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: no known allergies / adverse drug reactions attending: chief complaint: jaundice and malaise major surgical or invasive procedure: ercp history of present illness: the patient is a 46 year old female with a history of hypertension, osa, and depression who was transferred from after presenting to the ed there with 4 days of nausea, vomiting, diarrhea, and worsening jaundice. she was hypotensive to the 70s in triage and received iv fluids. she was noted to have creatinine 8, tbili 10, and lipase 3400. ruq ultrasound showed biliary sludge with no visible stone. ct abdomen showed colitis. she was treated with levofloxacin 500 mg iv and metronidazole 500 mg iv, and transferred to for ercp due to concern for biliary obstruction, cholangitis, and gallstone pancreatitis. . in the ed, initial vital signs were t 97.1, bp 103/60, hr 100, rr 20, spo2 98% on ra. she arrived on her seventh liter of ns, but was still hypotensive in the 90s systolic. central access was obtained with a right ij line. she also has access with two 18g pivs. foley catheter was placed for urine output monitoring. she was mentating well and in no acute distress. initial labs showed multiple electrolyte abnormalities including na 126, ca 6.7, and bicarb 12 with anion gap 16 and lactate 2.3. her creatinine had decreased to 4.6 from 8 at osh after iv fluids. her lfts were still abnormal but generally improved from osh labs. she had a leukocytosis with wbc 13.9 and anemia with hct 23.6. her inr was elevated to 1.6. her stool was guaiac negative. ercp and surgery were consulted in the ed, and she is planned for ercp this morning. she was admitted to the icu for further monitoring and management. vitals prior to transfer were bp 114/57, hr 102, and cvp 8. . once in the icu, she denied any pain or other specific complaints besides the foley catheter being uncomfortable. she was in no acute distress and mentating well. she denied any current nausea or abdominal pain. . review of systems: (+) per hpi. she noted some chills at home prior to admission but no fevers. she reports losing about 25 lbs over the last few weeks due to lack of appetite. she has an occasional cough which has not changed recently. (-) denies fever, night sweats. denies headache, sinus tenderness, rhinorrhea, or congestion. denies shortness of breath or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies abdominal pain. denies dysuria, frequency, urgency, or change in urine. denies arthralgias or myalgias. denies rashes or skin changes besides jaundice. past medical history: # hypertension # obstructive sleep apnea -- uses cpap at home # depression social history: social history: # tobacco: smoked 1 ppd for five years in the distant past. # alcohol: prior alcohol abuse, none in two years, now on campral. # illicits: none # lives at home with husband, family history: family history: # father: died from lymphoma at age 57 # mother: cad with cabg, rapidly progressive dementia recently # oldest sister: died from alcohol abuse # sister: cholecystectomy # brother: gerd and hypertension physical exam: admission physical exam: vitals: t 97.1, bp , hr 107, rr 23, spo2 100% on ra general: alert, oriented, no acute distress heent: scleral icterus, slightly dry mms, oropharynx clear neck: supple, jvp not elevated, no lad, right ij in place lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: mildtachycardia with regular rhythm. normal s1, s2. blowing holosystolic murmur at llsb with radiation to axilla. abdomen: bowel sounds present. soft, non-tender, mildly distended, no rebound tenderness or guarding. gu: foley in place ext: warm, well perfused, 2+ pulses. no clubbing, cyanosis, or edema icu discharge physical exam: vs tc 36.7 hr 98 bp 120/66 rr 21 o2 97/ra general: alert, oriented, no acute distress heent: scleral icterus, slightly dry mms, oropharynx clear neck: supple, jvp not elevated, no lad, right ij in place lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: mild tachycardia with regular rhythm. normal s1, s2. blowing holosystolic murmur at llsb with radiation to axilla. abdomen: normoactive bowel sounds present. soft, non-tender, mildly distended, no rebound tenderness or guarding. gu: no foley ext: warm, well perfused, 2+ pulses. no clubbing, cyanosis, or edema discharge exam: vitals: 97.9 98/62 94 20 95/ra 1000+300/brp general: aaox3 nad heent: scleral icterus, mmm, oropharynx clear neck: supple, no lad jvp 3+sternal angle lungs: ctab no r/r/w cv: rrr. normal s1, s2. holosystolic mumur llsb radiates to axilla. abdomen: soft, non-tender, distended no rebound tenderness or guarding, liver palpable, +bs ext: warm, well perfused, 2+ pulses. no c/c/e pertinent results: admission labs: 01:00am blood