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: amiodarone / lisinopril attending: chief complaint: gi bleed major surgical or invasive procedure: endoscopy bronchoscopy tracheostomy placement history of present illness: the patient initially presented to via ambulance following being found by his wife to have melena and hematemesis at home. there, he evidently endorsed generalized weakness, but denied chest/abdominal pain, fever, or dyspnea. cordis and 18 gauge placed. initial lactate was 8 and hematocrit 19. the patient was resuscitated with 6 units of prbcs, 2 units of ffp, and calcium gluconate. as volume was added, the patient was kept on phenylephrine to keep sbp > 85. the patient was intubated--difficult intubation with grade 3 view. octreotide and pantoprazole drips started. ceftriaxone also started. a fast exam showed fluid in the pouch, which may have been ascites or blood. patient had atrial fibrillation on ekg. in the emergnecy department here, the patient underwent trauma scans, which did not reveal acute problems with head or spine. the patient did have rll collapse and secretions in the right lower lobe bronchus on ct chest. ct abdomen showed attenuation of liver and edema of gallbladder. . on arrival to the micu, the patient was intubated and sedated. the liver service performed endoscopy and saw a substantial ulcer on posterior wall of duodenum, though the ulcer was not actively bleeding. no varices. past medical history: atrial fibrillation hypertension alcohol abuse, hyperlipidemia. hemochromatosis, hereditary. polio-induced lower extremity weakness. frequent falls, last a few weeks ago caused by loss of balance. chronic venous stasis felt to be secondary to venous insufficiency as opposed to cardiac causes. social history: he is a current smoker. he has had a problem with alcohol abuse in the past. he is currently drinking drinks a night and probably more. he is currently smoking a pack-a-day. this is down from 2 packs-per-day in the past. family history: father and brother had hemachromatosis. brother and mother have diabetes. physical exam: admission physical exam: heent: sclerae icteric, pinpint pupils, dried blood in mouth neck: supple, jvp cannot be appreciated due to habitus cv: irregularly irregular rhythm, no murmurs auscultated lungs: clear to auscultation to anterior auscultation, no wheezes, rales, rhonchi abdomen: distended, dull to percussion, no fluid wave gu: foley in place ext: warm, well perfused, + pitting edema bilaterally in lower extremities neuro: intubated, sedated, unable to respond to command. skin: asymmetric mole on lower left abdomen concerning for melanoma, darkened skin of lower extremities. discharge pe: vs: t98.6, p: 78, bp: 90/60, rr: 20, o2 100% on 40% face mask general - chronically ill appearing male in no acute distress, does not open eyes to name, not tracking or following commands. heent - nc/at, perrl neck - trach in place, ng tube in place, jvp to 5 cm above clavicle heart - irregular rate, rhythm, nl s1-s2, no mrg lungs - poor inspiratory effort but no rhonchi/ wheezes. no respiratory distress abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - 3+ pitting edema over the feet, 1+ pitting edema over lower legs, with blistering of le, rle bandaged weeping edema; right wrist- pain with movement, edematous, minimal swelling of wrist, left wrist- pain with movement neuro - eyes closed, does not open to voice, not following commands, not answering questions; passive movement of all extremities, grimaces to pain throughout but minimal withdrawal to pain pertinent results: admission labs: 07:50am wbc-8.5 rbc-4.26* hgb-14.0 hct-41.9 mcv-98 mch-32.8* mchc-33.3 rdw-20.9* 07:50am neuts-84.2* lymphs-11.5* monos-3.6 eos-0.3 basos-0.4 07:50am pt-16.5* ptt-32.1 inr(pt)-1.6* 07:50am plt count-111* 09:13am plt count-118* 09:13am pt-14.8* ptt-33.5 inr(pt)-1.4* 01:19pm hct-36.4* 06:32pm hct-35.1* 06:32pm glucose-129* urea n-29* creat-1.2 sodium-136 potassium-3.4 chloride-104 total co2-22 anion gap-13 09:13am glucose-157* urea n-30* creat-1.3* sodium-134 potassium-3.9 chloride-99 total co2-19* anion gap-20 09:13am calcium-8.6 phosphate-5.1* . 09:13am tsh-2.9 01:19pm afp-3.9 07:50am ctropnt-<0.01 . 