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: codeine / penicillins / sulfa (sulfonamides) attending: chief complaint: rectal bleeding major surgical or invasive procedure: -angiography -subclavian cordis / left subclavian central line placed , removed -colonoscopy history of present illness: mrs. is a -year-old female with a pmh significant for celiac disease, hemorrhoids, old cva (), hypertension, hypothyroidism, and known cecal avm who was recently admitted to () with a large gib 5 days prior to this admission. at that time her hct was 19, ngl negative, transfused several units of blood to bring her hct up to 35. no colonoscopy performed given her overall good clinical stability and discussion about risks/benefit of procedure. patient was discharged home yesterday and was doing well until the day of admission to this hospital, when she had several episodes of brbpr, associated with lightheadedness, but no cp/sob. also complained of some lower abdominal cramping discomfort that was, at worse, in severity and felt better after having a bowel movement. bleeding occurred in the setting of her bowel movements. she had been on aggrenox for an old cva, but this was held in the middle of , several days before her last admission. . patient has a history of lgib in , found to have large avm on c-scope that was clipped. no subsequent scopes or bleeding until now. . in the ed, initial vitals: 98.4, 89, 152/71, 18, 96% ra. the hct was 36.5. on rectal exam by ed resident, hemorrhoids were noted, and there was brb in the vault but no active source seen. gi was consulted. three pivs (two 16g and one 18g)were placed and the patient was typed and crossed by blood bank for 4 units prbcs. . on arrival in micu, she had no complaints and appeared fairly stable. on further ros at time of admission she denied chest pains, dyspnea, fevers/chills, nusea, vomiting, diarrhea. past medical history: celiac disease cva / right thalamic capsular stroke with resultant left sided ataxic hemiparesis htn glaucoma l eye hypothyroidism hyperlipidemia restless legs oa diverticulitis fe-deficiency anemia osteoporosis borderline pulm htn lgib in , found to have large avm in the cecum on c-scope that was clipped social history: lives in retirement facility. she is a widow and has one son who lives close by and is very involved with her care. denies alcohol, drugs, or smoking. extremely independent at baseline with her adls, iadls prior to this admission. family history: no known h/o ca, blood disorders, gi disorder physical exam: physical exam on admission to micu : vs t 96.1f, hr 85, bp 130/65, rr 17, oxygen saturation 94% on room air gen: elderly female in nad, pleasant & conversant heent: perrl, anicteric, mmm heart: s1s2 rrr pulm: scattered rhonchi abd: + bs, soft, minimal ttp in the lower quadrants, no rebound or guarding ext: no c/c/e rectal: + ext hemorrhoids; trace amt brb in vault neuro: a&o x 3, mae, nonfocal . . physical exam on transfer to general medical floor : vs: afebrile, bp 160s/60s, hr 70s, rr 18-20, oxygen saturation 93-94% on 4l nc general: alert, oriented, no acute distress, on 4l nc heent: sclera anicteric, mmm, oropharynx clear, clear scant rhinorrhea noted neck: supple, jvp not elevated, no lad lungs: coarse rhonchi over mid lung fields, r>l, decreased lung sounds at bases bilaterally, expiratory scattered wheezes cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, tender to palpation over right lower quadrant and right flank/large ecchymoses noted over right groin --> flank/lower right inguinal region, bowel sounds present and normoactive x 4 quadrants, guarding at rlq ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: . admission labs: 09:20pm hgb-12.5 calchct-38 09:10pm glucose-142* urea n-30* creat-1.2* sodium-137 potassium-4.5 chloride-102 total co2-24 anion gap-16 09:10pm calcium-9.3 phosphate-3.4 magnesium-2.3 09:10pm wbc-9.5 rbc-4.11*# hgb-12.1# hct-36.5# mcv-89 mch-29.3 mchc-33.1 rdw-15.5, plt count-367 09:10pm neuts-71.6* lymphs-18.6 monos-4.1 eos-5.1* basos-0.6 09:10pm pt-12.1 ptt-33.6 inr(pt)-1.0 . . cardiac enzymes: 09:10pm ck(cpk)-126 09:10pm ctropnt-<0.01 09:10pm ck-mb-9 07:36am blood ck-mb-6 ctropnt-<0.01 . . additional studies: ekg: rate 80s, normal sinus rhythm. normal tracing with normal intervals and no abnormal ischemic changes . imaging: . -rle doppler us: impression- no acute deep vein thrombosis of the right lower extremity. . : cxr / pa and lateral views: moderate bilateral pleural effusions, increased from . persistent mild pulmonary edema. . video swallow study: aspiration/penetration: there was one episode of penetration before the swallow with a cup sip of thin liquids due to premature spillover and swallow delay, however, cleared at the height of the swallow. impression: mild oral and pharyngeal dysphagia, with no aspiration to account for persistent cough following meals. . ugi air w/o kub: impression: 1. no gastroesophageal reflux observed. 