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: niacin / aspirin / codeine attending: chief complaint: gi bleed major surgical or invasive procedure: enteroscopy and history of present illness: hmed attending admission note . admit date: admit time: 2345 . pcp: , . address: , , phone: fax: . cardiology: dr. address: . phone: . 69 yo m with cad s/p cabg complicated be restenosis requiring multiple stents, mechanical aortic valve on coumadin, recurrent gi bleeding and iddm who is transferred from for advanced endoscopy for management of active upper gi bleed. . patient was admitted to approximately one week ago with melena and hematocrit of 22, found to have a nstemi (medical management per cardiology, restarted on plavix - d/c'ed in given recurrent gi bleeds, 1 month after bms placed). upper endoscopy was unrevealing except for mild gastritis. colonoscopy last done one year ago which was unremarkable except for benign polyps. patient was transfused 4 units of prbcs, hematorcrit increased to 27 and discharged three days ago. of note, he required diuresis for decompensated chf. was seen in the ed on for chest pain, no ekg changes, resolved with nitro, discharged home. . patient was re-admitted to today () with recurrent melena. last night he had two black/tarry stools. he also endorsed some mild chest pain. his hematocrit on admission was 26.2. patient transfused 1 unit of packed cells. he ruled out for acs by three sets of negative cardiac enzymes and non-ischemic ekg. patient underwent a ct angiogram which revealed 3 small bowel foci of hemorrhage likely in the proximal ileum. given the location of the bleeding decision made by gastroenterologist to transfer to for single balloon enteroscopy. patient has been continued on plavix given his significant cardiac comorbidities. he has been bridged with a heparin gtt for a subtherapeutic inr of 1.9. . of note, patient had recurrent gi bleeding at site of anastamosis from sigmoid colectomy in , requiring multiple transfusions. was on asa/plavix/coumadin with recent bms placed in diagonal. asa stopped and plavix discontinued 1 month after bms placement given recurrent bleeding. he had no further bleeding issues until this past week. . currently patient has no complaints. denies any current chest pain, sob, lightheadedness or dizziness. no nausea, vomiting or abdominal pain. reports one episode of black stool prior to transfer. . ros as per hpi, 10 pt ros otherwise negative. past medical history: -cad s/p cabg 2v , restenosis requiring multiple stents, des for rca stenosis, nstemi medically managed, bms diagonal -st. aortic valve replacement -iddm -copd -diverticulitis s/p sigmoid colectomy complicated by unstable angina, s/p cardiac cath and bms to diagonal, then developed recurrent bleeding on asa/plavix/coumadin therefore plavix d/c'ed after 1 month -htn -hypothyroidism -chf -anxiety -s/p knee replacement complicated nstemi and chf exacerbation -hernia repair social history: lives with wife, and grandson in , ma. retired heavy lift mechanic. + tobacco, 1 ppd x 55 yrs. no etoh or illicits. family history: + cad and dm, no hx of gi bleeds physical exam: on admission: vs: 97.9 138/79 56 20 96%ra appearance: alert, nad, obese eyes: eomi, perrl, anicteric ent: op clear s lesions, mmd, no jvd, neck supple cv: +s1, s2 mechanical aortic click, no peripheral edema, 2+ dp/pt bilaterally pulm: clear bilaterally, diminished at bases abd: soft, obese, midline scar, nt, nd, +bs msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing neuro: cn 2-12 grossly intact, no focal deficits skin: no rashes psych: appropriate, pleasant heme: no cervical pertinent results: labs: . . 6.3> <148 . 138 100 18 ------------< 161 3.2 28 1.0 . lfts wnl . images: . ct angio a/p: three small foci of hemorrhage, located in proximal ileum with extravasation of intraluminal intravenous contrast may be due to angiodysplasia, no evidence for underlying mucosal masses; colonic diverticulosis without diverticulitis, mild splenomegaly . : wbc 3.1 hct 24.6 plt 95 hct 25.7 plt 105 05:05am blood wbc-3.6* rbc-3.02* hgb-10.1* hct-29.2* mcv-97 mch-33.6* mchc-34.7 rdw-17.8* plt ct-129* 09:04pm blood hct-29.9* 03:16pm blood hct-30.9* 09:00am blood hct-28.5* 05:15am blood wbc-3.7* rbc-2.72* hgb-9.5* hct-26.8* mcv-99* mch-34.8* mchc-35.3* rdw-17.2* plt ct-134* 12:40am blood