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: patient recorded as having no known allergies to drugs attending: chief complaint: nausea, vomiting, diarrhea major surgical or invasive procedure: none history of present illness: ms. is a 58yo f w/ a h/ (d/c'd from 2d pta), htn, hl, gerd, duodenal ulcer s/p perforation/repair at who p/w 8 hours of nausea, vomiting, and diarrhea. after she was d/c'd on , she reports feeling well until yesterday evening at 5pm, when she began having large volumes of diarrhea q15 minutes. her stool was initially brown in color (no change from usual) and then became clear and foamy. denied blood, dark-colored, tarry stool. around 8-9pm, she began vomiting q15-20 min, initially food she had eaten earlier (carrots, steak) but also turned clear. non-bloody and non-bilious. the vomiting and diarrhea resolved at around 2am with continued nausea. early this morning she asked her daughter to call an ambulance to bring her here per discharge instructions to return with worrisome symptoms. . she reports several such episodes in the last year or so. she doesn't associate them with unusual foods or exposures. she feels the only thing that helps resolve these episodes is time. . per patient, she is up to date on cancer screenings. colonoscopy, pap, and mammogram within the last year were negative. no pets or recent travel. she is originally from (emigrated when she was 16yo to ) and last visited 2 years ago. she reports no infectious symptoms around the time of her visit. reports drinking rum drinks on the weekend and rum drinks on occasional weekdays. patient's family (on previous admission) noted her to drink 0.5 quarts rum/day. . ms. was recently admitted to the from for a similar complaint. she was found to with a cr 6.6 and diffuse, painful muscle cramps associated with hypomagnesemia (mg 0.5). was presumed to be due to contrast nephropathy given i+o+ abdominal ct 3d prior to that admission due to concern for renal mass (later dx as renal cysts). her was exacerbated by dehydration and poor pos due to n/v/d. fena was c/w a prerenal picture. aggressive volume repletion and mg repletion ensued, though patient became anuric and renal consult was placed. u/s concluded patent renal arteries and presence of renal cysts per above. further volume repletion corrected cr to 1.1. per patient's family, she had had 5 similar episodes in the last 1.5 years. . in the ed, 96.6 110 131/70 17 99%ra. physical examination notable for mildly distended abdomen, nontender. laboratory data significant for wbc 11.8, calcium 11.1, magnesium 1.1, creatinine 2.0 (1.1 ). received zofran iv, simethicone, magnesium sulfate 4 gram, ivf 1l. on transfer to medicine service, vital signs reportedly stable. . ros: (+) per hpi (-) for headache, dizziness, increased sweating, syncope, fevers, chills, cp, sob, cough, abdominal pain, vaginal bleeding, constipation, feeling of fullness, increased flatulence, changes in bladder habits, weakness, paresthesias, difficulty with coordination, gait disturbances . past medical history: two past episodes of ?arf (dehydration/diarrhea leading to need for mg repletion) htn hyperlipidemia hypokalemia of unclear origin previous duodenal ulcer with perforation and surgical intervention renal mass, dx as renal cysts by ct () and u/s () anemia social history: lives with her husband, has two adult children (28 and 38 who both live locally). works locally at nstar in an office setting. family history: no family hx of kidney disease, cad, cancer. mother has dm2. children are both healthy. physical exam: vs: tc 98.4 tmax 98.4 hr 110 bp 167/99 rr 18 o2sat 97% ra general: weak-appearing, lying in bed heent: sclerae anicteric, conjunctiva noninjected, mm moist, oropharynx without lesions, exudate cv: rrr with intermittent pauses (irregular intervals), soft systolic murmur @ lusb lungs: ctab abd: soft/nt, distended, hyperresonant to percussion; no fluid wave or shifting dullness, +bs, no guarding or rebound tenderness ext: le appear wasted, 2+ pulses, no c/c/e skin: wwp, no rashes neuro: cranial nerves ii-xii intact. 