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: sulfa (sulfonamide antibiotics) / shellfish / iodine containing agents classifier / codeine / morphine / heparin agents / levaquin in d5w attending: chief complaint: brbpr and abd pain major surgical or invasive procedure: internal jugular line placement flexible sigmoidoscopy history of present illness: 64 yo female with pmh esrd on hd, cad s/p mi, htn, dmii presents from home with 2 days of brbpr and abdominal pain. she was recently admitted from with abdominal pain felt to be acute on chronic pancreatitis. she was also treated for clostridium diphtheroids in her urine. she reports that abdominal pain is similar to her chronic abdominal pain in nature and mainly isolated to epigastric region. she reports one episode of non-bloody vomiting yesterday. she has had loose,watery, bloody diarrhea for the past two days, about 4 bm/day. she also reports dysuria during this time. . in the ed, initial vs were: 98, 84, 90/43, 16, 100%2l. patient underwent ct abd/pelv that showed ?proctitis. she was noted to have blood mixed with watery diarrhea. hct was stable at 44. bp dropped to mid 80's systolic so central line placed. she was also noted to have positive ua. she was cultured and started on broad spectrum abx with zosyn and flagyl. . in the icu, pt reports continued abdominal pain. no further diarrhea since being in the ed. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - "about 20" hospitalizations over the past 5-6 years for epigastric pain that has eluded definitive diagnosis. according to her primary care physician, carries a diagnosis of chronic pancreatitis, although this has not been confirmed. multiple attempts to have her seen in the outpatient gi unit have failed because she has not been able to keep her appointments. - coronary artery disease; s/p mi in (received stent to rca and right pda at ) - esrd diagnosed "10 years ago"; has received hemodialysis since that time. receives hd on tues, thurs, and sat. baseline creatinine is in range. - peripheral vascular disease: s/p aorto-femoral bypass with atherectomy in after near total occlusion; multiple revisions of her aorto-bifemoral and cross femoral grafts since then - possible chronic mesenteric ischemia with known occlusion of inferior mesenteric artery. - exploratory laparotomy for pancreas divisum with sphincterectomy of her minor duct in - asthma - schizoaffective disorder - hypertension - insulin-independent diabetes mellitus (last measured hba1c 6.6% in ) - history of dvt and clots in aorto-femoral bypass - lumbar disc disease (with associated back pain) - hyperlipidemia - gastroesophageal reflux/gastritis ( egd) - chronic pancreatitis - s/p exploratory laparotomy for pancreas divisum with sphincterotomy of her minor duct in - benign pelvic mass, s/p r oophrectomy and hysterectomy - s/p cholecystectomy - s/p arthroscopy of right knee and medial meniscectomy in ' - heparin-induced thrombocytopenia (positive antibody) social history: lives alone. used to work in central processing at the . smokes cig/day, down from ppd x many years. no etoh, no illicits. family history: siblings passed away from cad/heart attacks. physical exam: admission: tcurrent: 35.9 ??????c (96.6 ??????f) hr: 92 (88 - 92) bpm bp: 87/51(57) {87/51(57) - 126/59(75)} mmhg rr: 14 (14 - 19) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) . general: alert, oriented x 3, no acute distress heent: sclera anicteric, mm dry, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, soft holosystolic murmur at llsb abdomen: soft, + epigastric tenderness gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema cn: ii-xii grossly intact, 5/5 strength throughout . discharge vitals - tm:97.0 tc:97.0 bp:124/64 (104-137/60-76)hr:76 (75-82) rr:20 02 sat: 93% 2l general: middle aged female, alert chest: bl rales to mid posterior lung field. no wheezes cv: s1 s2 soft holosystolic murmur at llsb. normal in quality and intensity rrr. abd: non-distended, bs normoactive, soft, diffusely tender to palpatation ext: no edema. ttp over left pectoralis, no skin changes pertinent results: ## labs on admission . blood . 09:20am blood wbc-20.0*# rbc-6.04* hgb-13.9 hct-44.3 mcv-73* mch-23.0* mchc-31.4 rdw-19.0* plt ct-147* 09:20am blood neuts-88* bands-0 lymphs-5* monos-7 eos-0 baso-0 atyps-0 metas-0 myelos-0 09:20am blood plt smr-normal plt ct-147* 09:20am blood glucose-225* urean-63* creat-8.7*# na-124* k-4.8 cl-84* hco3-18* angap-27* 09:20am blood alt-16 ast-19 alkphos-197* totbili-0.2 09:20am blood lipase-18 09:20am blood albumin-3.9 calcium-9.0 phos-7.8*# mg-1.5* 03:51am blood lactate-0.7 08:03pm blood ck-mb-4 ctropnt-0.08* 06:30am blood ck-mb-3 ctropnt-0.08* 05:30pm blood ck-mb-3 ctropnt-0.06* 05:31pm blood ck-mb-3 ctropnt-0.06* 11:24pm blood ck-mb-3 ctropnt-0.06* 05:00am blood calcium-8.8 phos-4.2 mg-1.9 . urine . 10:00am urine color-yellow appear-hazy sp -1.017 10:00am urine blood-tr nitrite-neg protein-500 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-mod 10:00am urine rbc-0 wbc->50 bacteri-many yeast-none epi-21-50 transe-<1 10:00am urine hours-random creat-156 na-27 k-85 cl-11 10:00am urine osmolal-278 . ## labs on discharge . 