09:20am urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-tr 09:20am urine rbc-2 wbc-9* bacteria-none yeast-none epi-3 trans epi-1 09:20am urine hyaline-46* 09:20am urine mucous-rare discharge labs: 06:45am blood wbc-8.8 rbc-3.06* hgb-11.1* hct-35.8* mcv-117* mch-36.3* mchc-31.0 rdw-22.0* plt ct-137* 06:45am blood pt-16.2* ptt-39.3* inr(pt)-1.5* 02:44pm blood glucose-138* urean-44* creat-0.9 na-149* k-4.3 cl-106 hco3-37* angap-10 06:45am blood glucose-131* urean-46* creat-1.0 na-148* k-4.4 cl-105 hco3-35* angap-12 06:45am blood alt-26 ast-50* alkphos-101 totbili-0.5 06:45am blood calcium-9.3 phos-4.4 mg-2.2 03:52am blood caltibc-137* ferritn-1073* trf-105* 07:06am blood vitb12-1619* folate-greater th 06:45am blood cortsol-21.5* 12:26pm cerebrospinal fluid (csf) wbc-1 rbc-1* polys-0 lymphs-60 monos-40 07:30am blood wbc-7.8 rbc-3.06* hgb-11.0* hct-36.1* mcv-118* mch-36.0* mchc-30.5* rdw-21.5* plt ct-128* 07:30am blood glucose-132* urean-48* creat-1.1 na-150* k-4.1 cl-107 hco3-36* angap-11 endoscopy : duodenum: excavated lesions a single cratered non-bleeding 30 mm ulcer was found in the posterior bulb. impression: granularity and nodularity in the fundus compatible with portal hypertensive gastropathy ulcer in the posterior bulb otherwise normal egd to second part of the duodenum cxr: impression: endotracheal tube at the level of the clavicles, 9.9 cm above the carina, could be advanced ~ 3-5 cm. well-positioned nasogastric tube. right lower lung opacification may represent collapse. small right pleural effusion. asymmetry in opacification of bilateral upper lobes, right greater than left, may reflect patient positioning or possibly layering effusion. see immediately subsequent ct. . ct head: impression: no acute intracranial pathology. left frontal lobe encephalomalacia. . ct torso: impression: 1. endotracheal tube tip is 6 cm from the carina and needs further advancement. nasogastric tube in the proximal stomach. 2. secretions within the bronchus intermedius, with near-complete occlusion of the right lower lobe bronchus and collapse of the right lower lobe and partial collapse of the right middle lobe. 3. small amount of simple abdominal and pelvic ascites. 4. cirrhotic liver. heterogeneous attenuation of the liver, underlying focal liver lesions cannot be excluded. recommended a non-emergent liver ultrasound or a contrast-enhanced ct for further evaluation. 5. distended gallbladder with small amount of sludge. mild gallbladder wall edema is likely due to third spacing. . ct head w/o contrast : impression: motion-limited study, with no acute intracranial process. if clinical concern for infarct is high, mri is more sensitive. . mr head w/o contrast findings: there is no evidence of acute intracranial hemorrhage or mass effect. in the left frontal lobe, there is an unchanged area of encephalomalacia, previously described by ct. no diffusion abnormalities are detected to suggest acute or subacute ischemic changes. the basal ganglia are notable for high signal intensity on t1, which is compatible with hepatic encephalopathy, please correlate clinically. additionally, the flair sequences, the diffusion-weighted images demonstrate decreased signal in the basal ganglia, subtle areas of magnetic susceptibility in the occipital lobes on the gradient echo sequence (image #15, series #7,image #17, series 302) likely consistent with iron deposits, which correlates with a history of hemochromatosis. the major vascular flow voids are maintained with normal distribution. the paranasal sinuses demonstrate mucosal thickening on the left ethmoidal air cells and minimal mucosal thickening at the left maxillary sinus. bilateral mucosal thickening is noted at the mastoid air cells. the orbits are unremarkable. impression: 1. there is no evidence of diffusion abnormalities to suggest acute or subacute ischemic changes. 2. chronic area of encephalomalacia identified on the left frontal lobe, previously demonstrated by head ct. 3. low signal intensity is demonstrated on diffusion and flair sequences in the basal ganglia, with high signal on t1, likely consistent with a combination of iron deposits and possible hepatic encephalopathy and hemochromatosis, please correlate clinically. 4. bilateral mucosal thickening at the mastoid air cells and also mucosal thickening identified in the left ethmoidal air cells and left maxillary sinus. . mr head impression: 1. technically limited mri study because of motion artifact. signal abnormality in the left frontal region is suggestive of encephalomalacic changes with concern for ongoing edema. no abnormal enhancement is seen. attention on followup imaging is suggested. 