5/5 strength in ue/le, 2+ reflexes throughout. normal light touch sensation. negative romberg. coordination intact demonstrated by alternating hand slap and finger to nose tests. mini-mental status aao x 3; registration, recall; unable to assess attention due to ?education status (difficulty with spelling and arithmatic); naming intact. . pertinent results: renal ultrasound (): small renal hypoechoic lesions in both kidneys can be cysts. 6 months follow-up ultrasound is suggested to demonstrate stability. normal renal arteries and venous doppler. . ekg (): nsr @ 98bpm, pr/qrs intervals are wnl, leftward axis deviation, qrs in bundloid pattern (but without qrs prolongation). poor r wave progression, no findings to suggest st changes. previous ekg () had suggestion of pacs, lead misplacement makes comparison difficult. . egd/colonoscopy: 06:58am blood wbc-13.3* rbc-2.78* hgb-8.3* hct-24.7* mcv-89 mch-29.7 mchc-33.4 rdw-13.7 plt ct-591* 05:42am blood wbc-16.3* rbc-2.69* hgb-8.4* hct-24.3* mcv-90 mch-31.0 mchc-34.3 rdw-13.7 plt ct-435 06:31pm blood hct-24.3* 06:33am blood wbc-17.5* rbc-2.76* hgb-8.4* hct-23.8* mcv-86 mch-30.5 mchc-35.3* rdw-13.4 plt ct-444* 04:55pm blood hct-25.6* 04:37am blood wbc-16.1* rbc-2.94* hgb-8.9* hct-26.0* mcv-89 mch-30.3 mchc-34.2 rdw-13.9 plt ct-371 01:17pm blood hct-26.9* 12:39pm blood hct-25.0* 05:37am blood wbc-19.3* rbc-3.29*# hgb-9.9*# hct-30.2* mcv-92 mch-30.2 mchc-32.9 rdw-13.8 plt ct-400 12:00am blood wbc-25.0* hct-37.9 plt ct-578* 03:15pm blood wbc-21.9* rbc-5.01 hgb-15.4 hct-45.8 mcv-91 mch-30.7 mchc-33.6 rdw-13.7 plt ct-595* 12:00am blood wbc-25.0* hct-37.9 plt ct-578* 03:15pm blood wbc-21.9* rbc-5.01 hgb-15.4 hct-45.8 mcv-91 mch-30.7 mchc-33.6 rdw-13.7 plt ct-595* 06:19am blood wbc-17.2* rbc-4.09* hgb-12.4 hct-36.7 mcv-90 mch-30.3 mchc-33.8 rdw-13.6 plt ct-530* 06:38am blood wbc-12.8* rbc-3.92* hgb-11.8* hct-35.1* mcv-89 mch-30.1 mchc-33.7 rdw-13.8 plt ct-464* 02:57am blood wbc-11.8* rbc-4.64# hgb-14.1# hct-41.1# mcv-89 mch-30.4 mchc-34.4 rdw-14.2 plt ct-435 06:33am blood neuts-76.5* lymphs-18.8 monos-4.0 eos-0.2 baso-0.5 05:37am blood neuts-82* bands-1 lymphs-13* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 03:15pm blood neuts-85.3* lymphs-11.8* monos-2.1 eos-0.3 baso-0.5 06:38am blood neuts-70.6* lymphs-24.1 monos-3.7 eos-0.9 baso-0.6 02:57am blood neuts-64.7 lymphs-29.1 monos-4.3 eos-1.3 baso-0.6 06:58am blood plt ct-591* 05:42am blood pt-12.7 ptt-26.3 inr(pt)-1.1 05:42am blood plt ct-435 06:33am blood plt ct-444* 06:33am blood pt-13.9* ptt-31.7 inr(pt)-1.2* 04:37am blood plt ct-371 04:37am blood pt-23.9* ptt-37.7* inr(pt)-2.3* 05:37am blood plt smr-normal plt ct-400 05:37am blood pt-19.4* ptt-28.7 inr(pt)-1.8* 12:00am blood plt ct-578* 03:15pm blood esr-16 04:25pm blood glucose-132* urean-5* creat-0.7 na-136 k-3.5 cl-98 hco3-31 angap-11 06:58am blood glucose-106* urean-5* creat-0.7 na-140 k-3.8 cl-99 hco3-31 angap-14 05:42am blood glucose-95 urean-5* creat-0.6 na-138 k-4.1 cl-100 hco3-29 angap-13 06:31pm blood glucose-134* urean-6 creat-0.6 na-138 k-3.2* cl-99 hco3-30 angap-12 06:33am blood glucose-102* urean-8 creat-0.7 na-139 k-3.8 cl-101 hco3-29 angap-13 07:53pm blood glucose-142* urean-13 creat-0.8 na-137 k-3.2* cl-102 hco3-25 angap-13 04:55pm blood glucose-96 urean-14 creat-0.8 na-134 k-3.6 cl-103 hco3-21* angap-14 04:37am blood glucose-108* urean-22* creat-1.1 na-132* k-4.4 cl-108 hco3-18* angap-10 09:03pm blood glucose-108* urean-29* creat-1.3* na-132* k-3.6 