2. persistent irregularity along the wall of the mid third of the esophagus,which could be due to tertiary contractions, however may indicate presence of esophagitis. endoscopy could be performed for confirmation. . cxr - impression: the left subclavian line tip again projects over the expected location of the aorta, suggest rechecking position. cardiomegaly with worsening effusions and mild overhydration. bibasilar atelectasis. . cxr for line placement - (left subclavian)- indication: line placement.left subclavian vascular sheath has been placed, terminating in the left brachiocephalic vein. focal kinking of a catheter sheath is present at the expected skin insertion site. nasogastric tube terminates in proximal stomach with distal tip directed cephalad. new patchy right lower lobe opacity and worsening patchy left retrocardiac opacity. differential diagnosis includes aspiration, atelectasis and developing infectious pneumonia. . ct of abd/pelvis: ct of the abdomen: there is mild bibasilar atelectasis identified. there is no pleural effusion or pneumothorax identified. there is no pericardial effusion identified. there is calcification of the descending aorta and its branches identified. the kidneys demonstrate contrast within the collecting systems, likely from prior procedures. the spleen, liver, and adrenal glands are unremarkable. the pancreas demonstrates hypodensities which are incompletely characterized on this non-contrast exam ( 2, 30 and 29). the gallbladder is distended. small bowel loops are normal in caliber. there is no mesenteric or retroperitoneal lymphadenopathy. there is extensive right-sided retroperitoneal hemorrhage extending from the liver to the right inguinal region. high-density blood is seen within the perihepatic space as well as displacing the right kidney medially (2, 31). high-density fluid is also seen tracking into the presacral space (2, 63). ct of the pelvis: the bladder, rectum, and sigmoid colon are unremarkable. there is a small right-sided fat-containing inguinal hernia. there is no significant pelvic or inguinal lymphadenopathy. bone windows: there is diffuse osteopenia and degenerative changes throughout the spine. there are no focal lytic or sclerotic lesions identified. impression: 1. extensive retroperitoneal bleed extending from the hepatic dome to the right inguinal region. 2. pancreatic hypodensities, evaluated on this non-contrast exam. . cxr : scoliosis is noted, moderate to severe with right convexity. the position, contour and width of the mediastinum are stable since . lungs are essentially clear. there is no pleural effusion or pneumothorax. no evidence of acute abnormality demonstrated on the current radiograph. - angiogram w/ir : given the lack of active contrast extravasation or vascular abnormality,the catheter was removed and the sheath left in place for repeat angiography if indicated at a later time. impression: mesenteric angiogram demonstrating a replaced common hepatic artery arising from the sma. no evidence for contrast extravasation noted on our study. . mesenteric angiogram: impression: mesenteric angiogram including the celiac, sma, and with no evidence for active contrast extravasation, angiodysplasia, or neovascularity. incidental note made of a replaced common hepatic artery arising from the sma . . microbiology: c.difficile stool assay -negative urine culture -negative to date at discharge, final pending blood cultures x 2-no growth to date 2:23 pm sputum source: expectorated.//**final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci in pairs. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): sparse growth oropharyngeal flora. streptococcus pneumoniae. moderate growth. presumptively penicillin sensitive by oxacillin screen. mrsa nasal swab - negative . urine studies: 12:43am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 12:43am urine color-yellow appear-clear sp -1.010 . discharge labs: wbc 8.4, hemoglobin 11.4, hematocrit 33.7, mcv 86, mch 29.2, mchc 33.8, platelet count 443 glucose 87, bun 19, creatinine 0.9, sodium 143, k 3.9, cl 106 brief hospital course: initial admission and brief micu course: the patient was admitted to the micu in stable condition. gi advised starting golytely with plan for colonscopy in the am on the day after admission. on the night of admission, however, her hematocrit dropped to 28 and she was noted to have voluminous blood from the rectum. general surgery and ir were consulted simultaneously given the volume of bleeding, and it was felt that waiting for a tagged rbc scan would be unsafe so the patient was taken emergently to the ir suite. ngl negative. 