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: tetanus attending: chief complaint: syncope major surgical or invasive procedure: egd (upper endoscopy) history of present illness: 75m with hx afib on coumadin, cholecystectomy for gangrenous gb performed in in . had been admitted to for syncope with erc performed tuesday with sphincterotomy. since then had low bp, feeling light headed with standing. p/w hypotension and syncopal events over the past few days. had cholecystecomy for gangrenous gb done in in . was in on the 8th for syncope and had an ercp for ?stone last tuesday with spincterotomy, had syncopized . since then has had low bp, feelign lightheaded when standing, melanotic stools over last couple of days. on coumadin for afib. in the ed initially triggered for hypotension bps 80-90 guaic positive, got 3u ffp, 1u prbc, 3l u.vanc/cipro.flagyll. bps are 90/57. ercp consulted with plan for endoscopy/ercp in am. on arrival to the micu he was noted to be hypotensivee to the 80s systolic, asymptomatic past medical history: 1. paroxysmal atrial fibrillation (related to hyperthyroidism) 2. hypertension 3. diabetes c/b neuropathy and mild renal insufficiency 4. hypothyroidism (s/p resection and radioactive iodine ablation ). 5. prostate ca - monitored; neg bx , psa 1.5. 6. subdural hematoma - post-trauma, s/p drainage (~) 7. morbid obesity - s/p gastric banding 8. mitral regurgitation (mild echo ) 9. left knee replacement 10. depression 11. anxiety 12. coronary artery disease (s/p cabg lima to lad, rsvt to pda, om1, om2) 13. non-hodgkins lymphoma (tx in fl ) 14. renal cysts 15. retrohepatic cyst on ct (asymptomatic) social history: up north he lives in an in-law apartment above the garage of his daughter's home. he comes up 3-4x/year for about a month. he very much enjoys his independence in where he has a condominum in on the golf course. family history: parents are both deceased. (father: 88, peripheral vascular disease); (mother - 61, congestive heart failure). he has 1 brother (65, rheumatoid arthritis) and 3 children (a daughter with bipolar disorder). physical exam: admission exam t: 97.9 p: 73 bp: 100/61 rr: 12 99% ra general: alert, oriented, no acute distress, pale 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: clear to auscultation bilaterally, no wheezes, rales, rhonchi 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: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred discharge exam: t: af, hds, satting well on ra general: alert, oriented, no acute distress, pale 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: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no hsm ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait normal pertinent results: admission labs: 04:45pm blood wbc-10.3 rbc-2.96*# hgb-9.4*# hct-28.3*# mcv-96 mch-31.9 mchc-33.3 rdw-15.9* plt ct-300 08:15pm blood wbc-7.7 rbc-2.49* hgb-8.0* hct-23.8* mcv-96 mch-32.1* mchc-33.6 rdw-16.0* plt ct-244 04:45pm blood neuts-82.1* lymphs-14.3* monos-3.0 eos-0.3 baso-0.3 04:45pm blood pt-24.8* ptt-33.9 inr(pt)-2.4* 04:45pm blood glucose-162* urean-44* creat-2.0* na-137 k-4.9 cl-100 hco3-27 angap-15 04:45pm blood alt-40 ast-33 ld(ldh)-117 alkphos-95 totbili-0.2 04:45pm blood lipase-53 04:45pm blood ctropnt-0.03* 03:07am blood calcium-8.6 phos-3.4 mg-1.6 04:45pm blood albumin-4.2 iron-74 04:45pm blood caltibc-376 hapto-143 ferritn-82 trf-289 08:28pm blood lactate-1.5 pertinent results: hematocrit 08:15pm blood hct-23.8* 03:07am blood hct-25.8* 02:26pm blood hct-31.4* 07:30pm blood hct-37.0* 06:10am blood hct-33.6* creatinine 04:45pm blood creat-2.0* 08:15pm blood creat-1.8* 03:07am blood creat-1.6* 07:55am blood creat-1.2 06:10am blood creat-1.2 ct abdomen/pelvis: findings: abdomen: the visualized lung bases are clear. the liver demonstrates minimal pneumobilia within the left lobe. arising from the caudate lobe of the liver is a hypodense rounded exophytic mass that measures 4.3 ap x 6.1 tv x 10.7 cc (2:25 and 601b:40). it exerts minimal mass effect on the adjacent liver parenchyma and duodenum. there is no surrounding inflammation. its appearance is similar in the axial plane to prior study from . clips are present in the gallbladder fossa. spleen is normal in size. pancreas and adrenal glands show no masses or nodules. the small and large bowel shows no evidence of obstruction or wall edema. neither kidney shows evidence of hydronephrosis. multiple circumscribed hypodense structures arise from the kidney which consist of simple fluid, the largest of which measures 4.5 cm in diameter in upper pole of the right kidney. there is no free air, free fluid, or lymphadenopathy. pelvis: the bladder and prostate appear unremarkable. the prostate measures 3.1 x 5.2 cm in the axial plane (2:76). there is no free fluid or lymphadenopathy. minimal degenerative disc disease is present in the lumbar spine. otherwise, there is no aggressive-appearing lytic or sclerotic lesion. impression: 1. status post cholecystectomy and gastric banding without evidence of free air or free fluid. 