cl-105 hco3-17* angap-14 12:39pm blood glucose-184* urean-37* creat-1.7* na-132* k-3.3 cl-108 hco3-16* angap-11 05:37am blood glucose-104* urean-44* creat-2.1* na-133 k-3.7 cl-111* hco3-8* angap-18 12:00am blood glucose-127* urean-45* creat-2.2* na-136 k-2.6* cl-114* hco3-7* angap-18 03:15pm blood glucose-190* urean-38* creat-2.2*# na-130* k-4.0 cl-98 hco3-15* angap-21* 06:19am blood glucose-137* urean-25* creat-1.1 na-133 k-3.2* cl-105 hco3-15* angap-16 06:20pm blood glucose-108* urean-23* creat-1.2* na-132* k-4.2 cl-105 hco3-16* angap-15 06:38am blood glucose-133* urean-17 creat-1.1 na-135 k-2.7* cl-102 hco3-20* angap-16 04:17pm blood glucose-123* urean-19 creat-1.6* na-137 k-3.5 cl-99 hco3-26 angap-16 02:57am blood glucose-225* urean-13 creat-2.0* na-139 k-3.6 cl-93* hco3-21* angap-29* 06:33am blood alt-13 ast-13 ld(ldh)-140 alkphos-44 totbili-0.4 04:55pm blood alt-12 ast-11 alkphos-43 totbili-0.3 12:39pm blood ld(ldh)-138 03:15pm blood ck(cpk)-32 06:38am blood alt-23 ast-14 amylase-65 04:17pm blood ck(cpk)-76 02:57am blood alt-36 ast-27 ck(cpk)-154 alkphos-107* totbili-0.7 06:19am blood lipase-74* 06:38am blood lipase-72* 02:57am blood lipase-98* 03:15pm blood ck-mb-1 ctropnt-<0.01 04:17pm blood ck-mb-1 ctropnt-<0.01 02:57am blood ck-mb-1 ctropnt-<0.01 04:25pm blood calcium-8.0* phos-2.9 mg-2.0 06:58am blood calcium-8.0* phos-3.4 mg-0.9* 05:42am blood albumin-3.2* calcium-8.1* phos-2.3* mg-1.6 06:31pm blood calcium-7.5* phos-2.9 mg-1.6 06:33am blood albumin-3.0* calcium-7.1* phos-1.8* mg-1.7 iron-33 07:53pm blood calcium-7.6* phos-1.6* mg-1.3* 04:55pm blood calcium-7.9* phos-1.9* mg-1.4* 04:37am blood calcium-8.1* phos-2.3* mg-2.2 09:03pm blood calcium-7.4* phos-1.4* mg-1.8 12:39pm blood calcium-9.2 phos-2.8# mg-2.7* 05:37am blood albumin-2.8* calcium-7.3* phos-5.8*# mg-1.2* 06:20pm blood calcium-8.3* phos-2.5* mg-1.6 06:38am blood albumin-4.7 calcium-8.5 phos-2.6* mg-2.1 04:17pm blood calcium-8.2* phos-3.5 mg-2.9* 02:57am blood totprot-10.2* albumin-5.9* globuln-4.3* calcium-11.1* phos-3.8# mg-1.1* 06:33am blood caltibc-194* ferritn-173* trf-149* 04:37am blood vitb12-289 12:39pm blood hapto-213* 05:37am blood osmolal-288 06:19am blood osmolal-286 02:57am blood osmolal-289 02:57am blood tsh-2.6 06:19am blood pth-132* 02:57am blood pth-167* 03:15pm blood crp-3.4 02:57am blood pep-no specifi igg-1294 iga-170 igm-153 ife-no monoclo 12:00am blood hiv ab-negative 01:25pm blood ethanol-neg 02:57am blood asa-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 12:59pm blood type- temp-36.7 po2-35* pco2-28* ph-7.38 caltco2-17* base xs--6 intubat-not intuba comment-peripheral 03:26am blood lactate-0.9 03:57pm blood lactate-3.6* 12:59pm blood freeca-1.35* 11:41pm blood chromogranin a-pnd 11:41pm blood vasoactive intestinal polypeptide-pnd 11:41pm blood gastrin-pnd 12:00am blood serotonin-test elevated at 344 06:38am blood vitamin d 25 hydroxy-test . egd-atrophy and granularity in the esophagus congestion and hypertrophy in the stomach body and fundus (biopsy) congestion, nodularity, ulceration and hypertrophy in the whole examined duodenum compatible with acid excess or infiltration (biopsy) otherwise normal egd to third part of the duodenum . colonoscopy-diverticulosis of the ascending colon (biopsy) otherwise normal colonoscopy to cecum . egd biopsy- diagnosis: gastrointestinal mucosal biopsies (three): a. stomach: corpus mucosa with proton pump inhibitor effect. b. duodenum: chronic inactive duodenitis. c. random colon: colonic mucosa, no diagnostic abnormalities recognized. . ruq u/s-impression: 1. normal hepatic echotexture, without evidence of a focal lesion. 