4 units prbcs and one unit of platelets were transfsued immediately via the level one. no source of bleeding was identified on angio. the patient remained hd stable and returned to the micu with the sheath in the r femoral artery left in place in case of rebleeding. gi performed a colonscopy the next am w/o finding obvious source, concern for bleeding from small bowel. she returned to the ir suite; again no source could be identified. within one hour of patient returning to floor, abdomen became exquisitely tender, pt was already being transfused upon return then dropped bp. pt required 8u prbcs, 3 ffp, 3 platelets. a stat ct abd/pel revealed a large retroperitoneal hematoma, and the blood presure transiently dropped to the 70s. the patient had an epiosde of emesis with likely aspiration. vascular and ir were consulted, no intervention thought to be warranted as patient had stabilized. a left subclavian cordis line was placed. in total, the patient was transfused 13 units prbcs before her hct stabilized at 29. on hospital day 3, the patient was feeling better, without further rectal bleeding. she had a productive cough with evidence of aspiration on the cxr, sputum with gpcs and gnrs, and she was started on a course of iv levaquin/vancomycin before transfer to the general medical floor on the evening of . . additional hospital course after transfer from micu to general medical : in summary, mrs. is a -year-old female with known recurrent brbpr, and recent complication of retroperitoneal bleed after ir angiography procedure during gi bleed workup, and new aspiration pna, who was afebrile with stable hematocrits for nearly 2 days by the time she was transferred from micu to general medical floor on . . # gi bleed /brbpr: prior to this admission mrs. had a known history of cecal avm per records, as well as diverticulosis. she had gross blood noted in ed on rectal exam. it was thought that her known avm was the likely source although it was unable to be definitively located on both colonoscopy and repeat angiography. rectal bleeding had subsided by time of transfer to the medical floor. as above, her second interventional radiology angiography was complicated after sheath removal and sudden blood pressure drops, hematocrit drips and rlq / right inguinal and flank pains. ngt placed on for aspiration concerns and airway protection after an emesis episode with coughing. this was due to a confirmed retroperitoneal bleed. she needed ivfs,pressor support for bp control, about 13 units of blood and several bags of platelets and ffp to stabilize. she had been on aggrenox for cva history but this was held as of after presentation to an outside hospital prior her re-admission only days latter to for recurrent brbpr. gi team followed patient while she was in hospital and recommended another follow-up outpatient colonoscopy in 8 weeks time. the patient wished to resume her care with her prior gi physician . here at so she was asked to set up a follow-up appointment within a few weeks of discharge. left subclavian trauma line placed for about 2 days and then removed and she also had iv access with 2 large guage pivs up until and she was switched to one iv. team kept an active type and cross. she was kept npo immediately after the large blood loss and gi/rp bleeding over - but was then started back slowly on clears, then she had a video swallow study that confirmed no major aspiration issues so she was advanced to a regular po diet with gluten restrictions in place for her celiac disease. nutrition consult assisted with helpful diet recommendations and she tolerated a regular diet very well, although she limited some of her intake due to her worry that some of her loose stools from celiac disease would worsen. she was reassured that she was on a gluten free diet and that she needed to preserve her nutrition as much as possible given her deconditioned state. she had been placed on iv protonix during her active bleeding but this was transitioned to an oral 40mg protonix tablet several days prior to discharge. admission hct was 36.5 and nadir was to 27. if she was not given back multiple transfusions so rapidly in setting of heavy gi/rp bleeding her hematocrit would have likely plunged much lower, much quicker. by time of discharge her hct was stable for days at about the 31-34 range. . #retroperitoneal bleed: as above, hematocrits have been stable and climbing. abdominal pain at rlq continues to improve slowly. able to sit up in chair and ambulate with a walker. she was reminded not to lift any heavy objects >10-lbs. or to do any straining/strenuous activities for 2-3 weeks. pt/ot worked with patient and she progressed slowly. rp bleed should eventually fully reabsorb and this was explained to patient. as she was clinically stable the team felt there was no need to repeat ct again, and she can discuss timing of repeat imaging, if any, at her outpatient follow-up with pcp /or dr. , her gi physician here at . . # prior cva: she had a right thalamic capsular stroke with short-lived resultant left sided ataxic hemiparesis in . now she ambulates well at baseline with slight unsteadiness at times from her rlq discomfort but has been given a walker to be used for