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: patient recorded as having no known allergies to drugs attending: chief complaint: dizziness, lethargy major surgical or invasive procedure: none history of present illness: the patient is a 71 yo male with a past medical history significant for prior stroke, htn, and who obtains routine medical care from the who presented to the ed on with the chief complaint of dizziness, progressive lethargy and confusion x 5 days. the patient reported that in the past 5 days, he noticed increased lethargy and generalized weakness as well as presyncope with lightheadedness and dizziness but denies any syncope. he denied any fevers/chills/night sweats/abdominal/chest pain. his wife noticed the patient's increased confusion and change in his baseline activity over the week prior to admission (formerly 1 year ago used to take daily walks and within past 5 days, couldn't leave his bedroom on the so that his meals had to be brought to him). he denies any headache, change in vision (wears glasses at baseline), or focal weakness or change in balance. . interestingly, the patient notes that he has not felt "well" over the past 6 months to 1 year with slowly increasing lethargy. as mentioned, he has slowly cut down on his physical activity as a result of his fatigue. . the patient had seen his pcp 2 weeks ago as part of a routine physical exam at which time his nifedipine was stopped secondary to noted hypotension. his wife reports that his physician called him few days later to have his bp rechecked in his office but the patient did not make it to his appointment. as his symptoms of lethargy and confusion persisted, his wife called 911. as was on divert, the patient was brought to the ed. . in the ed, the patient was found to have pancytopenia with a hct of 14.5, he was guaiac negative with a sbp initially 86 that then dropped to 60 with a hr in the 60s. the patient had taken all of his bp meds on day of admission() including atenolol, lisinopril, and hctz. his bp rose to 110 with 3 liters ivf, 3 units prbc in the ed. . his labs were significant for a hct of 14.5 as mentioned above, plt 89, wbc 2.9, cr 1.7, ast 50, ldh 2374, inr 1.4, d-dimer 2608, troponin of 0.02. . . 2 large bore ivs were placed in the ed. . his ekg was as follows: . initial: nsr 79, nl axis, rbbb with depressions and twi v1-v6, < depression ii ( no prior ekg for comparison) . with bp normalization: nsr at 73 bpm, rbbb, nl axis. depressions with biphasic tw v1-v3, normalization of tw v4-v6. low voltage. . a ct of the head was also performed which showed: . 1. no acute intracranial hemorrhage. somewhat limited study due to motion artifact. brain atrophy. . 2. 1.5-cm hypodense area in the right occipital lobe, which may represent subacute-to-chronic infarction. clinical correlation is recommended. mri will be helpful for further evaluation. . the patient has a reported history of stroke in with no persistent neurologic deficits. he was evaluated by neurology in the ed who felt his neurologic exam was stable and not indicative for acute stroke. based on the ct findings above which showed subacute/chronic stroke, it was recommended that prior head imaging be obtained from to document his prior cva. mri may be considered otherwise. . according to his pcp and reports, the patient's last hct was 40 3 years ago with no more recent labs. he had a normal psa 1 week ago. the patient believes he had a colonoscopy 10-15 years ago but records from the need to be obtained to confirm. past medical history: htn stroke x 8 years ? cri baseline cr 1.7 by report (patient was unaware of this) social history: the patient formerly worked in a metal factory 35 years ago and then as a janitor. he is now retired and lives with his wife in . they live in a 2-storied single-family home. he denies any etoh and formerly only drank on occasion. he is a former smoker 3 ppd x 12 years - quit 35 years ago. family history: father, 4 brothers and 1 sister died of mi in 60-70s mother deceased from mi as well. , and htn run in family. no history of malignancy. physical exam: tc in ed 99 p=66 bp86/48->60 systolic ->110 rr 14 99% on ra . in micu . tc=98.6 p= 76 bp = 115/74 rr=16 99% on ra . . gen - nad, aox3, pale, light-skinned african-american male heent - muddy sclera, anicteric, pale conjunctiva, perla, eomi, no oral petechiae/mucosal bleeding, no jvd heart - rrr, no m/r/g lungs - ctab abdomen - soft, obese, nt, nd, no appreciable hepatosplenomegaly, active bs ext - onychomycosis bilaterally, no edema, old scars bilateral le from burn sustained secondary to work injury 35 years ago, +1 d. pedis bilaterally back - no cvat skin - no petechiae, bruising/purpura neuro - cn ii-xii intact, +2 dtrs x 4, negative babinski bilaterally, 5/5 strength x 4 pertinent results: 09:15pm urine hours-random 09:15pm urine uhold-hold 09:15pm urine color-amber appear-clear sp -1.014 09:15pm urine blood-neg nitrite-neg protein-neg glucose-1000 ketone-neg bilirubin-neg urobilngn-8* ph-5.0 leuk-neg 09:04pm hgb-5.7* calchct-17 08:52pm glucose-200* urea n-47* creat-1.7* sodium-139 potassium-4.2 chloride-106 total co2-21* anion gap-16 08:52pm alt(sgpt)-16 ast(sgot)-50* ld(ldh)-2374* ck(cpk)-43 alk phos-94 amylase-34 tot bili-1.4 08:52pm lipase-33 08:52pm ctropnt-0.02* 08:52pm ck-mb-notdone 08:52pm calcium-8.6 phosphate-3.0 magnesium-2.6 08:52pm haptoglob-<20* 08:52pm wbc-2.9* rbc-1.23* hgb-5.5* hct-14.5* mcv-118* mch-44.4* mchc-37.5* rdw-17.2* 08:52pm neuts-67.2 lymphs-30.8 monos-1.1* eos-0.9 basos-0.1 08:52pm anisocyt-1+ poikilocy-1+ macrocyt-3+ 08:52pm plt smr-low plt count-89* 08:52pm pt-15.6* ptt-26.2 inr(pt)-1.4* 08:52pm fibrinoge-225 d-dimer-2608* . ct head on : 1. no acute intracranial hemorrhage. somewhat limited study due to motion artifact. brain atrophy. 