wbc-13.9* rbc-2.28* hgb-8.1* hct-23.6* mcv-104* mch-35.6* mchc-34.3 rdw-15.0 plt ct-200 05:17am blood wbc-16.4* rbc-2.47* hgb-8.7* hct-25.3* mcv-102* mch-35.3* mchc-34.5 rdw-15.1 plt ct-202 01:00am blood neuts-86.8* lymphs-8.5* monos-2.5 eos-1.7 baso-0.4 05:17am blood plt ct-202 05:17am blood pt-18.8* ptt-37.1* inr(pt)-1.7* 05:17am blood glucose-100 urean-32* creat-1.7*# na-137 k-4.0 cl-105 hco3-18* angap-18 05:58am blood glucose-91 urean-53* creat-3.7* na-131* k-4.0 cl-102 hco3-14* angap-19 05:17am blood alt-50* ast-170* ld(ldh)-429* alkphos-497* totbili-8.4* 01:00am blood alt-53* ast-149* alkphos-463* totbili-8.8* 05:17am blood lipase-514* 01:00am blood lipase-760* 05:58am blood totprot-5.3* calcium-6.7* phos-3.6 mg-1.6 iron-50 05:58am blood caltibc-163* vitb12-1777* folate-6.0 hapto-142 ferritn-921* trf-125* 12:34am blood lactate-2.3* k-4.5 . dsicharge labs: 06:13am blood wbc-19.2* rbc-2.39* hgb-8.4* hct-25.2* mcv-106* mch-35.2* mchc-33.3 rdw-17.1* plt ct-252 06:13am blood glucose-93 urean-13 creat-1.2* na-134 k-4.0 cl-100 hco3-24 angap-14 06:13am blood alt-29 ast-113* ld(ldh)-202 alkphos-324* totbili-11.1* 06:13am blood albumin-2.9* calcium-9.0 phos-4.7* mg-2.2 . other pertinent labs: 05:58am blood hbsag-negative hbsab-negative hbcab-negative hav ab-negative 05:58am blood hcv ab-negative 04:55am blood ama-negative smooth-positive * 04:55am blood -negative 05:58am blood pep-no specifi igg-1232 iga-424* igm-138 ife-no monoclo 04:55am blood ttg-iga-61* 05:58am blood caltibc-163* vitb12-1777* folate-6.0 hapto-142 ferritn-921* trf-125* 04:55am blood tsh-13* 04:55am blood t4-7.2 t3-56* . -------- -------- micro , , , , 8/5 blood cultures negative except bottles on which grew: blood culture, routine (final ): staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. aerobic bottle gram stain (final ): reported to and read back by 8:45am 9-0958. gram positive cocci in clusters. ------- ------- imaging . cxr: indication: central line placement. comparison: none available. frontal radiograph of the chest: a right internal jugular central venous line terminates with the tip at the upper cavoatrial junction. there is no pneumothorax. lung volumes are low with resultant vascular crowding. cardiac silhouette is top normal. mediastinal and hilar contours are normal. there is no pleural effusion or pneumothorax. . cxr impression no evidence of pneumonia. . cxr findings: in comparison with the study of , there is no interval change or evidence of acute cardiopulmonary disease. specifically, no pneumonia, vascular congestion, or pleural effusion. . ercp impression: successful biliary cannulation was achieved. partial opacification of the biliary tree was performed because of clinical suspicion of cholangitis- no evidence of stones or filling defects was seen. successful placement of a 7cm x 10fr stent for biliary drainage- with drainage of clear bile. otherwise normal ercp to 3rd portion of duodenum. recommendations: juices when awake and alert, then advance diet as tolerated. continue antibiotics. no definitive explanation for jaundice found on ercp, although contrast opacification limited. it is possible that the patient passed a stone. consider evaluation for other causes of jaundice including viral hepatitis. follow-up ercp will allow for complete evaluation of intrahepatics given possibility of psc. repeat ercp in 4 weeks for stent removal and complete evaluation of biliary tree. . ruq us findings: the liver is diffusely increased in echogenicity, consistent with fatty infiltration of the liver. no focal hepatic mass is definitely noted. there is no intrahepatic or extrahepatic ductal dilatation with the common bile duct measuring 4mm. however, the known common bile duct stent is not visualized. the main portal vein is patent with hepatopetal flow. the gallbladder is mildly distended, without wall thickening, pericholecystic fluid, or son sign. sludge is visualized within the gallbladder. additionally, there are echogenic foci with dirty posterior shadowing in nondependent portions of the gallbladder is consistent with air within the gallbladder lumen, likely from recent ercp and sphincterotomy. the spleen is mildly enlarged measuring 13 cm. there is no ascites. bilateral kidneys are without evidence of hydronephrosis. the pancreas is not well visualized due to overlying bowel gas. impression: 1. gallbladder sludge without acute cholecystitis. there is also evidence of air within the gallbladder lumen, likely from recent ercp and sphincterotomy. 2. echogenic liver consistent with fatty infiltration of the liver. more significant liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded based on this study. 