2. no acute intracranial abnormality. 3. fluid signal in the right mastoid air cells. 4. abnormal high signal seen adjacent to the atlanto-occipital joint on the left, which may be related to degenerative changes. however, this may be further evaluated by an mri of the cervical spine with contrast. there is subluxation of the left lateral mass of c1 on c2. mr findings: there is a stable focus of encephalomalacia and gliosis in the left frontal lobe which may be related to prior ischemia. no new lesions are seen. there is no hydrocephalus or acute ischemia. no enhancing foci are noted. intracranial voids are maintained. right greater than left mastoid opacification is seen. there is volume loss with prominence of ventricles and sulci. impression: no acute abnormalities. stable focus of gliosis in the left frontal lobe. eeg findings: continuous eeg recording: began at 18:20 on the evening of . at the beginning, and through most of the record, there were generalized sharp wave discharges occurring usually with about a 1 hz frequency. for several periods over the first 2 hours, the discharges occurred with a frequency of up to nearly 2 hz. review of the video from this time did not show any clinical seizure or myoclonic activity. for much of the record, the sharp waves were not particularly rhythmic, and from 2 to 4 am on the morning of the 6th, there was a "calm" period, with primarily background slowing and relatively few sharp waves. later, the sharp waves recurred, with an average frequency of about 1 hz, or perhaps slightly slower by the end of the recording. there were no prominent focal findings. sleep: no normal waking or sleeping patterns were evident. cardiac monitoring: showed an irregular rhythm. spike detection programs: showed the same generalized sharp wave discharges. seizure detection programs: showed no definite electrographic seizures push button activations: there was one, at 19:38 on the evening of the 5th. it showed sharp wave discharges described above, but there was no clear clinical change on video. impression: this telemetry captured a single pushbutton activation. it did not show any change in the record. throughout most of the recording, there were generalized periodic epileptiform sharp wave discharges. early in the record there were some episodes with discharges up to 2 hz, but no clear clinical change was evident on video. there were some other periods with just a slow background. in general, these gpeds represent a severe encephalopathy with the potential for seizure activity though, at 1 hz, they're usually not considered active seizures at this time. there were no significant focal findings. the periodic discharges can at times signify ongoing seizures, and management remains a clinical decision. eeg findings: continuous eeg recording: began at 7:01 on the morning of the and continued through 19:33 that evening. at the beginning, it showed a widespread slow background of about hz in all areas. there were a few bursts of generalized slowing, very few of which had sharp features. the background did not change appreciably over the course of the recording. spike detection programs: showed almost entirely artifact. there were very few sharp waves. seizure detection programs: also showed artifact. there were no electrographic seizures. pushbutton activations: there were none. sleep: no normal waking or sleep patterns were evident. cardiac monitor: showed an irregularly irregular tachycardia with a rate of approximately 140, slowing to 105-110 later in the record. impression: this telemetry captured no pushbutton activations. it showed an encephalopathy throughout. generalized sharp wave discharges, however, frequent on earlier recordings had, for the most part, ceased. brief hospital course: 62 yo man with h/o hemochromotosis, etoh abuse, and atrial fibrillation admitted initially with massive gi bleed, admitted to the micu course complicated by persistent encephalopathy and respiratory failure. # encephalopathy: after the initial gi bleed, this becamae the patient's primary issue and was his main barrier to extubation. likely multifactorial. initially suspected that this was related to sedation in addition to poor liver function, however his encephalopathy persisted despite lactulose and rifaximin. sepsis from his pneumonia for which he completed a course of vanc/cefepime. given lack of improvement despite the above interventions, ct and mr of the head was obtained. mri