wbc-4.0# rbc-2.84*# hgb-9.5*# hct-27.7* mcv-98# mch-33.4*# mchc-34.3 rdw-17.1* plt ct-134* 12:40am blood neuts-55 bands-0 lymphs-35 monos-8 eos-2 baso-0 atyps-0 metas-0 myelos-0 12:40am blood hypochr-normal anisocy-2+ poiklo-2+ macrocy-2+ microcy-normal polychr-normal ovalocy-1+ pencil-occasional ellipto-occasional : inr 1.7 06:40pm blood pt-19.7* ptt-75.3* inr(pt)-1.9* 05:05am blood plt ct-129* 05:05am blood pt-19.2* ptt-109.9* inr(pt)-1.8* 02:48am blood pt-19.0* ptt-112.8* inr(pt)-1.8* 08:55pm blood pt-18.9* ptt-56.0* inr(pt)-1.8* 01:00pm blood pt-20.7* ptt-42.6* inr(pt)-2.0* 05:15am blood plt ct-134* 05:15am blood pt-22.3* ptt-150* inr(pt)-2.1* 12:40am blood plt smr-low plt ct-134* 12:40am blood pt-23.0* ptt-45.1* inr(pt)-2.2* renal & glucose glucose urean creat na k cl hco3 angap 02:22 glu131* urea n9 cr0.9 na140 k3.5 cl108 hco3 24 ag12 05:05am blood glucose-85 urean-13 creat-1.1 na-141 k-3.9 cl-105 hco3-25 angap-15 05:15am blood glucose-95 urean-11 creat-0.9 na-142 k-3.4 cl-104 hco3-26 angap-15 12:40am blood glucose-80 urean-12 creat-1.0 na-143 k-3.7 cl-105 hco3-28 angap-14 12:40am blood lipase-29 ca8.0* mg2.4* phos1.8 05:05am blood calcium-8.4 phos-3.2 mg-2.3 05:15am blood calcium-8.4 phos-3.0 mg-2.4 12:40am blood calcium-8.5 phos-3.1 mg-1.0* . echo: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. a mechanical aortic valve prosthesis is present. the transaortic gradient is higher than expected for this type of prosthesis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. a mitral valve annuloplasty ring is present. the gradient across the mitral valve is slightly increased (mean = 3-4 mmhg) resulting in trivial/minimal mitral stenosis. no mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. well seated mechanical aortic valve but with increased gradient. well seated mitral annuloplasty ring with trivial mitral stenosis. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. pulmonary artery hypertension. dilated thoracic aorta. compared with the report of the prior study (images unavailable for review) of , the aortic valve gradient is increased and minimal mitral stenosis is now identified. if clinically indicated, a tee may be better able to define the cause of the increased gradient across the aortic valve. . small bowel enteroscopy report: (from above) healthy surgical anastomosis at left colon corresponding to the previous colectomy. moderate to severe diverticulosis in the entire colon. the terminal ileum was entered and the scope was advanced to the proximal/mid ileum. a few tiny red spots were seen. but there was no active bleeding. no avm or mass lesions were seen. otherwise normal small bowel enteroscopy to third part of the duodenum. . small bowel enteroscopy report: (from below) the examined proximal ileum was normal. no active bleeding or avm or mass was seen. impression: normal esophagus; a tiny nonbleeding erosion seen at the antrum; mild and pathy erythema seen at duodenal bulb; normal jejunum. no active bleeding or avm or mass seen. itattooed for marking; normal proximal ileum. no active bleeding or avm or mass seen. otherwise normal small bowel enteroscopy to distal jejunum/proximal ileum. brief hospital course: reason for icu admission: pt is a 69 y.o male with h.o cad s/p cabg complicated by restenosis requiring multiple stents and recent nstemi, mechanical aortic valve on coumadin, recurrent gi bleeds and iddm who was transferred from osh with melena and cta showing active bleeding in proximal ileum. . #upper gi bleed/acute blood loss/anemia-cta per osh report showed active bleeding in the proximal ileum. pt with recent egd with non-bleeding gastritis. last colonoscopy 1 yr ago with polyps. ugib in the setting of restarting plavix 1 week ago for nstemi. pt also on couamdin for mechanical valve, and started on heparin ggt as coumadin was held in setting of procedure. hct remained stable. pt was placed on a protonix gtt. plavix was continued up until transfer to , then restarted. discussed anticoagulation with patient's cardiologist dr. who felt as though pt should be on heparin gtt as long as deemed safe from gi procedure prospective. would prefer to restart asap after any procedure. in addition, outpt cardiologist felt as though pt should be on plavix unless there is presence of hemodynamically significant gi bleeding. he agreed that pt does not tolerate dual anti-platelet therapy (per pt, asa caused bleeding). enteroscopy was performed at which showed no evidence of bleeding via approach from above. small bowel enteroscopy/colonoscopy was performed which was similarly unremarkable. pt was restarted on warfarin and heparin gtt. pt went home on lovenox as bridge, with inr checks planned for and . . #coronary artery disease: s/p cabg and pci x2, severe cad with chronic angina medically managed. recent nstemi with decision to restart plavix after being held x2 years due to recurrent gi bleeds. at plavix was held initially as gi team was uncomfortable doing procedure on plavix as interventions for bleeding (ex. clipping, cauterization could lead to more bleeding while on plavix). in addition, it was felt that at the time plavix effects would still be in his system as there was no complete washout period. as above, discussed case with pt's outpatient cardiologist who felt that pt would need to remain on plavix unless life hemodynamically significant gi bleeding. pt was continued on imdur, statin, beta blocker held, see bradycardia below. he was ruled out for mi at osh prior to transfer. he was monitored on tele. without events. . # mechanical aortic valve: placed at st. . patient's goal inr 3.5 for mechanical valve. was switched to heparin which was stopped 6 hours prior to procedures. given significant risk of thrombosis, heparin was restarted after procedures, despite patient's known gi bleed. hct was monitored closely and remained stable. heparin gtt was changed to lovenox on discharge, see above. . # bradycardia: patient noted to be bradycardic after procedure. thought to be related to sedation for procedure. improved as the patient woke up from sedation. still, hr remained in the 50-60 range throughout hospitalization. initially home beta blocker was held. pt was monitored on telemetry without events. he was asymptomatic. home atenolol restarted on discharge. . #diabetes mellitus - type 2, with complications, peripheral neuropathy. placed on conservative insulin regimen while npo. pt resumed meformin and glyburide upon discharge. continued gabapentin for neuropathy. . #hypertension - benign; initially held beta blocker in setting of bradycardia. continued imdur. held lisinopril while npo. on the morning of discharge his blood pressure was elevated in the 170s systolic. we then restarted his home medications (atenolol, lisinopril) which we had been holding and felt these would be adequate for blood pressure control. . #diastolic heart failure - chronic, but with recent acute exacerbation. lasix was held while pt was npo, and also was given with 1u prbcs. . #hypothyroidism-continued synthroid . #hl-continued simvastatin . #gerd-on ppi ggt for c/f gi bleed as above, transitioned to po ppi on discharge . #leukopenia/thrombocytopenia-unclear etiology. could be due to acute process. thrombocytopenia could be consumptive. plt count was monitored closely and remained stable. . pt was maintained as full code throughout the course of this hospitalization. . transitional issues: anticoagulation: pt sent home on warfarin (subtherapeutic after holding for procedures) and lovenox. he will need inr checked monday and wednesday likely to dc lovenox as ideally he would have a 48 hour therapeutic overlap. pt was instructed to follow up with pcp regarding this issue. medications on admission: medications on transfer: vicodin 5/500 q6h prn ativan 2mg po tid prn morphine 2mg iv prn ntg 0.4 q5 mins prn protonix gtt atenolol 25mg po bid plavix 75mg daily ferrous sulfate 325mg gabapentin 600mg qid humalog sliding scale synthroid 50mcg daily kdur ? dose daily simvastatin 20mg daily heparin gtt imdur er 60mg lasix 40mg daily lantus 10 units qam lisinopril 20mg daily . outpatient medications lantus 20 units qam metformin 850mg glyburide 10mg atenolol 25mg plavix 75mg daily tylenol prn vicodin 1 tablet q6h prn ativan 2mg tid prn ntg prn lasix 40mg daily gabapentin 600mg qid isosorbide mononitrate 60mg daily levoxyl 50mcg daily lisinopril 20mg daily simvastatin 20mg daily coumadin 5mg all days except 2.5mg on m or f omeprazole 40mg daily kcl 20 meq daily ferrous sulfate 325mg discharge medications: 1. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous once a day for 5 days: continue until inr is therepeutic. . disp:*5 syringes* refills:*2* 2. lorazepam 1 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for anxiety. 