2. 1.5-cm hypodense area in the right occipital lobe, which may represent subacute-to-chronic infarction. clinical correlation is recommended. mri will be helpful for further evaluation. . cxr on : apparent mediastinal widening and prominent aortic contours may be due to ap technique. no prior study available for comparison. clinical correlation is advised. if there is concern for aortic pathology, chest ct could be performed. . ekg on : sinus rhythm, right bundle branch block, left atrial abnormality, diffuse st-t wave abnormalities -are in part primary and suggest ischemia - clinical correlation is suggested. no previous tracing available for comparison. . ekg on : sinus rhythm, right bundle branch block, left atrial abnormality, anterolateral st-t wave abnormalities -may be in part primary and are nonspecific - clinical correlation is suggested. since previous tracing of same date, no significant change. . ekg on : mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. . eeg on : abnormal eeg in the waking and drowsy states due to the moderate slowing of the background in wakefulness. this suggests a widespread encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. there were no areas of persistent focal slowing, and there were no epileptiform features. . labs on d/c: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:45am 6.1# 2.90* 9.8* 27.8* 96 33.8* 35.2* 20.7* 126*# differential neuts bands lymphs monos eos baso atyps metas 08:52pm 67.2 30.8 1.1* 0.9 0.1 red cell morphology anisocy poiklo macrocy 08:52pm 1+ 1+ 3+ basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 05:45am 126*# basic coagulation (fibrinogen, dd, tt, reptilase, bt) fibrino fdp d-dimer 10:15am 10-40 03:27am * hemolytic workup ret aut 06:35am 3.1 chemistry renal & glucose glucose urean creat na k cl hco3 angap 05:45am 159* 19 1.0 139 4.2 107 24 12 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 06:35am 1188* other enzymes & bilirubins lipase ggt 03:27am 20 cpk isoenzymes ck-mb ctropnt 05:50am notdone1 0.04*2 1 notdone ck-mb not performed, total ck < 100 2 ctropnt > 0.10 ng/ml suggests acute mi chemistry totprot albumin globuln calcium phos mg uricacd iron 06:35am 8.4 3.2 2.0 hematologic caltibc vitb12 folate hapto ferritn trf 06:35am greater th1 1 greater than pituitary tsh 03:27am 1.3 thyroid free t4 03:27am 1.0 hepatitis hbsag hbsab hbcab hav ab igm hbc igm hav 03:27am negative negative negative positive negative negative hiv serology hiv ab 03:27am negative consent recieved lab use only redhold 12:15am hold blood gas blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph calhco3 base xs intubat 10:31am 37.2 24*1 39 7.38 24 -2 not intuba2 1 no calls made - not arterial blood 2 not intubated whole blood, miscellaneous chemistry lactate 10:31am 1.7 hemogloblin fractions ( cooximetry) hgb calchct 09:04pm 5.7* 17 calcium freeca 10:31am 1.19 . negative parvo igm. brief hospital course: # pancytopenia: on admission the patient was found to be pancytopenic - hct 14.5, wbc 2.9, ptl 89. the initial differential included idiopathic, medication-induced aplastic anemia (nifedipine, nsaids), viral-induced aplastic anemia (hiv, parvo b19), myelodysplastic syndrome (?lymphoma or other malignancy), ttp (without fever, acute renal dysfunction, with mental status changes, anemia, and thromboctopenia)or dic with elevated inr. there was evidence of hemolysis with ldh in range and hapto <20, d-dimer 2600. the patient received 3 units prbc in the ed and was transfered to the micu for further monitorin of his hypotension. he was given an additional 2 units of prbc in the micu. his hct rose appropriately to prbc, being 30.3 after a total of 5 units given. the peripheral smear was most notable for polychromatophilia and anisocytosis. the obtained additional labs revealed a vit b12 deficiency (75), folate normal (6.2), elevated iron (233) and ferritin (624) and low tibc (186). parameters indicating hemolysis were low: hapto(<20), elevated tbili (2.6) and dbili 0.7. the retic count of 0.9 showed impaired production in the bm. given that the pt was vit b12 deficient and that is presentation could be well explained a possible bm biopsy was postponed. he was started on cyanocobalamin 1000mcg sc/im daily and folate 5mg iv daily. the ldh increase persisted initially, and then started to steadily go down, same with tbili. since his retic count did not respond as expected to vit b12 supplementation (being 0.4 on ) a bone marrow biopsy was obtained (on ) to r/o an additional hemolytic disorder, such as aml, aplastic anemia. the bm biopsy confirmed the diagnosis of vit b12 deficiency as the underlying disorder and showed no