3. no biliary dilatation, although the common bile duct stent is not visualized. . mrcp mr abdomen with iv contrast: there is marked diffuse fatty deposition of the liver in addition to more focal areas of almost mass-like fatty deposition surrounding the gallbladder fossa (3a:9, 12). there is also deposits of increased fat within the periphery of the liver. there is a heterogeneous enhancement pattern to the liver suggesting diffuse liver disease beyond fatty deposition. this appearance could be seen with chronic fibrosis, although there are no other findings on this study to suggest cirrhosis. the hepatic and portal veins are patent. there is no intra- or extra-hepatic biliary dilation. a stent is noted in place within the common bile duct. while there is mild enhancement of the bile duct wall at the level of the stent, above the level of the stent, the bile ducts do not demonstrate any abnormal enhancement to suggest cholangitis. there is diffuse gallbladder wall edema which is likely related to the underlying liver process. there is no hyperenhancement of the gallbladder wall or surrounding liver to suggest acute cholecystitis. the gallbladder contains sludge. no pancreatic mass is identified. the pancreas demonstrates normal homogeneous enhancement throughout. the pancreatic duct appears normal. there is small amount of peripancreatic fluid/edema consistent with patient's diagnosis of acute pancreatitis. the splenic vein and superior mesenteric veins remain patent. there are no fluid collections. there is a trace amount of perihepatic and perisplenic ascites. the spleen, adrenal glands, kidneys, and stomach are within normal limits. there is no retroperitoneal or mesenteric lymphadenopathy. impression: 1. no evidence of pancreatic mass. small amount of peripancreatic fluid/edema is consistent with uncomplicated acute pancreatitis. trace perihepatic and perisplenic ascites. 2. marked diffuse fatty deposition in the liver. however, heterogeneous enhancement of the liver suggests diffuse liver disease beyond fatty liver, possibly reflecting hepatitis oor fibrosis, though there is not overt cirrhosis. 3. gallbladder wall edema, likely due to underlying liver disease. gallbladder sludge. 4. biliary stent in place without intra or extraphepatic biliary dilation. mild enhancement of the common bile duct is likely from stent placement. there is no evidence of abnormal biliary ductal enhancement above the level of the stent to suggest cholangitis. . echo findings left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). estimated cardiac index is normal (>=2.5l/min/m2). tdi e/e' < 8, suggesting normal pcwp (<12mmhg). no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal diameter of aorta at the sinus, ascending and arch levels. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. mild thickening of mitral valve chordae. no mr. tricuspid valve: normal tricuspid valve leaflets. physiologic tr. moderate pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: no pericardial effusion. general comments: suboptimal image quality - poor apical views. conclusions the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mitral regurgitation is seen. there is mild to moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. mild to moderate pulmonary hypertension. brief hospital course: 46 year old female with a medical history of hypertension & depression transferred from after presenting with 4 days of nausea, vomiting, diarrhea, and worsening jaundice. admitted to the icu, found to have acute alcoholic pancreatitis and hepatitis. . # acute alcoholic pancreatitis: pt presented to osh with symptoms consistent with acute pancreatitis. the patient has a history of alcohol abuse, but initial denied alcohol use within the past 2 years, so gallstone pancreatitis was suspected. ruq ultrasound at osh reportedly showed sludge without visible stone. she underwent ercp with cbd stent placement. lipase was initially quite elevated and trended down moderately after aggressive ivf. other possible causes for her pancreatitis were explored, including the possibility of abdominal trauma suffered in a single-car accident the patient suffered two weeks before this admission. however, mrcp was negative. when ttg was elevated and patient was confronted with the lack of other explanations for her acute pancreatitis/hepatitis, she admitted to drinking 1.5 bottles of wine/day prior to admission (see below, alcohol abuse). . # acute alcoholic hepatitis: pt also presented with elevated lfts and jaundice. alcoholic hepatitis was diagnosed when biliary obstruction and viral hepatitis were ruled out. she had initially been started on antibiotics in the ed, but these were stopped given lack of concern for infection. patient provided additional history of recent mva with 6 g/day tylenol use for 3 days thereafter () + intermittent alcohol