05:00am blood wbc-9.2 rbc-3.83* hgb-9.1* hct-28.8* mcv-75* mch-23.8* mchc-31.6 rdw-19.4* plt ct-189 05:00am blood neuts-66 bands-0 lymphs-19 monos-13* eos-2 baso-0 atyps-0 metas-0 myelos-0 05:00am blood glucose-90 urean-19 creat-3.8*# na-135 k-4.3 cl-93* hco3-35* angap-11 . . ## microbiology . urine culture - corynebacterium species blood cultures x2 - no growth final blood culture - no growth *preliminary as of * blood culture - no growth *preliminary as of * blood culture - no growth *preliminary as of * . stool studies (all) - negative c. diff toxin x 3 - negative cmv igg - positive, cmv igm - negative cmv viral load - negative . ## imaging / other studies . flexible sigmoidoscopy: ulceration at the rectum and sigmoid colon. biopsies taken and non-diagnostic immunohistochemistry is negative for cytomegalovirus, controls are adequate. . cxr (): findings: in comparison with study of , there is increased opacity at the left base consistent with volume loss and possible supervening pneumonia. increased blunting is seen of the left costophrenic angle, consistent with a small adjacent effusion. streaks of a right basilar atelectasis are also seen. no evidence of vascular congestion. central catheter tip is in the lower portion of the svc. . abdominal/pelvis ct impression: 1. evidence of proctitis with rectal bowel wall thickening and inflammation of the perirectal fossa. 2. thrombosis of the right aortofemoral bypass graft which appears chronic, given the clinical history. left aortofemoral graft and femoral-femoral bypass graft appear patent. 3. left common femoral bifurcation pseudoaneurysm unchanged compared to prior study allowing for differences in technique. 4. multiple hypodense lesions are visualized throughout bilateral kidneys with those larger than 1 cm consistent with cystic structures and those smaller being too small to characterize. . ct head impression: no acute intracranial injury. . upper extremity doppler findings: a focused ultrasound examination of the left mid and upper arm was performed over the area of swelling. no focal fluid collection is seen. the neighboring appear patent. . echocardiogram: the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with inferior akinesis. no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. with borderline normal free wall function. 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. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. . compared with the prior study (images reviewed) of , the pericardial effusion is new. . ekg (): sinus rhythm. infero-posterolateral myocardial infarction, most likely old. possible left atrial abnormality. st-t wave abnormalities, especially in the anterolateral leads. cannot rule out underlying myocardial ischemia. compared to the previous tracing of anterolateral st-t wave abnormalities persist and are somewhat more prominent. clinical correlation is suggested. brief hospital course: 64-year-old female with multiple medical problems including esrd on hd, chronic pancreatitis, pvd, and cad presenting with continued abdominal pain, bright red blood per rectum and noted to be hypotensive in the ed, initially admitted to micu. on floor, bps well controlled, but developed cp not considered to be ischemic in nature, and flex sig showed rectal and sigmoid ulcerations determined to be secondary to ischemic colitis. . # brbpr / proctitis: ct abdomen/pelvis showed possible proctitis along with bloody diarrhea could be related to an infectious, inflammatory, ischemic or medication-related etiologies. initial c. diff toxin testing was negative, but she was started on iv metronidazole empirically, given recent antibiotic use for a presumed uti and frequent hospitalizations. further testing confirmed c. diff toxin negative x3 results and the patient completed a course of 7 days of flagyl. she has a history of occlusions and ischemic colitis was also a strong consideration. in the course of her hospitalization, she was transfused one unit of prbc and her hct remained stable. she continued to have frankly bloody bowel movements which resolved with time, her hematocrit remained stable. a flexible sigmoidoscopy was performed and showed ulcerations in the rectum and sigmoid colon. she was found to be cmv igg positive and cmv viral load was negative, immunohistochemistry on biopsy from colon was negative for cmv. due to concern for hypotension/ischemic cause of her ulcerations, many of her antihypertensives (amlodipine, lasix, hydralazine, imdur) were held and gradually added back (only metoprolol and valsartan restarted at lower dose) to keep her bp > 110. for symptomatic relief, she was treated with loperamide, hyoscyamine, ranitidine and simethicone during his hospital stay. due to continued hematochezia and hct trending on her plavix was stopped to allow her rectal ulcerations to heal faster and was restarted the day of discharge. . # hospital-acquired pneumonia: upon transfer from the micu to the floor, the patient desaturated to the 60%s and a chest x-ray showed bilateral infiltrates, left greater than right. she completed a 8-day course of vancomycin and zosyn on . she continued to have intermittent desaturations to the high 80%s, but was mostly comfortable on room air and had a minimal oxygen requirement. on , the patient was febrile, had decreased respiratory rate and oxygen saturation in . she had recently been somnolent during the days and appearing oversedated (see below) which suggested aspiration pneumonia. repeat cxr was concerning for worsening bilateral infiltrates. the patient was restarted on vancomycin and cefepime to continue another 8 day course for hap. . # acute on chronic abdominal pain: patient had tenderness to palpation in epigastrium that may be related to chronic pancreatitis and somatization, chronic in nature. her diarrhea was treated as above. her pain was well managed with her home