2. portocaval mass as described above; evaluation with contrast-enhanced ct may be considered once the patient's renal function improves. echocardiography report (tte): at 10:01:00 am echocardiographic measurements results measurements normal range left atrium - four chamber length: *6.0 cm <= 5.2 cm right atrium - four chamber length: *6.1 cm <= 5.0 cm left ventricle - ejection fraction: 55% >= 55% tr gradient (+ ra = pasp): 21 mm hg <= 25 mm hg findings this study was compared to the prior study of . left atrium: elongated la. right atrium/interatrial septum: moderately dilated ra. no asd by 2d or color doppler. left ventricle: suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. low normal lvef. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aortic valve: aortic valve not well seen. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. trivial mr. tricuspid valve: mildly thickened tricuspid valve leaflets. physiologic tr. normal pa systolic pressure. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: no pericardial effusion. general comments: suboptimal image quality - poor parasternal views. suboptimal image quality - poor apical views. conclusions: the left atrium is elongated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). right ventricular chamber size and free wall motion are normal. the aortic valve is not well seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: suboptimal image quality. no clinically significant pericardial effusion. low normal global left ventricular systolic function. no clinically significant valvular regurgitation or stenosis. normal pulmonary artery systolic pressure. compared with the prior study (images reviewed) of , mild pulmonary artery systolic hypertension is no longer appreciated. due to the suboptimal image quality on the current study a comprehensive comparison of all other parameters could not be made. egd (): indications: 75 yo with recent ercp/sphx had melena and upper gibleed findings: esophagus: mucosa: normal mucosa was noted. stomach: mucosa: normal mucosa was noted. cold forceps biopsies were performed for histology to evaluate for h.pylori. duodenum: excavated lesions a single cratered 2 cm ulcer was found in the posterior duodenal bulb. no active bleeding was noted. other duodenoscope was introduced and the site of previous sphincterotomy. there was clear bile draining from the sphincterotomy. no bleeding was noted. impression: normal mucosa in the esophagus normal mucosa in the stomach (biopsy) ulcer in the posterior duodenal bulb duodenoscope was introduced and the site of previous sphincterotomy. there was clear bile draining from the sphincterotomy. no bleeding was noted. otherwise normal egd to third part of the duodenum recommendations: clears when awake and advance diet as tolerated. protonix 40 mg orally twice a day. await pathology for h.pylori. treat if positive for h.pylori. repeat egd in 4 weeks to document healing of duodenal ulcer. if ulcer is persistent then obtain biopsies to rule out malignancy. additional notes: the procedure was performed by dr. and the ercp fellow. the patient's reconciled home medication list is appended to this report. ebl = zero. final diagnosis as above. specimens as above. discharge labs: 06:10am blood wbc-10.3# rbc-3.63* hgb-11.7* hct-33.6* mcv-93 mch-32.1* mchc-34.6 rdw-16.6* plt ct-220 06:10am blood pt-11.8 ptt-27.3 inr(pt)-1.1 06:10am blood glucose-129* urean-17 creat-1.2 na-144 k-4.3 cl-109* hco3-26 angap-13 brief hospital course: assessment: 75 year old male with hx cad s/p cabg, afib on warfarin, pr prolongation s/p ccy and more recently ercp with sphincterotomy for 1.5cm cbd stone, now presenting with syncope and hypotension, likely secondary to gi bleed. brief hospital course by problem: active issues: # gi bleed: he was initially admitted to the icu with concern for active upper gi bleeding with evidence of a hct drop and melena. the ercp service was consulted and recommended consulting the gi service for upper endoscopy before attempting a repeat ercp. while awaiting this study, he received the following infusions: 6l ns iv, 4 units prbcs, 1 units ffp, and 10mg vitamin k in order to reverse an inr of 2.4. due to a prior history of a transfusion reaction, he was pre -treated with diphenhydramine and transfused at a slower rate. his hematocrit was followed closely and continued to trend up over the course of his micu stay so he was transferred to the floor. had egd with side viewing scope which showed cratered ulcer at duodenal bulb. biopsies were taken, gi rec'd: 1. following up in 4 weeks for rescope to evaluate for healing of ulcer; 2. if h pylori positive, will need treatment; 3. continue ppi. . # hypotension: due to a presumed ongoing gi bleed, he was admitted to the micu for observation of his hypotension without tachycardia. he was felt to be hypovolemic from the gi bleed and was resuscitated as above. he did not appear to be septic. his blood pressure remained stable