use. hepatology was consulted in the icu with concern for psc or other liver parenchymal process, in addition to alcohol and possible tylenol overdose; the patient was transferred to the hepatology service after discharge from the icu. her leukocytosis persisted, lfts remained elevated and she continued to spike fevers. these were thought to be underlying alcoholic hepatitis rather than infection, especially since only 1 bottle of many many blood culture samples was ever positive for bacterial growth, and thus was thought to be a lab contaminant. she received a 7-day course of vancomycin, then was started on pentoxyfilline. . # coagulopathy: related to hepatitis. the patient??????s inr was elevated to 1.6 on arrival at the ed. she does not have a reported history of liver disease and is not on anticoagulation at home. best explained by new diagnosis of acute alcoholic hepatitis. . # hypotension: related to pancreatitis. patient was hypotensive on admission with sbp 90s despite receiving significant iv fluids at osh. her hypotension was likely related to fluid shifts from acute alcoholic pancreatitis rather than sepsis. sbp improved to the 110s with iv fluids. she was restarted on a decreased dose of home metoprolol (25 mg qd) but home lisinopril was held given acute renal injury (below). lisinopril was restarted at discharge. . # hyponatremia: related to pancreatitis/hepatitis. resolved with current na 137 in the icu, up from 126 on admission and 123 at osh. this likely represented hypovolemic hyponatremia from her pancreatitis and volume depletion from gi losses and poor po intake. . # : creatinine 8.0 on admission to osh, fell gradually during this admission, to 1.2 at discharge. baseline creatinine was unknown. the most likely etiology was prerenal from hypotension and fluid shifts in the context of pancreatitis. maintained urine output in the context of aggressive ivf hydration as above. . # metabolic acidosis: patient had an anion gap acidosis at the osh. lactate was 1.2 at osh and 2.3 here. acidosis thought to be related to pancreatitis, , and ketones from alcohol intake/poor nutrition prior to admission. resolved by time of discharge, with bicarb 24 and anion gap 10. . # anemia: hct was 28.2 at osh. baseline hct unknown. she reports recent diarrhea that was sometimes black, but her stool was guaiac negative in the ed. she has not had a menstrual period since . her rbcs are macrocytic with mcv 104. iron panel was difficult to interpret in the setting of her current acute illness. hct was trended, iron panel, b12, and folate were checked. she received b12, folate, and iron supplementation during this admission. . # leukocytosis: patient presented with a leukocytosis, wbc 13.9; this rose during admission. attributed to alcoholic hepatitis. cultures all negative apart from a single spuriously-positive gpc blood culture. wbc remained >15 after treatment with vancomycin. . # depression: reports 25-lb weight loss in past 3 weeks secondary to stress. she is on lexapro for depression and . these should be held for now pending improvement in her renal and hepatic function, both of which are currently impaired. recent alcohol use likely contributed to her current presentation, and should be readdressed prior to and after discharge as she will continue to need support for this ongoing issue. . # alcohol abuse: patient has longstanding history of alcohol abuse; she sees a therapist -weekly and a psychopharmacologist for campral prescription. denies alcohol use within the past 2 years until confronted with laboratory data (ggt) confirming her providers' suspicion of ongoing alcohol use. family meeting was held prior to discharge, to discuss prognosis for alcoholic hepatitis, request that husband remove all alcohol from the home, agree upon a plan for post-discharge detox program, and to re-inforce the absolute importance of abstinence for her survival. inpatient social work has arranged for outpatient detox, to begin the monday after discharge (); patient was unwilling to be discharged directly to a detox facility. outpatient therapist aware and will follow-up; psychopharmacologist alerted by telephone. . # recent motor vehicle accident: large bruise noted on pt's lower back during physical examination in the icu. pt reported history of a single-vehicle car accident on : she drove over two curbs in trying to avoid other drivers, resulting in two blown tires. she denies steering wheel impact and did not seek police or medical attention after the accident. denied alcohol use prior to this accident. took 6 g/day tylenol in the 3 days following, which may have contributed to her liver failure. transitional issues 1. ***alcohol abuse follow-up.