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: chronic blood loss anemia, respiratory distress major surgical or invasive procedure: egd with banding blood transfusion history of present illness: ms. is an 81 y/o f with a history of dchf (ef 50-65% in ), afib, and chronic blood loss from gave syndrome who presented today for elective egd under mac anesthesia. per endoscopy report, the findings were consistent with known diagnosis of nodular gastric antral vascular ectasia. mild sponaneous oozing was noted. band ligation was performed for homeostasis. after the procedure the patient was complaining of shortness of breath. she reports that she has been chronically short of breath for 11 years, however she does not require any oxygen at home. of note the patient had not taken her lasix the morning of the procedure and received 800cc of lactated ringers during the endoscopy. she denies chest pain, cough, wheeze, or leg pain. no known history of copd or asthma. she reports that her bilateral leg swelling is no worse than baseline (documented to be 3+ edema in recent pcp ). . on arrival to the medicine floor she was desatting to the low 80s on nasal cannula and was placed on 5liter facemask. her blood pressures were in the 90s systolic which is slightly below baseline according to outpatient records of 100s-110s systolic. heart rates 90s in afib. diuresis was not initiated on the floor because of concern for low blood pressures. the patient was therefore transfered to the for further management. vs prior to transfer were 87/57 87 20 99% on 5liter facemask. ekg showed atrial fibrillation with rate of 96, na/ni no majors change compared to prior. . on arrival to the icu, patient denies any chest pain. she reports shortness of breath is improved while wearing the oxygen. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, 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: gastric antral vascular ectasia anemia requiring transfusion related to gi bleed right heart failure (ef 50-65% in ), 3+ tricuspid regurgitation atrial fibrillation, not on coumadin or asa due to chronic blood loss hypertension hyperlipidemia type 2 diabetes mellitus hypothyroidism chronic kidney disease stage ii (recent creatinine 1.3) social history: lives at home with husband - : none - alcohol: drinks/month - illicits: none family history: 3 siblings had lung cancer physical exam: physical exam: general: alert, oriented with face mask in place heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp elevated 5cm above sternal angle lungs: diminished breath sounds diffusely. no wheezes, rales, or rhonchi. no accessory muscle use. cv: irregular. 4/6 systolic murmur heard throughout. abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, 2+ pitting edema bilaterally at baseline per patient. no tenderness or erythema. . pertinent results: . hosp records: - echo : ef 60%, rv enlarged with preserved systolic function, biatrial enlargement, mild as with valve area 2.2, moderate mr, severe tr, mildly elevated pulm artery systolic pressure 29 plus estimated right atrial pressure. -on admitted to hosp seen for sob and pedal edema, given lasix diuresed from weight 73->70 kg . on initial presentation during that admission, she was satting 96% on 2l. bp 125/65. hr 48.cr 1.4, d-dimer 0.4. they transfused her 1 u prbc on , discharge hct 31. sent out on lasix 40mg po daily. (of note, in past: was on amiodarone 200mg daily in .) . reports/labs- ekg- atrial fibrillation. low voltage throughout. non-specific t wave abnormality in the lateral leads. abnormal tracing. no previous tracing available for comparison. . cxr : findings: cardiac silhouette is enlarged. prominence of right cardiac border could reflect enlarged right-sided cardiac or adjacent pericardial abnormality such as a pericardial cyst or prominent fat pad. attention to this on standard pa and lateral chest radiograph is recommended when the patient's condition permits. no focal areas of consolidation are present within the lungs. questionable small pleural effusions, which could also be more fully address by standard pa and lateral chest radiographs. . ekg : atrial fibrillation. low voltage throughout. abnormal tracing. compared to the previous tracing st segment abnormalities are resolved. tracing #2 . echo the left atrium is moderately dilated. the right atrium is markedly dilated. a patent foramen ovale is present. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the right ventricular cavity is moderately dilated with mild global free wall hypokinesis. the ascending aorta is mildly dilated. