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: cipro / doxycycline / paxil / quinine / compazine / levaquin / lithium attending: chief complaint: acute mental status change major surgical or invasive procedure: left internal jugular central line intubation history of present illness: 54f with h/o hepatic sarcoid (cirrhosis), grade 2 esophageal varices, tips procedure, h/o gib (colonic avm and diverticulum), idipathic cm with ef 40-45%, h/o cva and sah with aneurysms p/w altered mental status to hospital ed--> ed. . husband reports pt was normal last evening, however this morning was noted to be somnolent and difficult to arouse. he states that she had been feeling well since her most recent discharge on and mental status was clear when she went to bed the night pta. her husband reports compliance with medications (although this has been a concern on her 2 most recent hospitalizations) and states she has had bms daily--it was later revealed that she was not taking her lactulose. he reports she had not been c/o fever/chills, dysuria, cough, abdominal pain, n/v/diarrhea, blood in stool. she was taken to ed where she was then transferred to ed as she gets her care here. . in the ed here initial vitals were 99.8 86 112/66 20 95%ra. she was unarousable and was intubated in this setting for airway protection. ammonia was 159 (224 at presentation last admission for hepatic encephalopathy). ct head was negative for acute intracranial process. she was afebrile and without elevated wbc count. cxr was negative for infiltrate. she was guaiac negative on rectal exam with hard stool in vault (concern for med noncompliance given pt. on lactulose as outpatient). ua was negative. paracentesis was not performed but she received ceftriaxone 1g iv and vancomycin 1g iv for empiric coverage. she also received 45g lactulose. . of note, she was admitted for altered mental status thought hepatic encephalopathy and med noncompliance. lp was negative during that admission. . she was then readmitted /08 with symptoms of worsening abdominal distention, n/v and was found on ct to have e/o sbo. she was kept npo with ngt in place with resolution of sbo. imaging during that admission demonstrated complete occlusion of the left portal vein and distal branches of the right portal vein, the proximal right portal vein and main portal vein were patent, the tips was patent and enhanced appropriately. she was transiently started on heparin gtt at that time, but this was discontinued prior to discharge without plan for anticoagulation given her history of aneurysms and sahs. . ros: unable to obtain from patient given intubated/sedated. per husband, patient was without complaints since last d/c on . no fevers/chills, no n/v/diarrhea, no dysuria/hematuria. no cough/sob. no confusion prior to this am. past medical history: past medical history: #. hepatic sarcoid #. s/p tips #. idiopathic cardiomyopathy: -echo demonstrating an ef of 15-20% (no report, ?osh) and a p-mibi that confirmed an ef of 23% with no ischemic changes--> improving to ef 40-45%, mild-to-moderate global left ventricular hypokinesis -cardiac cath : no angiographically apparent flow-limiting lesions, mild mitral regurgitation, and severe systolic ventricular dysfunction with a left ventricular ejection fraction of 20%. -right heart cath: : normal right sided filling pressures. mild pulmonary artery hypertension. preserved cardiac index. #. copd, followed by #. hx of sah s/p coiling, 2 new aneurysms seen on angio #. grade ii esophageal varices #. colonic avm and diverticulum #. evidence of cva/tia #. hypothyroidism #. anemia #. s/p hysterectomy #. s/p cholecystecomy #. reflex sympathetic dystrophy s/p fall social history: social history: lives in with her husband. 2 adult sons. smoked 1 ppd x 36 years, quit . no etoh. used to work as housekeeper, on disability rsd. family history: mi physical exam: physical exam upon micu admission vs: temp: 100.5 bp: 137/67 hr: 96 rr: 15 o2sat 100% ac 550/15 peep 5 fio2 1.0 gen: intubated, sedated heent: perrl, anicteric, mmm, op without lesions neck: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: cta b/l anteriorly cv: rrr, soft systolic murmur heard rusb, llsb abd: + mild distention, +b/s, soft, small soft tissue mass freely moveable right mid abdomen, +ascites ext: no edema, feet cool, palpable dp pulses b/l skin: no rashes/no jaundice neuro: 2+ biceps , 2+ right patellar dtr, 1+ left patellar dtr, achilles 2+ symmetric. . physical exam on transfer to medical : vs: afebrile, bp: 135/59 hr: 70 rr: 17 o2 sat 100% ra gen: comfortable, conversational heent: edentulous mouth, op without lesions, perrla, anicteric, mmm, neck: no supraclavicular or cervical lymphadenopathy, no jvd, appreciated faint hepatojugular reflex, no carotid bruits, l ij (3 ports) in place resp: cta bilaterally cv: rrr, soft holosystolic systolic murmur heard rusb, llsb abd: hyperactive b/s, soft, minimal ascites, palpable liver ~8 finger breadths below the costal margin, spleen also ~5 finger breadths below the costal margin. ext: no edema, feet cool, palpable dp, pt pulses bilaterally skin: no rashes/no jaundice neuro: moves all extremities well; nonfocal neurological exam; no asterixis pertinent results: laboratories on admission: urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg blood asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg lactate-1.7 sodium-143 potassium-4.1 chloride-109 total co2-25 urea n-24 creat-1.1 glucose-123 wbc-8.3 (neuts-83.7 lymphs-10.1 monos-4.2 eos-1.6 basos-0.5)hgb-10.8 hct-31.6 plt count-125 alt(sgpt)-47 ast(sgot)-33 alk phos-175 amylase-93 tot bili-1.6 albumin-3.2 ammonia-159 pt-12.4 ptt-41.1 inr(pt)-1.0 ret aut-3.7 urine color-yellow appear-clear sp -1.008; blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-1 ph-6.5 leuk-neg . laboratories on discharge: wbc-2.8 (neuts-67.3 bands-0 lymphs-22.6 monos-7.0 eos-2.9 baso-0.2) hgb-8.0 hct-23.5* (*prior to transfusion with 2uprbcs); plt ct-79 peripheral smear: hypochr-normal anisocy-1+ poiklo-normal macrocy-normal microcy-normal polychr-occasional spheroc-1+ na-140 k-3.3 cl-111 hco3-22 urean-16 creat-0.9 glucose-84 calcium-8.2 phos-2.6 mg-1.8 ret aut-3.1 ld(ldh)-190 totbili-0.6 06:45am blood hapto-37 . other labs: 06:45am blood ama-pnd 11:57am blood -positive titer-greater th cntromr-positive 03:33am blood igm-103 04:08pm blood lactate-1.7 . microbiology: stool fecal culture-pending; campylobacter culture-pending; ova + parasites-negative; clostridium difficile toxin assay-negative fecal culture - r/o vibrio-pending; fecal culture - r/o yersinia-pending; fecal culture - r/o e.coli 0157:negative . blood culture blood culture, routine-no growth to date of discharge-pending final read blood culture blood culture, routine-no growth to date of discharge-pending final read studies: cxr: heart and mediastinal contours are unremarkable. the lungs are clear and well expanded. there is no pleural effusion or pneumothorax. . ct head: no acute intracranial process. no change from . . duplex dop abd/pel limited impression: patent tips stent with flow velocities within similar range to recent evaluations. . small bowel only (barium) impression: small bowel containing large amount of feculent material with areas of thickened folds in the jejunum and ileum consistent with slowly resolving small bowel obstruction. brief hospital course: #. delirium secondary to hepatic encephalopathy the most likely explanation for her delirium is hepatic encephalopathy given her recent admissions for the same in which lactulose non-adherence has been suspected; this is her 3rd admission with delirium secondary to hepatic encephalopathy within the last month. ms. was intubated for airway protection in the ed; she was extubated without difficulty in the micu and remained stable on room air. she admits to taking less lactulose than prescribed due to diarrhea and frequent bowel movements (12-14 per day) several days prior to admission. hard stool was noted on rectal exam in ed, which reinforced the theory that she was non-adherent with the lactulose as prescribed. her home regimen of lactulose 30 ml po tid was restarted (with 3-4 bms per day) and her mental status quickly cleared. . other differential diagnosis for her delirium was considered, including infection, hypothyroidism, intoxication, and medication overdose. however, these alternate diagnoses were felt to be less likely. specifically, sbp was considered. paracentesis was not performed in the ed, and she was empirically covered with ceftriaxone for 3 days. ceftriaxone was discontinued on the day prior to discharge considering her marked clinical improvement with lactulose and the low probability of sbp. meningitis was unlikely clinically--nonelevated wbc and no systemic symptoms; she also underwent lp during late for a similar presentation of delirium and the lp was negative. cxr was negative; urinalysis was negative; and wbc count was nonelevated to suggest other infection. gastrointestinal infectious workup was negative for ova and parasites in the stool, e. coli 0157:h7, and clostridium difficile x1. infectious diarrhea was unlikely as the patient was having a normal bowel movements for her level of lactulose (3-4 per day) upon discharge and showed no other signs of infection. . also, her altered mental status was too acute to be a typical presentation of hypothyroidism affecting the sensorium; tsh was within normal limits at the end of . urine/serum tox screen was negative in the ed. sedating meds including amitriptyline and gabapentin were held on presentation but were restarted once her mental status returned to baseline. . #. hepatic sarcoid/cirrhosis transaminases were stable as compared to baseline. the total bilirubin level was more elevated than previously (at 1.6 on admission) but trended downward to within-normal-limits range, 1.3 on dicharge. alkaline phosphatase was stably elevated at ~175. the patient appears chronically thrombocytopenic in low 100s but upon discharge her platelet count was 80. coagulation panel is essentially normal except for an elevated ptt, which may be more elevated than normal but could be secondary to heparin flushes/subcutaneous heparin. albumin 3.0 suggests relatively preserved synthetic hepatic function. home medications, nadolol, , lactulose, and ursodiol were continued. also her patient's outpatient dose of prednisone (10 mg daily) was continued for sarcoid. . #. anemia/thrombocytopenia: her baseline hct appears to be in the high 20s, low 30s; she was approximately baseline