptt: 40.5 inr: 2.4, plt ct 369. she takes aspirin, coumadin and lovenox (60 )- and by one report (but not in rehab notes) plavix as well. pt denies abdominal pain, nausea, vomitting, chest pain. she does report overall "not feeling well," "weak," "dizzy" and overall fatigue. past medical history: cad s/p nstemi pci , 3 vd pci to lcx, rca, lad, om1 htn hypothyroid s/p thyroidectomy bl pleural effusions on ct "small" anemia afib hyponatremia ihss? moderate diastolic dysfunction by cath social history: the patient lives at rehab. she has two daughters, , and who lives in , ri. she has no tobacco history or alcohol history. she is a retired bookkeeper. family history: mother deceased at 56 with dm father deceased at 65 unknown causes 2 daughters healthy and living widowed for 4 years physical exam: on admit: tc= 94.1 oral, axillary p=90-110 sbp=96/43 rr=16 100% on ra gen - weak, thin, pale elderly woman, fatigued but aox3 heent - pale conjuctiva, dry mmm heart - irregular, grade ii/vi sem at lsb not radiating to the carotids lungs - decreased breath sounds mid-bases bilaterally abdomen - soft, nt, nd + bs ext - no c/c/e, bilateral calf tenderness with no edema, +1 d. pedis pertinent results: pertinent labs: 05:20am blood wbc-11.3* rbc-3.47* hgb-9.9* hct-30.1* mcv-87 mch-28.5 mchc-32.8 rdw-15.4 plt ct-535* 05:15am blood wbc-6.7 rbc-3.86* hgb-11.5* hct-34.7* mcv-90 mch-29.7 mchc-33.1 rdw-16.2* plt ct-297 09:41pm blood wbc-10.4 rbc-2.49* hgb-7.1* hct-20.5* mcv-82 mch-28.6 mchc-34.7 rdw-15.6* plt ct-305 02:00pm blood wbc-8.0 rbc-2.72* hgb-7.4* hct-23.1* mcv-85 mch-27.2 mchc-32.0 rdw-16.3* plt ct-369 02:00pm blood neuts-74.3* lymphs-20.7 monos-4.9 eos-0 baso-0.2 06:20am blood neuts-68.1 lymphs-23.9 monos-7.4 eos-0.1 baso-0.5 05:20am blood pt-16.4* ptt-102.4* inr(pt)-1.8 02:00pm blood pt-18.8* ptt-40.5* inr(pt)-2.4 05:45am blood ret aut-2.3 05:20am blood glucose-101 urean-23* creat-1.0 na-133 k-4.2 cl-101 hco3-23 angap-13 02:00pm blood glucose-175* urean-26* creat-1.0 na-134 k-4.5 cl-102 hco3-23 angap-14 11:06am blood alt-28 ast-20 ld(ldh)-169 alkphos-100 totbili-0.2 03:20am blood ck(cpk)-58 09:41pm blood ck(cpk)-73 02:00pm blood ck(cpk)-24* 08:35pm blood ck-mb-notdone ctropnt-0.02* 04:15pm blood ck-mb-2 ctropnt-0.02* 05:10am blood probnp-2190* 03:20am blood ck-mb-4 ctropnt-0.01 09:41pm blood ck-mb-4 ctropnt-<0.01 02:00pm blood ctropnt-0.02* 05:20am blood calcium-7.8* phos-4.0 mg-2.0 11:06am blood totprot-4.8* albumin-2.3* globuln-2.5 calcium-7.9* phos-3.1 mg-1.9 02:00pm blood iron-28* 02:00pm blood calcium-8.0* phos-3.0 mg-1.7 05:45am blood vitb12-482 folate-9.9 02:00pm blood caltibc-176* ferritn-370* trf-135* 05:25am blood tsh-29* 02:00pm blood tsh-14* 05:15am blood pth-53 05:25am blood free t4-1.1 06:37am blood free t4-1.5 05:25am blood cortsol-21.9* 05:35am blood freeca-1.10* 11:37am urine color-straw appear-hazy sp -1.007 11:37am urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-mod 11:37am urine rbc-* wbc-* bacteri-mod yeast-none epi- 07:58pm urine rbc-9* wbc-14* bacteri-none yeast-none epi-0 02:50pm urine rbc-* wbc->50 bacteri-many yeast-none epi-0-2 04:28pm pleural wbc-57* rbc-556* polys-33* lymphs-11* monos-42* meso-1* macro-13* 04:28pm pleural totprot-3.2 glucose-121 creat-1.0 ld(ldh)-82 amylase-27 albumin-1.6 triglyc-29 12:00pm pleural wbc-115* rbc-1083* polys-36* lymphs-3* monos-0 meso-2* macro-59* 12:00pm pleural totprot-3.1 glucose-162 ld(ldh)-88 albumin-1.7 03:51pm pleural wbc-50* rbc-6475* polys-27* lymphs-17* monos-6* macro-50* 03:51pm pleural totprot-3.1 glucose-123 ld(ldh)-79 albumin-1.9 12:00pm other body fluid adenosine deaminase, fluid-pnd micro: urine inpatient pending pleural fluid inpatient gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (preliminary): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): urine inpatient contamination pleural fluid inpatient gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): blood culture inpatient no growth urine inpatient no growth blood culture inpatient no growth