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. an eccentric jet of moderate to severe (3+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. severe tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . impression: moderately dilated right ventricle with mild systolic dysfunction. normal global and regional left ventricular systolic function. severe tricuspid regurgitation. moderate to severe mitral regurgitation. at least mild pulmonary hypertension. . cxr : impression: no acute intrathoracic process. . leni: impression: no evidence of dvt in the right or left lower extremities. . vq scan interpretation: ventilation images obtained with tc-m aerosol in 8 views demonstrate some accumulation of tracer in the large airways. matched defects in the right lung base, is likely due to pleural effusion. perfusion images in the same 8 views show >2 mismatched segmental defects in the right upper lobe and superior segment of the right lower lobe. chest x-ray shows a small right pleural effusion and cardiomegaly. the above findings are consistent with a high likelihood ratio for pulmonary embolism. impression: high likelihood ratio of pulmonary embolism in the right upper lobe. . renal u/s : 1. limited study showing no evidence of hydronephrosis and no direct evidence of venous clot. 2. suggested reversal of diastaolic flow in the left renal artery. the significance of this is unclear given the limitations noted, and may be related to a high-resistance system including acute tubular necrosis, or might be artifactual. if vascular thrombus is still of concern, noncontrast mrv of the renal veins may be of use to confirm patency. 3. small bilateral kidneys, consistent with chronic medical renal disease. . ekg - significant baseline artifact precludes an accurate interpretation of the rhythm. no clear p waves are seen suggesting possible atrial fibrillation. poor r wave progression in leads v1-v3 of unclear significance. no other interpretation is possible based on this tracing. compared to the previous tracing of atrial fibrillation is likely still present. . ekg : findings: since , mild right pleural effusion and mild to moderate right basilar atelectasis is worse. mildly enlarged heart size is stable and a suspicion for pericardial effusion was raised. findings were discussed with dr. who mentioned regarding recent echocardiogrpaphy which revealed sever cardiomegaly secondary to multivalvular involvement, but no pericardial effusion. aorta is generally larger, however, there is no evidence of a focal aneurysm. there is no evidence of pulmonary edema. . cxr : findings: in comparison with the study of , there is further accumulation of fluid within the right pleural space with compressive atelectasis. the upper right lung and the entire left lung are clear with no evidence of pulmonary vascular congestion . bcx-negative . labs: 08:30am blood wbc-8.0 rbc-3.25* hgb-8.9* hct-28.0* mcv-86 mch-27.4 mchc-31.9 rdw-18.0* plt ct-361 04:20am blood wbc-7.1 rbc-3.17* hgb-8.6* hct-27.2* mcv-86 mch-27.2 mchc-31.8 rdw-17.7* plt ct-352 06:33am blood wbc-5.3 rbc-3.07* hgb-8.3* hct-26.7* mcv-87 mch-27.0 mchc-31.0 rdw-17.8* plt ct-336 07:15am blood wbc-6.4 rbc-2.63* hgb-7.0* hct-23.6* mcv-90 mch-26.8* mchc-29.9* rdw-17.0* plt ct-340 12:50pm blood wbc-7.2 rbc-2.80* hgb-7.7* hct-25.1* mcv-90 mch-27.4 mchc-30.6* rdw-17.1* plt ct-379 07:00am blood wbc-6.9 rbc-2.68* hgb-7.4* hct-24.1* mcv-90 mch-27.8 mchc-30.9* rdw-17.0* plt ct-339 03:43pm blood wbc-6.5 rbc-2.81* hgb-7.8* hct-25.4* mcv-91 mch-27.7 mchc-30.6* rdw-17.1* plt ct-368 03:02am blood wbc-8.6 rbc-2.81* hgb-7.8* hct-25.7* mcv-91 mch-27.9 mchc-30.5* rdw-17.4* plt ct-328 05:08am blood wbc-7.6 rbc-2.93* hgb-8.1* hct-26.3* mcv-90 mch-27.6 mchc-30.7* rdw-17.2* plt ct-367 07:46pm blood wbc-5.7 rbc-3.22* hgb-9.0* hct-29.7* mcv-92 mch-28.1 mchc-30.4* rdw-17.4* plt ct-387 05:08am blood neuts-86* bands-0 lymphs-4* monos-10 eos-0 baso-0 atyps-0 metas-0 myelos-0 07:46pm blood neuts-82* bands-0 lymphs-7* monos-10 eos-1 baso-0 atyps-0 metas-0 myelos-0 05:08am blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-1+ microcy-occasional polychr-occasional ovalocy-1+ fragmen-occasional 07:46pm blood hypochr-occasional anisocy-1+ poiklo-normal macrocy-1+ microcy-normal polychr-occasional 07:00am blood pt-13.8* ptt-26.6 inr(pt)-1.3* 08:30am blood glucose-170* urean-23* creat-1.1 na-138 k-3.6 cl-103 hco3-29 angap-10 04:20am blood glucose-94 urean-32* creat-1.0 na-139 k-3.7 cl-104 hco3-27 angap-12 06:33am blood glucose-91 urean-39* creat-1.2* na-138 k-3.7 cl-103 hco3-30 angap-9 07:15am blood glucose-109* urean-47* creat-1.3* na-140 k-4.1 cl-105 hco3-29 angap-10 07:00am blood glucose-149* urean-58* creat-1.6* na-139 k-4.0 cl-104 hco3-28 angap-11 03:43pm blood glucose-187* urean-60* creat-1.7* na-139 k-4.4 cl-103 hco3-27 angap-13 03:02am blood glucose-151* urean-62* creat-1.8* na-138 k-4.1 cl-102 