2. probable right renal cyst. 3. small left pleural effusion. brief hospital course: 58yo f with h/o alcohol misuse, hypertension, and recent admission for presumed contrast-induced and dehydration admitted with nausea/vomiting/diarrhea and with recurrent . . # nausea/vomiting/diarrhea: leukocytosis prompted fever workup esp for viral gastroenteritis, blood and stool cultures sent as well u/a, although bacterial infection less likely given 64.7% pmns. blood, stool cultures negative, u/a negative. lipase was elevated suggesting ?pancreatitis, but lipase can be falsely elevated in the setting of . per patient's daughter, patient drinks a bottle of bacardi rum every 2-3 days. patient did not report abdominal pain and exam was benign but for distention and hyperactive bowel sounds. ingestion was also on the differential. patient history does not corroborate this, but anion gap observed to be 25 (discussion below). osmolar gap was found to be normal, but urine tox was positive for barbiturates and amphetamines. patient adamantly denied drug use, symtoms suggest a more severe underlying process. patient was administered zofran and aggressive rehydration with ivf, >5l. on day 3 of admission () patient appeared more somnolent and began having massive volumes of purely liquid stool. she continued on ns @ 150, was drinking ginger ale but had unremitting nausea requiring both zofran and compazine. around midday she was found listless on the commode, her sbp measured dropped to 80s, and her extremities were cold to touch. she brought up 2-3 teaspoons of brown, coffee grounds type liquid. she immediately received about 750ml ns bolus and bp returned to 140s/80s. ekg was unchanged from baseline. she was transferred to the micu. while in the micu, a left ij was placed and the patient was fluid resuscitated w ns along with bicarb for a bicarb of 8. her diarrhea was calculated to be secretory in nature and she had up to 7l of stool output a day when her symptoms were at the worst. her diarrhea improved with a short course of tincture of opium. several hormonal studies (vip, gastrin, serotonin, chromogranin a, hiaa) and a ttg were sent to determine the etiology of her diarrhea and were pending when she was transferred back to the floor. her hiv antibody was negative. prep for an egd and c-scope was started prior to transfer to the floor. egd showed hypertrophy of stomach, duodenal hypertrophy congestion consistent with excess acid secretion. patient's diarrhea resolved and she began taking pos. pt's neuroendocrine markers were pending at the time of discharge as well as her biopsy results. she will follow up with her pcp and gi for these results. . # coagulopathy, anemia. while in the micu, the patient's ptt and inr rose to 2.3 and her hct decreased to 25. hemolysis labs were negative. it was thought her coagulopathy was likely related to malabsorption and poor nutrition. she was treated with subq vitamin k given concern that she is not absorbing pos. a ruq u/s was ordered and negative for liver pathology. . # : cr 2.0 upon admission. likely to dehydration from large volume diarrhea/vomiting, fena was 0.2% suggesting a prerenal process. underlying process not excluded given electrolyte derangements on last admission (hypocalcemia, hyperphosphatemia, hypomagnesemia also seen). ttkg is 10.28, above normal limits and suggesting renal potassium wasting. diuretic screen sent. spep sent given ?hypercalcemia, elevated serum proteins, , and patient's age, slight suspicion for multiple myeloma. also on the differential is amyloidosis given gi sx (particularly diarrhea), and proteinuria per prior admission (possibly due to rbcs in urine), some evidence of conduction abnormalities on ekg (skipped ventricular beats). spep and upep were negative. cr resolved to 1.1 with ivf by day 2. on day 3, it was found to be 2.2 (bun 38) but improved with additional ivfs. by discharge her cr was