showed mild encephalomaclacia and gliosis. seizures were considered and he was maintained on continuous eeg. while there was no frank seizure activity, there were frequent gpeds which neurology felt was likely contributing to his ams. he was started on an antiepileptic regimen which was uptitrated to keppra 2g , lacosamide 200mg , and dilantin 150mg tid. it was ultimately decided to taper the dilantin by 50mg every 3 days as his mental status still waxed and waned despite antiepileptics and we felt that this may have been sedating him further. his aed regimen on discharge was lacosamide 200 mg iv bid and levetiracetam 1000 mg po/ng . his mental status improved minimally throughout admission from completely unresponsive to grimacing to pain. a trach was placed by thoracic surgery given inability to completely wean from vent (see below). # respiratory failure - intubated initially for airway protection for egd, with course complicated by vap and encephalopathy as main barrier to extubation. sputum grew h. influenza, and he was maintained on vanc/cefepime as above. his pneumonia was treated and his altered mental status was managed as above. he remained on psv for several days with the main barrier to extubation being mental status. trach was placed by thoracic surgery on (given concern for cervical spine disease on mri) and he was intermittently trach masked . # anasarca: pt with significant total body volume overload and was +28l for los. he had + total body pitting edema. he was on a lasix drip intermittently throughout the admission which diuresis limited by hypotension. he was then transitioned to lasix 40mg iv tid and his volume status improved. his bun and hco3 increased suggesting intravascular volume depletion. his lasix was stopped at discharge. # afib w/ rvr ?????? pt with difficult to control a.fib throughout admission. would frequently hit 140 bpm requiring multiple intermittent metoprolol and diltiazem pushes. he was on a dilt ggt at 2 different points over the early part of the admission with occasional control but limited by hypotension. he was eventually transitioned to an oral metoprolol regimen of 25 mg po q6h and was digoxin loaded and maintained on a dose of digoxin 0.125 mg po/ng daily. by discharge, his rate was moderately controlled in the 90s-100s. he was started on aspirin for anticoagulation as his initial gib was stable # gi bleed: this was initial reason for admission. liver performed endoscopy and discovered a significant ulcer on the posterior wall of his duodenum. the patient's hematocrit has stabilized, and no active bleeding was seen on endoscopy. he required no subsequent transfusions, he was weaned from portonix drip. hpylori was negative. # hypernatremia: pt initially came to the micu with na of 133. however this climbed over admission, often to the high 140s-150s. he was given free water flushes through his dobhoff to help control this and electrolytes were monitored . on discharge, na was 150. he had been getting lasix 40 mg iv tid until . given improvement in his volume status, his lasix was stopped on discharge. he was continued on free water flushes 200 mg q4h which can be decreased as hypernatremia improves. # hpotension: pt intermittently hypotensive over the admission with maps as low as 50s-60s. likely combination of baseline cirrhosis, complicated by diuresis and beta blockade for a.fib. by discharge sbps were in 90s-100s # anemia: steady hct drop over admission from 41.9 to the low 30's. predominantly macrocytic (initially normocytic). likely combination of nutritional factors and dilantin causing a macrocytic anemia. his dilantin was weaned down as above. hct was stable at 32 on discharge # gi bleed - due to duodenal ulcer, bleeding appears to have stopped, hct stable, h. pylori negative # alcohol use/abuse: the patient's family reports significant alcohol use. there was concern for alcohol withdrawl. he was maintained on midazolam boluses for sedation, but given minimal responsiveness, further benzos were avoided. patient did not demonstrate any signs or symptoms of etoh withdrwal during his icu stay. #code: in discussion with patient's wife, patient remained full code throughout his hospitalization. ### transitional issues ### - please check daily bmp and decrease free water flushes as hypernatremia improves. - patient noticed to have watery bowel movement on discharge. no fever or leukocytosis so low suspicion for c. diff but may consider testing. - l mainstem endobronchial lesion-will defer repeat bronchoscopy and biopsy for now, will need further evaluation in the future - atlanto-axial changes: noted on mri and of unclear significance. - concerning abdominal mole: will need follow up with derm regarding atypical mole on abdomen if mental status improves. medications on admission: 1. aspirin 325 daily. 