blood culture inpatient no growth blood culture inpatient no growth urine inpatient contamination blood culture inpatient no growth blood culture inpatient no growth urine inpatient contamination pleural fluid inpatient gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (pending): urine inpatient no growth urine emergency no growth pertinent reports: radiology chest (pa & lat) findings: pleural effusions have increased in size since prior, right greater than left. this is not accompanied by increased distention of the pulmonary vasculature. the frontal perspective is in a more lordotic position. due to the sizable pleural effusions, it is not possible to determine evolution of underlying air space disease. no new sites of air space disease in the upper lungs. impression: worsening pleural effusions. radiology chest (pa & lat) impression:bilateral pleural effusions which are difficult to compare to prior given technical and positioning differences. increasing air space consolidation in the left retrocardiac region which could be atelectasis or pneumonia. cardiology ecg sinus rhythm premature atrial contractions long qtc interval nonspecific st-t abnormalities since previous tracing of , not suggestive of left ventricular hypertrophy cytology pleural fluid , a. logged only radiology ct chest w/contrast impression: 1) large amount of bilateral pleural effusion, partially loculated and greater on the left, associated with bibasilar atelectasis. the pleural effusion measures hounsfield units and no enhancement or nodularity of the pleura is noted. 2) increased size of pretracheal lymph node measuring 18 mm in short axis, as well as perivascular and subcarinal lymph nodes. 3) coronary artery calcification and small pericardial effusion. 4) incidental note is made of calcifications in right breast. please correlate with physical examination and finding on mammography cytology pleural fluid negative for malignant cells. reactive mesothelial cells, macrophages, lymphocytes and neutrophils. cytology pleural fluid negative for malignant cells. rare mesothelial cells, macrophages and blood radiology art ext (rest only) findings: doppler evaluation shows triphasic waveforms at the femoral levels bilaterally. all other waveforms are monophasic and that at the dp and pt level on the right, absent. thus no abi measurement on the right, that on the left measures .56 cm. the volume recordings suggest a waveform widening diffusely and bilaterally with essentially absent waveform at the right ankle and metatarsal levels. impression: findings as stated above which indicate: 1. significant sfa and likely tibial disease on the left. 2. significant right sfa and significant right-sided tibial disease. cardiology echo conclusions: 1. the left atrium is normal in size. the left atrium is elongated. 2. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function appears normal (lvef>55%) though the views are limited. 3.the aortic valve leaflets are mildly thickened. there is mild aortic valve stenosis. mild (1+) aortic regurgitation is seen. 4.the mitral valve leaflets are moderately thickened. there is severe mitral annular calcification. moderate (2+) mitral regurgitation is seen. 5.moderate to severe tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. 6.there is a small pericardial effusion. there are no echocardiographic signs of tamponade. 7. there is a large bilateral pleural effusion present. cardiology ecg atrial fibrillation with moderate rapid ventricular response extensive st-t changes may be due to myocardial ischemia repolarization changes may be partly due to rhythm since previous tracing of , atrial fibrillation is new and st-t wave abnormalities seen radiology gi bleeding study impression: large amount of tracer collection in the groin, which is due to fecal and/or urinary incontinence. findings suggest rectosigmoid source of blood. radiology chest (portable ap) chest, upright ap portable: comparison is made to . the heart is markedly