*** patient has agreed to inpatient detox but wanted to go home first to see her 8-year-old son. inpatient social worker and outpatient therapist will follow-up to ensure this happens. medications on admission: lexapro 30 mg po daily lisinopril 10 mg po daily metoprolol 50 mg po bid campral (acamprosate) 333 mg 2 tabs tid omeprazole otc po daily discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*90 tablet(s)* refills:*2* 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*90 capsule, delayed release(e.c.)(s)* refills:*0* 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever, pain: please limit to 2gm. 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. lisinopril 10 mg tablet sig: one (1) tablet po once a day. 8. lexapro 20 mg tablet sig: one (1) tablet po once a day. 9. campral 333 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po three times a day. 10. pentoxifylline 400 mg tablet extended release sig: one (1) tablet extended release po tid (3 times a day). disp:*90 tablet extended release(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnoses: alcoholic pancreatitis alcoholic hepatitis . secondary diagnoses: depression alcohol abuse sleep apnea hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: thank you for allowing us to participate in your care. . you were admitted to the hospital for abdominal pain and jaundice. . you underwent an endoscopic procedure called ercp, to visualize your gallbladder and biliary tree. no gallstones or obstruction was seen. a stent was placed in the bile duct, to allow free drainage of bile into your intestines, in case there was some mild obstruction not seen on the test. . your liver and pancreas enzyme levels were followed during this admission. these were very elevated when you first arrived, but they trended down with iv fluids and time. however, they were still elevated at the time of discharge and you were still jaundiced. you were not having any abdominal pain. we looked for infection but did not see any signs. the inflammation in your pancreas and liver appeared to be from another non-infectious cause. . we thought your liver and pancreas inflammation was due to alcohol consumption. lab tests showed that this was true. you do have several reasons for increased stress in your life recently. you met with a social worker during this hospitalization who will help coordinate your care after you leave the hospital. we felt it was very important that you get adequate support after you leave the hospital so that you can stay sober. drinking alcohol will further injury your pancreas and liver, which are already fragile. you will see your own therapist, , twice a week from now on. she will help you follow-through with your intention to enroll in a full-time alcohol detox program within a week after leaving the hospital. . when you first arrived, we treated you with intravenous antibiotics to fight a possible bacterial infection in your gallbladder. later we gave you antibiotics again when we suspected an infection in your blood. laboratory tests showed that you were not infected at the time you left the hospital. . we made the following changes to your medications: 1. we decreased your metoprolol dose to 25 mg per day. 2. we started you on pentoxifylline 400 mg po three times daily 3. we started you on multivitamins and thiamine which you should take daily . please continue to take all other medications as prescribed, or as instructed by your doctor. . followup instructions: we arranged a follow-up appointment with your primary care doctor: name: , location: medical association address: , , phone: appointment: friday 2:15 pm . please call dr. office if you need to reschedule this appointment. please also call your psychopharmacologist dr. at to book a follow up appointment within 1 week. . you should also see your therapist next week. the social worker will be in contact with your therapist to ensure a smooth transition so you can receive the support you need. . you will also need to follow-up with the ercp service, to have the stent removed. dr administrator, , will call you to arrange this appointment. if you don't hear from her by next monday, please call her at . procedure: venous catheterization, not elsewhere classified endoscopic insertion of stent (tube) into bile duct diagnoses: acidosis obstructive sleep apnea (adult)(pediatric) anemia, unspecified unspecified essential hypertension acute kidney failure, unspecified hyposmolality and/or hyponatremia depressive disorder, not elsewhere classified obesity, unspecified other and unspecified coagulation defects other and unspecified alcohol dependence, unspecified acute pancreatitis volume depletion, unspecified acute alcoholic hepatitis family history of other lymphatic and hematopoietic neoplasms 

Answer: The patient is high likely exposed to