3. gabapentin 300 mg capsule sig: two (2) capsule po qid (4 times a day). 4. insulin glargine 100 unit/ml solution sig: twenty (20) units subcutaneous once a day. 5. metformin 850 mg tablet sig: one (1) tablet po twice a day. 6. atenolol 25 mg tablet sig: one (1) tablet po twice a day. 7. clopidogrel 75 mg tablet sig: one (1) tablet po once a day. 8. glyburide 5 mg tablet sig: two (2) tablet po twice a day. 9. vicodin 5-500 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. 10. lasix 40 mg tablet sig: one (1) tablet po once a day. 11. isosorbide mononitrate 60 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 12. levoxyl 50 mcg tablet sig: one (1) tablet po once a day. 13. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 14. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 15. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 16. potassium chloride 20 meq tablet, er particles/crystals sig: one (1) tablet, er particles/crystals po once a day. 17. ferrous sulfate 325 mg (65 mg iron) capsule, extended release sig: one (1) capsule, extended release po twice a day. capsule, extended release(s) 18. outpatient lab work please have inr drawn and discharge disposition: home discharge diagnosis: acute blood loss anemia from gastrointestinal bleeding cad s/p stenting and mechanical aortic valve recent nstemi htn discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you were admitted for further evaluation of gastrointestinal bleeding. for this, you had endoscopic procedures both from above and below the level of the stomach, both which were unrevealing for a source of bleeding. this likely occurred in the presence of multiple blood thinners, causing leaking of a vessel which stopped once we held your blood thinners. we discussed the risks and benefits of being on blood thinners. given your cardiac history, including stents and mechanical heart valves, it is necessary that your remain on warfarin and an antiplatelet (such as aspirin or clopidogrel aka plavix), to prevent a stroke and a heart attack respectively. you will be discharged on warfarin at your usual home dose as well as clopidogrel (plavix). please note to follow up with your cardiologest within the week to assure you are on the most appropriate therapy for your cardiac health. as you know, your inr was below goal prior to discharge (goal 2.5-3.5), since we held your warfarin in the hospital so you could have procedures. you will be going home on enoxaparin (aka lovenox)injections to keep your blood thin while your inr becomes therepeutic. medication changes: please start taking clopidogrel (aka plavix) 75mg po qday please start taking enoxaparin subcutaneous injections until your inr is therepeutic please continue taking the rest of your medications as prescribed. . it has been a pleasure taking care of you mr. ! followup instructions: please arrange follow up with your primary care doctor and your cardiologist within 1 week of discharge. you will need to have your inr on monday and wednesday . speak to your primary care physician but you should stop lovenox on wednesday if dr. approves. md procedure: other endoscopy of small intestine other endoscopy of small intestine diagnoses: thrombocytopenia, unspecified esophageal reflux congestive heart failure, unspecified acute posthemorrhagic anemia unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified coronary atherosclerosis of autologous vein bypass graft diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes percutaneous transluminal coronary angioplasty status heart valve replaced by other means anxiety state, unspecified other specified cardiac dysrhythmias other and unspecified angina pectoris long-term (current) use of insulin blood in stool long-term (current) use of anticoagulants knee joint replacement subendocardial infarction, subsequent episode of care diverticulosis of colon (without mention of hemorrhage) chronic diastolic heart failure personal history of colonic polyps leukocytopenia, unspecified other sedatives and hypnotics causing adverse effects in therapeutic use benign essential hypertension other agents affecting blood constituents causing adverse effects in therapeutic use salicylates causing adverse effects in therapeutic use acquired absence of intestine (large) (small) 

Answer: The patient is high likely exposed to