enlarged. there is upper zone redistribution of the pulmonary vascularity, kerley b lines, and perihilar alveolar opacity, consistent with chf, as well as a large left-sided pleural effusion. a small left effusion is also present. there is no pneumothorax. the surrounding osseous structures and soft tissues are unremarkable.impression: congestive heart failure, with large left-sided pleural effusion. brief hospital course: the patient is a year old female with a history of afib on coumadin, hypothyroidism, htn, and 3 vessel cad who presented on with bright red blood per rectum, hypotension and a 10 point hct drop from baseline consistent with lgib s/p sigmoidoscopy on . # lower gi bleed/brbpr with positive tag red cell showing bleeding in the rectosigmoid region:resolved, no further bleeding with stable hemodynamics - the patient had an ng lavage that was negative in the ed - the patient received 6 units prbcs, 4 units ffp, and vitamin k 10 mg sq in the ed. - lovenox was held, aspirin was decreased to 81 mg can coumadin was continued with a goal inr - sigmoidoscopy did not reveal any source of bleeding but did show grade ii internal hemorrhoids - colonoscopy revealed a single angioectasia that was not bleeding was seen in the distal sigmoid colon. protruding lesions a few benign appearing polyps were found in the right colon. they were not removed given the patient's age and her need to be on anticoagulation. grade 2 internal hemorrhoids were noted. excavated lesions a single deep linear non-bleeding 1.5 cm ulcer was found in the sigmoid colon. # ischemic right toe: - underwent angiography per vascular surgery which revealed diffuse stenosis of right popliteal with significant extension. given patient's overall health status she was considered too hight risk to undergo bypass. the plan was to continue to monitor with no plans for reperfusion. she is to follow up as an outpatient with dr from vascular surgery # pleural effusions: - pt had large left pleural effusion and mod right pleural effusion on admit, which was initially thought chf despite 3 taps in at that were exudate by light's criteria. underwent a tte which revealed ef 55%, 3+ tr, 2+ mr, with no evidence of hocm. she had diffuse tw changes on admission, which were attributed to demand ischemia in the setting of anemia. on admit, she was started on standing lasix and lisinopril for afterload reduction, and had no symptoms of chf for most of her admission. she underwent three separate thoracenteses of her recurrent pleural effusions which were also exudative in nature but still thought possibly secondary to chf with diuresis causing exudative picture. she underwent evaluation by pulmonary and interventional pulmonary, who recommended re-tap and if these effusions are to recur, possible vats/pleurodesis. cytology and laboratory studies and culture were all negative. most cxrs were negative for pulm edema or vasc resistribution, and these effusions may indeed be from an alternative etiology. however, given that effusions seem to have recurred and the patient is tolerating them well with no sob and only mild hypoxia, may not need to pursue vats and pleurodesis. of note, patient did have chf at one point during this admission in the setting of afib with rvr, urosepsis and ivf, and did have sob at that point. however, after this resolved, she had no sob for the rest of her stay. # cad - the patient had diffuse new twi on admit likely secondary to demand ischemia. she ruled out for acute mi by cardiac enzymes. - her cardiologist is dr. and her last cath was by dr. in . - she has stents in her lad, om1, lcx, and rca with a history of nstemi in the past. - currently stable, no asa, on b-blocker and statin. patient to f/u with dr. one week after discharge # afib - hospitalization complicated by afib with rvr with rates to 160s exacerbating chf. she responded to lopressor and was started on amiodarone with good effect. - will need to monitor inr closely given coumadin interaction with amiodarone. # htn - titrated during hospital course to lisinopril 5 qd, metoprolol 25 . # uti - completed a course of levoquin for uti/urosepsis. ua from day pta still with wbcs, bacteria; patient remains afebrile though with mildly elevated wbc. culture pending. will treat with cipro x 7d, day #1 . #hypothyroidism - currently on synthroid 112 mcg qd. had an elevated tsh on admission will need repeat tft's in 4 weeks. # communication - # code - patient is full code, confirmed with patient and daughter/hcp medications on admission: lopressor 25 mg lasix 40 po qam prozac 10 mg po qd lipitor 10 mg po qd ecotrin 81 mg po qd coumadin lovenox 60 mg po qd discharge medications: 1. atorvastatin calcium 10 mg tablet sig: one (1) tablet po hs (at bedtime). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. levothyroxine sodium 112 mcg tablet sig: one (1) tablet po daily (daily). 4. metoprolol tartrate 25 mg tablet sig: two (2) tablet po twice a day. 5. amiodarone 200 mg tablet sig: two (2) tablet po once a day. 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). capsule(s) 8. warfarin sodium 2 mg tablet sig: 1.5 tablets po hs (at bedtime). 9. lasix 20 mg tablet sig: three (3) tablet po twice a day. discharge disposition: extended care facility: for the aged - acute rehab discharge diagnosis: afib with rvr cad htn lower gi tract hemorrhage anemia, from blood loss hypovolemic shock pvd/ischemic right toe multiple rle arterial occlusions orthostasis bilateral pleural effusions, l>r hypoxia chf hypothyroidism urosepsis; also had borderline uti on clean catch on day prior to d/c, sent straight cath specimen on day of discharge, will call rehab with results discharge condition: hemodynamically stable, with no further orthostasis and stable pleural effusions, stable mild hypoxia (94-95% on ra while lying down with hob at 30%). discharge instructions: please continue to take all medications as prescribed, cooperate with your rehab team, and follow up with your doctors. you will need to have repeat thyroid function tests in weeks as your thyroid medication dose has been changed. also, you will need to have serial ekgs while at the rehab facility to watch the qt length as you are on amiodarone for your atrial fibrillation. you may also have a urinary tract infection (uti) based on a urinalysis (clean catch) that was done on the day prior to your discharge. we repeated the ua by straight cath on the day of your discharge, and will let the healthcare team at your rehab facility know if it returns positive for a uti. followup instructions: you have an appointment with dr. (pulmonary): provider: , m.d. where: center medical specialties phone: date/time: 8:00 you will also have the following appointments that day: provider: breathing tests where: pulmonary function lab phone: date/time: 7:45 also, you have an appointment with dr. (cardiology) on wednesday , at 1230pm. please call dr. to confirm . please call dr (vascular surgery) to set up a follow up appointment . you will also need to schedule an appointment with your pcp to follow up on the many issues raised during this admission. if you would like to have a pcp at the , please call to set up an appointment with either or another doctor. procedure: arteriography of femoral and other lower extremity arteries thoracentesis thoracentesis thoracentesis aortography colonoscopy flexible sigmoidoscopy transfusion of packed cells other irrigation of (naso-)gastric tube transfusion of other serum diagnoses: unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute posthemorrhagic anemia unspecified acquired hypothyroidism atrial fibrillation percutaneous transluminal coronary angioplasty status ulcer of other part of foot other specified forms of chronic ischemic heart disease blood in stool atherosclerosis of native arteries of the extremities with gangrene other and unspecified coagulation defects unspecified hemorrhoids with other complication ulceration of intestine 

Answer: The patient is high likely exposed to