pain regimen of fentanyl patches and percocet, with the addition of hydromorphone. the hydromorphone was quickly transitioned from iv to po formulation when she was able to eat. however, the patient was markedly somnolent during her hospital stay and respiratory drive was compromised. we felt that she had too many narcotics on board, thus fentanyl patch was discontinued and hydromorphone was changed to oxycodone and standing tylenol. her pain was at baseline upon discharge. . #. chest pain: patient began to complain of chest pain upon transfer to the floor, described as like "being punched in the chest", especially with deep inspiration. pain was constant without improvement. troponins and ck-mb were stable and at baseline, but ekg showed deepened t-wave inversions, possibly suggestive of ischemia. cardiology evaluated her and had no immediate concern for ischemia, despite his cardiac history. she was continued on aspirin and restarted on plavix prior to discharge. chest pain which is most likely musculoskeletal related to a fall prior to admission. at discharge, she coneinued to complain of left sided chest pain but appeared somnolent when offered pain medication. . # blood pressure control: given initial hypotension, high concern for evolving sepsis given leukocytosis to 20,000 and ct showing proctitis. ruled out gi sources with negative c. diff and av fistula infection with ultrasound. urine and stool cultures were negative. the patient was also quite hypovolemic in setting of poor po intake and profuse diarrhea for the past 2 days prior to admission. patient was admitted to the micu for fluid resuscitation and continued monitoring. hct initially dropped, likely from hemodiluation, but subsequently remained stable. her blood pressures were well controlled on minimal medications. her home anti-hypertensive regimen was held (amlodipine, lasix, hydral, imdur) and decreased (metoprolol and valsartan). her blood pressures should be monitored closely to avoid low's and subsequent further episodes of ischemia. . # delirium: the patient was intermittently noted to say strange things at night, and developed hallucinations of people talking and interacting with her who were not present. an infectious work up (cxr and bcx) was unrevealing. she had recently had her fentanyl patch increased from 25 mcg/d to 50 mcg/d and her hallucinations increased as this had been on 3 days so it was decreased back to 25 mcg/d. fentanyl was ultimately discontinued and delirium resolved. ambien was also discontinued. . # hyponatremia: patient had an admission sodium of 124 thought to be consistent with hypovolemic hyponatremia in setting of decreased po intake for two days. sodium subsequently resolved and remained stable. . # esrd on hd: patient noted to have particularly high creatinine elevation, which may be representative of being overdue for . there is also suspected elemented of pre-renal azotemia. she received 2 consecutive days of on admission and subsequently returned to her normal schedule of tuesday, thursday, and saturday while in house. calcium acetate was discontinued given diarrhea. sevelamer was discontinued. ferrous sulfate and aranesp were continued for anemia of chronic disease. . # follow up: at the time of discharge, blood cultures drawn , 12/28 showed no growth to date but final reports of them had not been released. after discharge, she will need follow up to ensure that cultures remain negative and antibiotic regimen does not need to be altered. medications on admission: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation every 4-6 hours as needed for sob. 2. amitriptyline 25 mg tablet sig: one (1) tablet po at bedtime. tablet(s) 3. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 4. abilify 15 mg tablet sig: one (1) tablet po once a day. 5. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 6. calcitriol 0.25 mcg capsule sig: one (1) capsule po once a day. 7. calcium acetate 667 mg capsule sig: one (1) capsule po three times a day. 8. citalopram 20 mg tablet sig: two (2) tablet po once a day. 9. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 10. aranesp (polysorbate) 60 mcg/0.3 ml syringe sig: one (1) injection injection every other week. 11. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a week. 12. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). 13. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk inhalation twice a day. 14. folic acid 1 mg tablet sig: one (1) tablet po once a day. 15. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 16. hydralazine 50 mg tablet sig: one (1) tablet po three times a day. 17. ipratropium bromide 0.02 % solution sig: one (1) inhalation inhalation every six (6) hours. 18. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 19. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 20. lidocaine-prilocaine 2.5-2.5 % cream sig: one (1) application topical 3 days per week: use 30 minutes prior to treatments 3 days a week. 21. metoprolol succinate 100 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po once a day. 22. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 23. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. disp:*84 tablet(s)* refills:*0* 24. prochlorperazine maleate 5 mg tablet sig: one (1) tablet po three times a day as needed for nausea. 25. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 26. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 27. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). 28. valsartan 160 mg tablet sig: one (1) tablet po bid (2 times a day). 29. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). 30. aspirin 81 mg tablet, delayed release (e.c.) sig: two (2) tablet, chewable po daily (daily). 31. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 32. senna 8.6 mg tablet sig: one (1) tablet po daily (daily) as needed for constipation. 33. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for gas pains. 34. ferrous sulfate 325 mg (65 mg iron) tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for shortness of breath, wheezing. 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 3. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 4. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 5. aripiprazole 15 mg tablet sig: one (1) tablet po daily (daily). 6. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). 7. aranesp (polysorbate) 60 mcg/0.3 ml syringe sig: one (1) injection injection every other week. 8. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po once a week. 9. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 11. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 12. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 13. prochlorperazine maleate 5 mg tablet sig: one (1) tablet po three times a day as needed for nausea. 14. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 15. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 16. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day): prior to meals. 17. fluticasone 110 mcg/actuation aerosol sig: one (1) inhalation twice a day. 18. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day): hold for sbp < 90, hr < 50. 19. oxycodone 5 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain: hold for excess sedation, rr< 10. 20. acetaminophen 500 mg tablet sig: two (2) tablet po bid (2 times a day). 21. valsartan 40 mg tablet sig: two (2) tablet po bid (2 times a day): hold for sbp < 100. 22. simethicone 80 mg tablet, chewable sig: 1.5 tablet, chewables po qid (4 times a day) as needed for gi upset. 23. insulin lispro 100 unit/ml solution sig: one (1) unit subcutaneous asdir (as directed): per sliding scale. 24. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual qid (4 times a day). 25. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 26. vancomycin 1000 mg iv hd protocol start: start after hd on 27. cefepime 1 gram recon soln sig: 0.5 recon soln injection q24h (every 24 hours) for 9 days: 500mg daily . 28. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po bid (2 times a day). 29. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: lower gastrointestinal bleeding, secondary to ulcers from ischemic colitis hospital-acquired pneumonia chronic abdominal pain secondary diagnosis: end-stage renal disease type 2 diabetes mellitus heparin-induced thrombocytopenia discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure being a part of your care at the . you were initially admitted to the intensive care unit because you were having bloody bowel movements and your blood pressure was very low. after you received some blood, you were transferred to the floor and we managed your abdominal pain with medications. you had some chest pain and we called the cardiology team to evaluate you. they were not concerned about a heart attack. the gastroenterologists looked inside your digestive system with a camera and found that you had ulcers causing your bleeding. the ulcers were related to your low blood pressure causing ischemic colitis. you also had some trouble breathing at a few times during your hospitalization and we treated you with antibiotics for a pneumonia. you will continue these antibiotics at your rehab facility. you continued to get according to your normal schedule. we have made the following changes to your medications: stop the following medications: amlodipine calcium acetate lasix hydralazine imdur fentanyl patch lidocaine sevelamer ambien colace senna change metoprolol succinate 300mg daily to metoprolol tartrate 100mg twice a day change percocet to oxycodone 10mg as needed for pain and tylenol 1000mg twice a day decrease valsartan to 80mg twice a day start these medications: hyoscamine ranitidine vancomycin to be dosed at hemodialysis for 9 more days cefepime daily for 9 more days insulin sliding scale continue all your other medications as prescribed followup instructions: department: when: wednesday at 12:20 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage procedure: venous catheterization, not elsewhere classified hemodialysis closed [endoscopic] biopsy of rectum diagnoses: pneumonia, organism unspecified end stage renal disease other chronic pain renal dialysis status coronary atherosclerosis of native coronary artery esophageal reflux tobacco use disorder urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hyposmolality and/or hyponatremia asthma, unspecified type, unspecified peripheral vascular disease, unspecified percutaneous transluminal coronary angioplasty status pulmonary collapse hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia acute respiratory failure hypotension, unspecified pneumonitis due to inhalation of food or vomitus disorders of phosphorus metabolism long-term (current) use of insulin old myocardial infarction personal history of venous thrombosis and embolism encephalopathy, unspecified chronic pancreatitis acute vascular insufficiency of intestine chronic vascular insufficiency of intestine heparin-induced thrombocytopenia (hit) schizoaffective disorder, unspecified 

Answer: The patient is high likely exposed to