hco3-26 angap-14 05:08am blood glucose-146* urean-63* creat-1.7* na-139 k-4.8 cl-102 hco3-28 angap-14 07:46pm blood glucose-108* urean-62* creat-1.6* na-141 k-4.6 cl-103 hco3-29 angap-14 03:02am blood ck(cpk)-37 03:52pm blood ck(cpk)-24* 05:08am blood ck(cpk)-27* 07:46pm blood ck(cpk)-31 03:02am blood ck-mb-2 ctropnt-0.02* 03:52pm blood ck-mb-2 ctropnt-0.02* 05:08am blood ck-mb-3 ctropnt-0.02* probnp-4777* 07:46pm blood ck-mb-3 ctropnt-<0.01 08:30am blood calcium-8.4 phos-1.8* mg-1.7 07:00am blood calcium-8.4 phos-3.2 mg-2.8* 03:02am blood calcium-8.3* phos-4.3 mg-2.8* 05:08am blood calcium-8.6 phos-5.4* mg-3.1* 07:46pm blood calcium-9.3 phos-5.4* mg-3.1* 03:43pm blood tsh-3.9 05:34am blood lactate-1.5 12:49am blood lactate-3.0* 12:49am blood type-art po2-82* pco2-43 ph-7.36 caltco2-25 base xs--1 brief hospital course: 81 y/o female with a history of chronic diastolic chf (ef 50-65% in ), atrial fibrillation, not on coumadin, and chronic blood loss anemia from gasric antral vascular ectasias admitted with hypoxemia following endoscopic banding of her gastric avms. #hypoxemia/acute vs. chronic pulmonary embolism/chronic diastolic heart failure with secondary pulmonary hypertension: etiology of acute onset worsening hypoxemia on admission was initially not obvious. physical exam was consistent with volume overload but exam was complicated by tricuspid regurgitation and v-waves to the jaw. aspiration was considered but absence of significant lung pathology on exam or chest x-ray made this less likely. a v/q scan was performed and was read as having high probability for pe in the right upper lobe. additionally, an echocardiogram was notable for preserved ef, but with mod-severe mitral regurgitation, right ventricular dilatation and reduced systolic function with severe tricuspid regurgitation and the presence of a pfo (no valsalva or agitated saline contrast maneuvers were performed). these echo findings were similar to echo in . . given her multiple contraindications for anticoagulation, including history of requiring blood transfusions every 10 days for her gastric avms transfusion dependance and recurrent gi bleeds, anticoagulation was not pursued. additionally, bilateral lower extremity ultrasounds were negative for dvt, so an ivc filter was not placed. despite lack of intervention, the patient improved slowly with reduced oxygen requirement with re-initiation of diuretic regimen. the risks and benefits of anticoagulation and the current clinical dilemma were discussed with the patient and the patient's pcp and pt's son on . in addition, pt was given 1 unit of prbcs during admission. however, should the patient get to a place where she may only require monthly transfusion or should she develop chest pain, hypotension, tachycardia, increasing hypoxia, etc, the risk/benefit ratio of anticoagulation for pe may change to favor anticoagulation. in addition, the patient also did not show signs of a hemodynamically significant pe. she did have periods of relative hypotension during times of afib with rvr. pt carries a diagnosis of afib prior to admission and her bp was improved predictably with better hr control. in addition, there was question of the acute vs. chronic pe. the echo findings appear to be present in and could be explained by her valvular disease. pt had sats of ~94-96% on ra, ambulatory sats 92-93% on ra. however, pt did experience occasional noctural hypoxia to 84% on ra and was therefore sent home with home oxygen at 1-2l nightly for now. troponins 0.02 x3, bnp ~4000 during admission. oxygenation much improved during admission. vna can also help with monitoring for hypoxia. pt has a scheduled appointment with her cardiologist and pcp after dc to continue this discussion. can discuss whether patient may benefit from an ivc filter in the future. # atrial fibrillation: not on coumadin or aspirin due to chronic gi bleeding. the patient is on rate control with atenolol at home (25mg tid?). she was restarted on metoprolol given her renal failure and ckd and this was uptitrated to 25mg tid by day of discharge. pt tolerated this well and seemed to have better bp's with appropriate rate control. bp range 90's-110's during admission. she did have periods of afib with rvr prior to uptitration of meds. she was discharged with vna for cardiopulmonary monitoring. . #chronic blood loss anemia/gastric antral vascular ectasia s/p banding on the day of admission: she requires transfusion ~every 2 weeks at the present time. work up to date has included multiple egds with argon plasma coagulation which has been unsuccessful thus far and therefore patient had scheduled egd on admission for banding. the patient did have drop in her hematocrit during her admission and was