2. colace as needed 3. fluticasone spray. 4. hydrochlorothiazide 25 mg daily. 5. ibuprofen 800 mg by mouth 4 times a day. 6. magnesium oxide 400 mg by mouth every day. 7. multivitamin. 8. spirolactone 25 mg every day. 9. lotrisone (betamethasone/clotrimazole 0.05%/1%) discharge medications: 1. acetaminophen 650 mg po tid:prn pain, grimacing do not exceed 2 gm in 24 hrs 2. aspirin 325 mg po daily 3. chlorhexidine gluconate 0.12% oral rinse 15 ml oral 4. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 5. digoxin 0.125 mg po daily 6. fluconazole 200 mg po q24h duration: 7 days please continue x 7 days after foley removed. last day = 7. folic acid 1 mg po daily 8. glucagon 1 mg im q15min:prn hypoglycemia protocol 9. heparin 5000 unit sc tid 10. insulin sc sliding scale fingerstick q6h insulin sc sliding scale using reg insulin 11. lacosamide 200 mg iv bid 12. lactulose 30 ml po qid titrate to bms 13. lansoprazole oral disintegrating tab 30 mg po daily 14. levetiracetam 1000 mg po bid 15. metoprolol tartrate 25 mg po q6h hold for sbp < 95, hr < 60 16. miconazole powder 2% 1 appl tp tid:prn rash 17. multivitamins 1 tab po daily 18. rifaximin 550 mg po bid 19. thiamine 100 mg po daily 20. outpatient lab work daily bmp (na, cl, hco3, k, bun, creatinine) until hypernatremia normalizes 21. voiding trial please discontinue foley on arrival and give patient voiding trial. please straight cath if unable to void. discharge disposition: extended care facility: northeast - discharge diagnosis: primary: upper gi bleed, duodenal ulcer, respiratory failure, encephalopathy secondary: hemachromatosis discharge condition: mental status: minimally responsive level of consciousness: lethargic and minimally arousable. activity status: bedbound. discharge instructions: you were admitted to the hospital after you began vomiting blood at home. you were found to be bleeding from ulcer in your gut. you were given blood transfusions and medications to help stop the bleed and keep your blood pressure normal. the bleeding stablized. a breathing tube was placed to prevent blood from going into your lungs. your hospital course was complicated by a pneumonia that was treated with antibiotics. you also became minimally responsive during your hospitalization. we were unable to take you off the ventilator and a tracheostomy was placed. we are not sure of what is causing your altered mental status but it was likely caused by a variety of factors, including low blood pressure from bleeding and your previous history of hemachromatosis and liver disease. followup instructions: please follow-up with in neurology clinic in one month. an appointment should be made for you. if you do not hear from them, please call to make an appointment. procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung other endoscopy of small intestine enteral infusion of concentrated nutritional substances percutaneous abdominal drainage temporary tracheostomy closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus arthrocentesis diagnoses: acidosis thrombocytopenia, unspecified tobacco use disorder acute posthemorrhagic anemia alcoholic cirrhosis of liver acute kidney failure, unspecified portal hypertension atrial fibrillation pulmonary collapse other and unspecified hyperlipidemia acute respiratory failure other sequelae of chronic liver disease other ascites chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction encephalopathy, unspecified hyperosmolality and/or hypernatremia other specified disorders of stomach and duodenum other and unspecified coagulation defects pneumonia due to hemophilus influenzae [h. influenzae] other and unspecified alcohol dependence, continuous hip joint replacement venous (peripheral) insufficiency, unspecified late effects of acute poliomyelitis foreign body in larynx other specified disorders of nervous system other conditions of brain history of fall inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation physical restraints status hereditary hemochromatosis 

Answer: The patient is high likely exposed to