on admission with a hct of 31. she has a normal mcv and relatively normal fe/folate/b12 studies; her anemia is likely anemia of chronic disease. her hematocrit trended downward to <23.5. prior to discharge, she was transfused 2 units of packed red blood cells after consulting the liver service. she showed no evidence of hemolysis on labs (normal total bilirubin, normal haptoglobin), no evidence of gastorintestinal bleeding though she has known esophageal varices and a known colonic ateriovenous malformation. . #. cardiomyopathy her most recent ef was 40-45% (echo in ), which was improved from 15% previously. the etiology of her cardiomyopathy was not entirely clear and has been classified as idiopathic in the past. the patient is only on a beta-blocker; she is on neither an acei nor diuretics. continued nadolol as per outpatient regimen. . #. chronic obstructive pulmonary disease she showed no signs of bronchospam throughout her hospitalization. an albuterl prn inhaler was provided. #. hypothyroidism: tsh was last checked late at which time it was normal. continued outpatient dose of levothyroxine. . #. f/e/n: repleted lytes prn. she was tolerating low protein diet upon discharge. . #. prophylaxis: bowel regimen, proton pump inhibitor, and subcutaneous heparin were administered. . #. access: left internal jugular venous central catheter (discontinued upon discharge). . #. code: full medications on admission: 1. omeprazole 40 mg daily 2. prednisone 10 mg po daily 3. gabapentin 300 mg po q12h 4. nadolol 40 mg po daily 5. levothyroxine 88 mcg po daily 6. diltiazem hcl 30 mg po bid 7. amitriptyline 50 mg po hs 8. folic acid 1 mg po daily 9. ursodiol 300 mg po tid 10. 400 mg po tid 11. lactulose 30 ml po (titrate to bms) 12. albuterol 1-2 puffs inhalation q6h prn 13. thiamine hcl 100 mg po daily 14. metoclopramide 10 mg po tid 15. sucralfate 1 gram qid 16. ferrous sulfate 325mg discharge medications: 1. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 2. prednisone 10 mg tablet sig: one (1) tablet po once a day. 3. nadolol 20 mg tablet sig: two (2) tablet po daily (daily). 4. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 5. nadolol 20 mg tablet sig: two (2) tablet po daily (daily). 6. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 7. diltiazem hcl 30 mg tablet sig: one (1) tablet po bid (2 times a day). 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 9. ursodiol 300 mg capsule sig: one (1) capsule po tid (3 times a day). 10. 200 mg tablet sig: two (2) tablet po tid (3 times a day). 11. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 12. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po bid (2 times a day). 13. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). 14. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): goal of bowel movements per day. disp:*2700 ml(s)* refills:*2* 15. amitriptyline 50 mg tablet sig: one (1) tablet po hs (at bedtime). 16. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 17. gabapentin 300 mg capsule sig: one (1) capsule po q12h (every 12 hours). discharge disposition: home discharge diagnosis: primary: delirium secondary to hepatic encephalopathy sarcoidosis . secondary diagnoses: hypothyroidism anemia discharge condition: hemodynamically stable, afebrile discharge instructions: you were admitted to the hospital in a state of delirium or altered mental status. you were intubated in the ed for airwary protection and transferred to the medical intensive care unit (micu). you did well in the micu and were extubated successfully. you mental status cleared with lactulose therapy and loose bowel movements per day. for low blood counts, you received a blood tranfusion prior to discharge. you showed no evidence of gastrointestinal bleeding or bleeding from any other site. please have your pcp, . , recheck your hematocrit (blood count) at your appointment in one week. . a small bowel follow through was performed which showed evidence of a resolving obstruction. . please keep all followup appointments. . please call your doctor or return to the emergency room if you have any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. -it is very important that you take lactulose exactly as directed to prevent future episodes of altered mental status secondary to hepatic encephalopathy. -reglan (metoclopramide) was discontinued as the indication was unclear. please followup with your primary care provided regarding permanently discontinuing or restarting this medication. followup instructions: 1. you have a follow up appointment scheduled with your hepatologist (liver doctor), provider: , md phone: date/time: 9:15 am. . 2. you have been scheduled for the following followup appointment with your pcp: , md. phone: at health care on wednesday, , at 11:15 am. her office is located at , , ma. please have dr. recheck your hematocrit (blood count) at your appointment. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube diagnoses: other primary cardiomyopathies anemia of other chronic disease cirrhosis of liver without mention of alcohol unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified sarcoidosis personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits hepatic encephalopathy 

Answer: The patient is high likely exposed to