down to 0.7. . # hypercalcemia: upon admission, patient's ca was 11.1, corrected to 9.6 after accounting for albumin of 5.6. ionized calcium was found to be low. hypercalcemia with hypophosphatemia (though also hyperphosphatemia) on last admission might suggest primary or tertiary hyperparathyroidism. pth sent to parse out etiology of hypercalcemia, found to be elevated at 167. patient reports taking calcium supplements but not in excess. zollinger- possible given history of reflux symptoms (tx with ppi until last admission, now on h2 blocker) and history of duodenal ulcer s/p perforation. no clinical symptoms or signs of paget's disease (pain, fractures). after day 3 patient was consistently hypocalcemic when corrected for albumin. she was found to have vitamin d deficiency and was therefore sent home on calcium and vitamin d supplementation. . # anion gap: presumed metabolic acidosis with anion gap of 25. likely due to starvation based on excessive diarrhea/vomiting and recent etoh use. serum osms were calculated and there was no gap. cr 2.0 and continued urine production does not suggest uremia. patient has no documented history of diabetes and did not report taking salicylates. toxic ingestion was considered as well. ag resolved with fluids, metabolic acidosis persisted and urine ag was found to be negative suggesting appropriate renal response to loss of hco3. . #electrolyte derangements-including hypomagnesemia-likely related to ivf repletion, dehydration, vomiting, diarrhea and acid base status. pt's hypomagnesium related to the above and possible due to ppi use. pt should have electrolytes followed in the outpatient setting. she was discharged on magnesium and potassium supplementation. . # fen: diet advanced as tolerated. . # prophylaxis: heparin sc 5000u tid . medications on admission: simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). labetalol 200 mg tablet sig: one (1) tablet po bid (2 times a day). amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). potassium chloride 10 meq tablet sustained release sig: two (2) tablet sustained release po once a day. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. multivitamin tablet sig: one (1) tablet po once a day. discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. labetalol 200 mg tablet sig: one (1) tablet po bid (2 times a day). 3. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once (once) for 1 doses. 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. disp:*30 tablet(s)* refills:*2* 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 7. maalox 200-200-20 mg/5 ml suspension sig: one (1) po every 6-8 hours as needed for heartburn: you may purchase this medication over the counter. 8. vitamin d 50,000 unit capsule sig: one (1) capsule po once a week for 6 weeks. disp:*6 capsule(s)* refills:*0* 9. calcium 600 600 mg (1,500 mg) tablet sig: two (2) tablet po once a day. disp:*60 tablet(s)* refills:*2* 10. magtab 84 mg tablet sustained release sig: tablet sustained releases po once a day: this medication may need adjustment in 1 week's time. disp:*120 tablet sustained release(s)* refills:*0* 11. outpatient lab work please have your magnesium level checked next week on at your pcp . office. discharge disposition: home discharge diagnosis: major: nausea vomiting diarrhea hyper and hypocalcemia acute renal failure hypomagnesemia hematemesis anemia due to chronic disease elevated parathyroid hormone vitamin d deficiency discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital for nausea, vomiting, and diarrhea. when you arrived we found that your electrolytes were abnormal and you had kidney injury. this was likely related to your diarrhea and dehydration. you were given iv fluids and electrolyte medications. we also performed a