better stability. she was taken off of aggrenox 3/22 per records and was asked not to restart her aggrenox or aspirin. despite sudden drops in her blood pressure due to hemorrhage in retroperitoneum while in the icu, she has no signs of any lasting mentation deficits. a&ox3 and no focal deficits on neurological exam for the entirety of her hospital course. physical therapy followed patient during hospitalization and felt she was stable for discharge back to her facility with some home services and use of a walker for ambulation while she fully recuperates. . # hypertension: blood pressures slightly elevated to 140-160s systolic ranges for a few days after transfer out of the icu. the medical team was purposefully allowing more laxity due to recent bleeds. she was continued on her usual home valsartan and norvasc was initially held but gradually added back and the dose was slowly uptitrated to her usual 10mg daily dose, which is the dose she was discharged on. blood pressures on day of discharge were predominantly normotensive in the 118-140/50-70s range. . #aspiration pna: per notes and patient reports, mrs. has a chronic cough at baseline in recent months. sputum production and coarse rhonchi with progressive cough occurred soon after she had an aspiration event. cxr infiltrates all appeared new from prior comparisons and her cough flared up within minutes after she had an aspiration on . sputum production but no hemoptysis. no cp, mild sob with improving oxygen requirement now. she weaned quickly from 4l to 2l nc and is now comfortable on room air with oxygen saturation levels in the mid-90s. sputum culture confirmed streptococcal pneumonia. she was given 10 days of iv vancomycin and levaquin with improvement in her breathing and cough. she was also given nasal saline spray and guaifenisen for more cough suppression. shortness of breath and cough markedly improved by time of discharge and she had no fevers or leukocytosis so she was not placed on any extended oral antibiotics at discharge. she will plan to see her pcp on thursday, for close follow-up. . # chronic facial neuralgia: chronic issue, symptoms for > 1 year. most painful around forehead area. continued on tylenol and avoided nsaids/motrin due to gi & rp bleeding. . #right lower extremity swelling: on the team noticed that her right lower extremity was a little more swollen and there was asymmetry. given her immobility she was certainly at risk for dvt. fortunately, lower extremity ultrasound showed no evidence of any dvts. edema is on same side a her large rp bleed which may explain the swelling. . #cellulitis left forearm: after her iv was pulled out on she had an erythematous 2" diameter circular area over her left antecubital region with some tenderness, and some purulent fluid at prior iv site. she was given local bacitraicin ointment and continued on her usual iv vancomycin and levaquin through the weekend, prior to discharge. on day of discharge the area was nonedematous, and there was no additional expressible discharge and erythema had abated so an additional oral antibiotic was not added. . # hypothyroidism: she was continue on her usual home dose of levoxyl therapy daily. . # glaucoma of left eye: she was continued on home eye drop routine daily with cosopt drops to left eye twice daily and she also got her nightly left eye latanoprost drops as well. no loss of vision or report of any visual changes while in the hospital. . # celiac disease: stable, gluten free regular diet continued. she had some loose stools which were likely due to her celiac condition. however, given her recent hospitalizations and antibiotics a c.difficile assay was collected and was negative. if results return positive, team will notify pcp. above, she was followed by the inpatient nutrition service as well. . # code status: dnr/dni, confirmed with patient . medications on admission: - valsartan 160 qd - amlodipine 10 qd - mirapex 0.25 qd - protonix 40 qd - lumigan 0.03% one drop qhs - tramadol 50mg q6h prn - levothyroxine 0.112 mg qd - klonopin 0.25mg q 12h prn - cosopt one drop os - tylenol 1000mg q6 h saline nasal spray 2 sprays each q2h prn - colace 100mg qd prn discharge medications: 1. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic twice a day: one drop to left eye only; twice daily . 2. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical once a day. 3. clonazepam 0.5 mg tablet sig: tablet po bid (2 times a day) as needed for insomnia. 4. pramipexole 0.25 mg tablet sig: one (1) tablet po qd (). 5. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 6. valsartan 160 mg tablet sig: one (1) tablet po daily (daily). 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 9. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime): one drop in left eye at bedtime . 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 11. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 12. colace 100 mg capsule sig: one (1) capsule po once a day as needed for constipation. 