signs of leukemia. the pt was kept inpatient over the weekend because his thrombocytes continously dropped (32 on ) despite the initiated vit b12 therapy; however, his platelets gradually increased and he was discharged to rehab with all counts trending upwards. . # hypotension on admission the pt presented with bp of 86/48. he reported light-headnesses and dizziness but denied syncopal episodes, falls, cp or sob. his physical exam did not reveal signs of hf, such as increased jvd, hepatojugular reflux, ascites or peripheral edema. his hypotension was to dehydration and his bp was successfully elevated by volume resuscitation (3l of ivf and 5 units of prbc) and d/c of home bp-meds. he was transfered to the micu for overnight supervision. his sbps have remained stable over the rest of his hospital stay (sbp 110-130) and he was put back on lisinopril 10mg po daily. before discharge patient's blood pressure improved and he was restarted on atenolol 25 with sbp 100-110 range. . # lethargy, confusion pt presented with 5 days h/o worsening confusion, possible baseline dementia, to the ed. he has a pmh for stroke in , with no residual deficits per wife. in the ed a ct of the head was obtained to r/o possible stroke as cause for ms changes. it showed subacute/chronic infarcy in right occipital lobe. neuro evaluated the patient in the ed and felt that this was most likely consistent with chronic infarct. pt had waxing and episodes of confusion (disoriented to date, location and context; agitation) when still on the micu and after he was transfered to the floor. since the ct had been negative for acute bleeding, the changes in his ms to his hypotension on presentation as well as to the vit b12 deficiency. a eeg was performed, following neuro recs, which showed widespread encephalopathy. since the pt ms improved over the course of his hospital stay, and considering the facts presented above, neuro did not think that a mri of his head was indicated for further work-up. patient is likely to have baseline dementia (atrophy seen on initial ct) and (resolving) neurologic manifestation from vit b12 deficiency. . # ekg changes the ekg drawn in the ed showed the following abnormalities: rbbb, st-depressions and twi in v1-v6, which were thought to be a result of demand ischemia. his ck was 43 and his troponin 0.02. there was only little suspicion for acs as the etiology for his hypotension, since the pt had no complaints of shortness of breath/chest pain or radiating pain. ekg and troponin were monitored closely over the following days and resolved after the pt was normotensive and had received prbc. a repeat ekg on showed rbbb, no remaining st-depressions or twi. his troponin on was 0.04. he was started on lipitor 10mg daily. given the pt pmh and his strong fh for cad, he should receive outpatient work-up of underlying cad. . # chronic renal insufficiency creatinine presented with creatinine of 1.7 on admission, which was his baseline crea according to old recs. the chronic renal insufficiency might be due to diabetic nephropathy. however, since the creatinine steadily improved over the course of the hospital stay, being 1.1 on , a prerenal component (secondary to dehydration) was thought to play a key role. . # pt has a h/o dm, which he is seen for by his pcp at the . on admission he was on oral hypoglycemics, metformin and glyburide, but was changed to a iss (humalog). patient was subsequently restarted on his oral hypoglycemic before discharge with suplemental sliding scale. medications on admission: atenolol 75 mg po qd lisinopril 40 mg po qd glyburide 5 mg qd metformin 500 mg hctz 25 mg po qd asa 81 stopped nifedipine 30 mg qd 2 weeks ago discharge disposition: extended care facility: - discharge diagnosis: vitamin b12 deficiency pernicious anemia pancytopenia mental status changes peripheral neuropathy htn dm cri discharge condition: stable discharge instructions: please take your medications as listed below. please see your primary care physician or come to the ed if you notice any of the following symptoms: headache, dizziness, changes in vision, nausea, vomiting, shortness of breath, chest pain, confusion, increased weakness in legs or tendency to fall or any other reasons that are concerning you. . please follow up with your pcp . in weeks after discharge. followup instructions: please follow up with dr. on tuesday . call 1-800--999 for an appointment. test for consideration post-discharge: cbc, reticulocyte count, intrinsic factor antibody, anti parietal cell antibody with referral to gi based on results. consider outpatient stress test for ekg changes and slightly elevated troponin on presentation. . please follow up with dr. , in hematology. we scheduled an appointment with her for you on at 11.30am, at the . phone: procedure: biopsy of bone marrow transfusion of packed cells diagnoses: nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere unspecified essential hypertension chronic kidney disease, unspecified other b-complex deficiencies mononeuritis of lower limb, unspecified personal history of other diseases of circulatory system dehydration diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled 

Answer: The patient is high likely exposed to