throughout his micu stay. # bradycardia/syncope- his ekgs were initially concerning for a high-degree av block, but review of the ekgs with the cardiology service revealed atrial flutter with variable conduction (usually 3:1) as well as known pr prolongation. tte was done and showed stable ef and no effusion. troponins trended downward. ep consulted who felt no acute intervention was needed. # atrial fibrillation/flutter: inr was supratherapeutic in setting of coumadin at presentation .patient appears to have slow atrial flutter, per ep, and does not require ep intervention at this time. reversed with ffp and 10 vitamin k for egd. patient was instructed to restart coumadinon if no signs of bleeding/melena. plans to have inr drawn the week of with results sent to his nurse at his anticoagulation lcinic in fl. they will manage his dosing from there. inactive issues: # cad s/p cabg: patient was w/o chest pain throughout. troponins negative. no evidence of active/acute ischemia on ekg. home statin was continued. # portacaval lesion: first noted on ct in . appears stable. being followed by pcp in with mri and surgical referral. # diabetes: on metformin, saxaglipitin and januvia at home. he was given insulin sliding scale while in house. # hypothyroidism (s/p thyroidectomy): patient was maintined on home dose of levothyroxine. no issues while in house. transitional issues - full code - f/u pending egd biopsies - f/u h pylori, treat if positive - repeat egd in 4 weeks to evaluate healing and rule out malignancy - re-initiation of coumadin on - goal inr - continued workup of portocaval mass medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. clonazepam 2 mg po qhs 2. levothyroxine sodium 150 mcg po daily 3. metformin (glucophage) 500 mg po bid 4. aspirin 81 mg po daily 5. onglyza *nf* (saxagliptin) unknown oral daily 6. tamsulosin 0.4 mg po hs 7. rosuvastatin calcium 30 mg po daily 8. tramadol (ultram) 50 mg po q6h:prn pain 9. escitalopram oxalate 20 mg po daily 10. warfarin 7.5 mg po daily16 discharge medications: 1. aspirin 81 mg po daily please restart this on only if you have no signs of bleeding or dark stool 2. clonazepam 2 mg po qhs 3. escitalopram oxalate 20 mg po daily 4. levothyroxine sodium 150 mcg po daily 5. metformin (glucophage) 500 mg po bid 6. onglyza *nf* (saxagliptin) 0 oral daily 7. rosuvastatin calcium 30 mg po daily 8. tamsulosin 0.4 mg po hs 9. tramadol (ultram) 50 mg po q6h:prn pain 10. pantoprazole 40 mg po q12h rx *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours disp #*60 tablet refills:*0 11. warfarin 7.5 mg po daily16 please restart this on only if you have no signs of bleeding or dark stool. modify dose as directed by rn at clinic discharge disposition: home discharge diagnosis: primary diagnoses: acute blood loss anemia gi bleed atrial fibrillation/flutter discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure taking care of you during your hospitalization. you were admitted with passing out and low blood pressures. you were found to have a low blood count and blood in your stool. you were given blood transfusions and your blood count remained stable. you had an upper endoscopy which showed a large ulcer in your intestines which was not actively bleeding, but we believe this was the source of your bleeding. you will need a repeat endoscopy in 4 weeks to recheck the ulcer to make sure it is healing. we also were holding your aspirin and coumadin because of this bleeding. you may restart these medications on monday if you are still feeling well and have no signs of bleeding or dark stools. your lap band was deflated by our bariatric surgeons in order to have the egd. they said this can be reinflated by your regular bariatric doctors. please call your surgeon to schedule an appointment to follow up on this. you were also noted to have a slow heart rate at times. you were seen by our electrophysiologists (heart rhythm specialists). they felt this was a benign rhythm and did not require treatment. they suggested you follow up with your usual cardiologist. followup instructions: dr. 9:30am department: cardiac services when: thursday at 10:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage department: surgical specialties when: tuesday at 10:30 am with: , m.d. building: campus: east best parking: garage procedure: esophagogastroduodenoscopy [egd] with closed biopsy diagnoses: acute posthemorrhagic anemia atrial fibrillation personal history of malignant neoplasm of prostate coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes personal history of tobacco use atrial flutter dysthymic disorder other malignant lymphomas, unspecified site, extranodal and solid organ sites atrioventricular block, complete unspecified disorder of kidney and ureter long-term (current) use of anticoagulants chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction hypovolemia diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled bariatric surgery status 

Answer: The patient is high likely exposed to