number of tests on your urine and blood to check for different hormonal disorders that could lead to severe diarrhea. we think you might have gotten a viral illness that made you vomit and have diarrhea but that you also may have something else that is causing these episodes so frequently. you had an episode of low blood pressure and vomiting a small amount of blood that led to an icu stay. in addition, you had an upper endoscopy and a colonoscopy. your endoscopy shows some abnormalities that can be seen with excessive acid production or possibly due to another disorder. therefore, biopsies were taken for further evaluation. your diarrhea and lab abnormalities have improved and you were able to tolerate food by the time of discharge. you should be sure to follow up with your pcp . and the gastroenterologists to discuss the results of your biopsy and follow up on the remainder of your laboratory results. . you may have a possible abnormality near your "thoracic aorta"-blood vessel in your chest. we discussed this finding with you. we will notify your pcp of this finding. you should have an mri or ct scan in the outpatient setting for further work up. if diarrhea returns at home, please be sure to drink plenty of fluids or gatorade. . we spoke with you about alcohol. please know that excessive drinking is dangerous for your health. it can lead to many long-term problems including liver failure and heart problems. it is also very dangerous to take medications or drugs that are not prescribed to you by your doctor. if you need help or have concerns with any of this, you may use the resources that were provided to you by the social worker. . medication changes: 1) your ranitidine was increased to 150mg twice a day 2) you were started on mag-tab for magnesium replacement 3) you were started on vitamin d for vitamin d deficiency 4) you were started on calcium for your bones. . please keep all follow up appointments. . if you develop any of the symptoms described below or any other symptoms concerning to you please call your primary care doctor or go to your local emergency room. followup instructions: please have your magnesium level checked next week at dr. office. . name: , e. when: tuesday, , 10am address: ,, , phone: . name: , location: address: , , phone: appointment: thursday 2:20pm the office is fitting you in for this appointment please be advised you may need to wait a little longer than expected. please ask the gi doctors to follow up on your neuroendocrine hormonal markers and biopsy results. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified esophagogastroduodenoscopy [egd] with closed biopsy esophagogastroduodenoscopy [egd] with closed biopsy closed [endoscopic] biopsy of large intestine transfusion of packed cells diagnostic ultrasound of digestive system diagnoses: acidosis anemia of other chronic disease anemia, unspecified esophageal reflux urinary tract infection, site not specified unspecified essential hypertension acute kidney failure, unspecified unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia hypopotassemia nausea with vomiting other and unspecified hyperlipidemia disorders of phosphorus metabolism duodenitis, without mention of hemorrhage hemorrhage of gastrointestinal tract, unspecified dehydration disorders of magnesium metabolism disorders of magnesium metabolism diverticulosis of colon (without mention of hemorrhage) leukocytosis, unspecified unspecified intestinal malabsorption mixed acid-base balance disorder cyst of kidney, acquired infectious diarrhea neoplasm of uncertain behavior of stomach, intestines, and rectum primary hyperparathyroidism unspecified disorders of arteries and arterioles abnormality of secretion of gastrin 

Answer: The patient is high likely exposed to