transfused 1 unit prbcs. a repeat egd with banding was recommended in 1 month follow-up with gi. hct on discharge was 28. she was instructed to have repeat hct at pcp follow up. . #chronic diastolic heart failure: continued outpt regimen of lasix, bb . # le edema: she reports chronic worsening bilateral le edema over the last 5-6 weeks. lenis were negative for pe. pt was continued on lasix therapy . #hypertension: home anti-hypertensives were initially held upon admission and then restarted. she was discharged on metoprolol 25mg tid . # hyperlipidemia: she was continued on home simvastatin. . # type 2 diabetes mellitus: home oral medications including glipizide were held on admission. she was treated with an insulin sliding scale. she was instructed to resume glipizide upon discharge. . # hypothyroidism: she was continued on levothyroxine. . #acute-on-chronic renal failure, stage ii-iii: her renal function on admission was 1.6 and rose to 1.8, but improved during admission. cr on discharge was 1.1. pt should also have repeat cr at pcp f/u to ensure continued improvement. . transitional issues: code: dnr/i follow-up: repeat egd and banding with gi in 1 month should have pcp and cardiology follow up given chronic diastolic heart failure, pulmonary hypertension and now pe with minimal therapeutic options. should discuss whether there may be benefit to ivc filter in the future. medications on admission: from micu admit note: simvastatin 10mg qhs levothyroxine 112mcg daily glipizide 5mg daily mvi 1 tab daily loratadine 10mg daily iron 160mg slow realease po bid omperazole 20mg po bid ascorbic acid 250mg po bid atenolol 25mg po tid furosemide 40mg po daily discharge medications: 1. simvastatin 10 mg tablet sig: one (1) tablet po hs (at bedtime). 2. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 3. multivitamin tablet sig: one (1) tablet po once a day. 4. loratadine 10 mg tablet sig: one (1) tablet po once a day. 5. iron 160 mg (50 mg iron) tablet extended release sig: one (1) tablet extended release po twice a day. 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 7. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 8. dm glipizide 5mg daily 9. ascorbic acid 250 mg tablet sig: one (1) tablet po twice a day. 10. home oxygen therapy 2 liters continuous oxygen therapy at night. dx: pulmonary embolism, pulmonary hypertension saturation 84% on ra at night 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*1* discharge disposition: home with service facility: steward vna discharge diagnosis: gi bleed secondary to gave probable pulmonary embolism chronic diastolic heart failure atrial fibrilliation with rvr . chronic -diabetes -ckd -hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were initially admitted to the hospital after an elective endoscopic banding procedure for the abnormal blood vessels in your stomach causing gastrointestinal bleeding and chronic anemia. after the procedure, you were noted to have low blood pressure and low oxygen levels, due most likely to a combination of an aspiration event(inhaling some of your mouth secretions) and also to a blood clot (pulmonary embolism) in the lungs. however, after discussion with the gi specialists, given the risk of bleeding, especially in the gi tract, we have decided not to put you on blood thinning medication for the lung clot. you initially required a significant amount of oxygen, however, your oxygen levels improved and you will only need oxygen at night time for now. you will be continuing this discussion with your pcp . and cardiologist dr. after discharge. . also, your kidney function was slightly impaired during admission. this improved, but should be followed up after discharge. . medication changes: 1.your atenolol was changed to metoprolol given your kidney function. your discharge dose will be 25mg of metoprolol three times a day. stop taking atenolol. followup instructions: name: , a./ pcp : , , phone: when: , :00 am name: , md/ cardiology address: ,ste 2c, , phone: when: , :00 pm name: , location: s. w. gastroenterological associates address: 886 , , phone: *it is recommended that you see dr. within 2 weeks. his office staff will contact you to schedule an appointment. procedure: endoscopic excision or destruction of lesion or tissue of stomach diagnoses: congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation other chronic pulmonary heart diseases chronic kidney disease, stage iii (moderate) hypotension, unspecified iatrogenic pulmonary embolism and infarction hypoxemia do not resuscitate status chronic diastolic heart failure angiodysplasia of stomach and duodenum with hemorrhage tricuspid valve disorders, specified as nonrheumatic 

Answer: The patient is high likely exposed to