13. ultram 50 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 14. saline nasal 0.65 % aerosol, spray sig: one (1) nasal q2-4hrs as needed for congestion. 15. bacitracin 500 unit/g ointment sig: one (1) topical twice a day for 1 weeks: please apply a coat of topical ointment to left forearm affected area twice daily x 1 week. . disp:*1 1* refills:*0* discharge disposition: home with service facility: senior life discharge diagnosis: primary: -lower gi bleed -pneumonia -retroperitoneal bleed . secondary: -celiac disease - hypertension - hypothyroidism - iron-deficiency anemia - osteoarthritis - prior right thalamic capsular stroke (left sided ataxic hemiparesis for several months in ) - osteoporosis - glaucoma (left eye) discharge condition: stable. alert and oriented to person, time and place. no apparent distress. discharge instructions: it was a pleasure taking care of you here at . . you were admitted after having some bloody bowel movements. you continued to have dropping levels of red blood cells and required multiple blood transfusions. you had an interventional radiology procedure to try to find the bleeding source in your gi tract. after having a sheath placed and then removed from a major blood vessel in your groin area you had a complication called a retroperitoneal bleed with some bleeding into your right lower abdominal region. this eventually stabilized after additional blood transfusions, ivfs and medications to help keep your blood pressure from dropping. . shortly after having a colonoscopy you experienced some nausea and vomiting which may have been from bloating post-colonoscopy or from increased abdominal pressure from some internal bleeding you had. this vomiting episode unfortunately involved some aspiration which is when droplets of digestive contents and vomit can go down the wrong passage way and end up in the lungs. this led to a cough, fevers, and a pneumonia that was identified on chest x-ray. therefore, you were placed on antibiotics which helped you to recover. later in your hospital course you also had some redness over your left arm where an iv had been placed. this was concerning for a local skin infection but improved within 48 hours. please continue to cover it with bacitraicin ointment topically for 1 week. . please follow-up with all of your appointments as outlined below. also, please be sure to have a repeat colonoscopy in about 8 weeks time. . lastly, please do not lift any heavy objects greater than 10 lbs for at least 2 weeks time after being discharged. if you experience any acute worsening abdominal pain, enlargement or spread of the bruising over your right flank/lower abdomen, dizziness, fainting, visual changes, recurrent bloody stools, excessive diarrhea, chest pains, shortness of breath, chills, fevers, night sweats, burning with urination, or an other health concerns please return to the emergency room or call your primary care physician. . medication changes: 1)your tylenol dose has been slightly altered to 325-650mg every 6 hours as needed 2)please continue the anti-acid medication called protonix (pantoprazole) daily 3) do not take aspirin or your previous aggrenox medication for several more weeks ; discuss specific timeline with your pcp as an outpatient. 4) please continue application of topical bacitraicin ointment to your left forearm twice daily for 1 week. 5)otherwise, your usual eye drops, blood pressure medications, and all of your other home medications have not been changed, please continue taking all of your usual medication as previously prescribed followup instructions: 1) please make a follow-up to see your pcp, . , over the next 10 days. phone # . 2) please call to schedule a follow-up colonoscopy in 8 weeks time. . 3) please make a follow-up appointment with , md, phd, in the gastroenterology department. phone # procedure: venous catheterization, not elsewhere classified colonoscopy arteriography of other intra-abdominal arteries diagnoses: unspecified essential hypertension acute posthemorrhagic anemia unspecified acquired hypothyroidism hematoma complicating a procedure unspecified glaucoma other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pneumonitis due to inhalation of food or vomitus osteoporosis, unspecified cellulitis and abscess of upper arm and forearm osteoarthrosis, unspecified whether generalized or localized, site unspecified celiac disease personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits angiodysplasia of intestine with hemorrhage pulmonary congestion and hypostasis other vascular complications of medical care, not elsewhere classified phlebitis and thrombophlebitis of upper extremities, unspecified restless legs syndrome (rls) infection following other infusion, injection, transfusion, or vaccination swelling of limb other facial nerve disorders 

Answer: The patient is high likely exposed to