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: past medical history: 1. end-stage liver disease secondary to alcohol-induced cirrhosis diagnosed with alcoholic hepatitis at the age of 37 in . he had an episode of hepatic encephalopathy, history of ascites and scrotal edema. liver mass on ct noticed in with new masses on mri. 2. asthma. 3. herpes zoster in . 4. diet-controlled diabetes. 5. status post cholecystectomy. 6. status post appendectomy. 7. history of colonic polyps with last colonoscopy in . allergies: the patient has no known drug allergies. admission medications: 1. spironolactone. 2. ultram. 3. lactulose. 4. flovent. 5. combivent. 6. albuterol. family history: negative for liver disease. positive for glaucoma. social history: no alcohol for the past 25 years, prior to that about a quart per week. tobacco: he is a former smoker. he is a retired business manager for and is married with two children. physical examination on admission: vital signs: temperature 97.8, blood pressure 95/68, heart rate 78, respiratory rate 16, saturations 98% on room air. general: he is a chronically ill appearing male in no acute distress. heent: normocephalic, atraumatic. the pupils were equal, round, and reactive to light. the extraocular muscles were intact. moist mucous membranes. the oropharynx was clear with positive scleral icterus. neck: no jvd. cardiovascular: normal s1, s2, no murmurs, rubs, or gallops. regular rate and rhythm. lungs: clear to auscultation bilaterally. abdomen: protuberant with central midline scar and tympanitic. extremities: no clubbing, cyanosis or edema. neurologic: no asterixis. the patient was awake, alert, and oriented times three. the examination is otherwise nonfocal. skin: numerous spider nevi. multiple ecchymoses. poor skin turgor. laboratory/radiologic data: on admission, white count 11.6, hematocrit 43.5, platelets 157,000. sodium 106, potassium 5.4, chloride 81, bicarbonate 16, bun 22, creatinine 0.9, glucose 127. inr 1.6, alt 76, ast 73, alkaline phosphatase 341, total bilirubin 5.4, total protein 6.3. ammonia 76. amylase 64, lipase 41. chest x-ray showed question of a retrocardiac density, spiculated nodular opacification in the left upper lobe and a flattened diaphragms consistent with copd. hospital course: this is a 66-year-old gentleman with end-stage liver disease secondary to alcoholic-induced cirrhosis and history of hepatic encephalopathy and ascites who presented initially with lower extremity weakness, confusion, and hypernatremia. initially, the patient was admitted to the intensive care unit for further monitoring with severe hypernatremia. the patient was hydrated with normal saline overnight and sodium continued to slowly improve and was otherwise stable. the patient was then transferred out to the floor. 1. end-stage liver disease: secondary to alcoholic hepatitis for which he has had disease for about 30 years. he presented with a bilirubin of 5.4, elevated alt, ast, and alkaline phosphatase. the patient had an ultrasound of his right upper quadrant eventually to assess for ascites and his flow. ultrasound did have evidence of perihepatic ascites and in light of the patient's lethargy and confusion, plans were made for a diagnostic paracentesis. this was done on without complications and laboratories returned later that evening with a white count in the fluid of greater than 20,000, red blood cells 4,800, with 78% polys. he had an saag of 1.8 and this was consistent with portal hypertension with superimposed infection. the patient was then started on ceftriaxone but on the morning of the results was found to be less responsive and hypotensive. the patient was hydrated with fluid boluses and pressures remained persistently in the 70s to 80s even after 2 liters. the patient was groaning to pain and touch to palpation of his abdomen but otherwise poorly responsive at that time. we were unable to get iv access in the patient and a right internal jugular central line was placed and laboratories were sent. further workup was started. the micu team was eventually called to evaluate the patient and the patient had a blood gas during this time also which showed a ph of 7.34, pc02 14, p02 73, lactate 5.3. as the patient continued to remain unresponsive, plans were made to transfer the patient into the intensive care unit. in terms of supporting his blood pressure, the patient was started on a dopamine drip on the floor and eventually it transitioned to a levophed drip in the unit. he had a repeat gas done on the floor as the patient's oxygen requirement increased. eventually it was on 100% nonrebreather. prior to that, a gas on 10 liters face mask showed a ph of 7.23, pc02 17, p02 89 with a lactate of 6.0. the patient was transitioned to 100% nonrebreather eventually as he continued to desaturate on face mask. he was with an elevated lactate and concern for sepsis. plans were made to consider a stat abdominal ct. plans were to stabilize the patient prior to transferring to the ct scanner. eventually, the patient was intubated by anesthesia for airway protection and for increasing acidemia and hypoxia. the patient was also initially started on ceftriaxone in the morning but coverage was broadened to conclude zosyn and vancomycin for which was also started upon arrival in the intensive care unit. his blood pressure remained in the 80s to 60s range and he started to receive boluses of albumin in attempts to help his fluid remain intravascularly. over the course of the morning with fluids, the patient's abdomen continued to increase in distention. repeat laboratories returned with inr from 1.6 to 2.9, albumin 2.2, total bilirubin of 2.7, ast/alt of 40 and 64, white count of 11.8. no growth on preliminary gram's stain of the fluid culture. however, with increasing lactate, hypotension, and white count concern for sepsis. the patient was again transferred to the intensive care unit on broad coverage antibiotics including vancomycin, zosyn, and flagyl empirically. surgery evaluation was also called at the time to rule out perforation. kub did not show any free air and the patient had a ng tube placed for suctioning and a rectal tube placed for decompression. the patient also had an arterial line placed in his left radial artery for better blood pressure monitoring. in the micu the patient was switched over to levophed with thoughts of adding vasopressin if required additional pressors. again, the patient was continued on respiratory support via the ventilator. his blood gases were serially followed. his lactate remained elevated secondary to his sepsis. eventually, he went down for a ct of his abdomen with gastrografin which revealed dilated loops of colon and small bowel with colonic wall thickening and no evidence of microperforation. we continued to follow his examinations via kubs and his dilated loops of bowel seemed to resolve and no evidence of free air throughout his stay. the patient was continued to be seen by surgery while in the micu. secondary to his end-stage liver disease and criticalness of his illness, the patient was not considered a liver transplant candidate and was given lactulose for history of hepatic encephalopathy and with continued lactulose mental status did continue to improve but did continue to wax and wane even upon transfer to the floor when his orientation waxed and waned. the liver team continued to follow him throughout his stay for his liver disease. his liver disease remained stable even on transfer to the floor on the lactulose. his abdomen had decreased with diuresis, however, with a bump in creatinine the diuretics were held and the patient's abdominal girth remained stable, however, with a drop in blood pressures. the patient continued to receive fluid boluses once he was titrated off pressors and with increasing hydration, his abdominal girth continued to increase and with iv fluid replacement or free water replacement did not remain intravascular. he continued to have episodes of hypotension once he was weaned off the pressors and transferred to the floor. these remained as above with iv fluid boluses and occasionally with albumin boluses. his pressures remained in the 80s/60s range and at that blood pressure the patient continued to talk and mentate and continued to have reasonable urine output. overall, his blood pressure low at baseline, per family, run 90s/60s and were slightly lower as he was dehydrated and would drop at night as he would lose some vagal tone and receive some boluses. no thoughts of recurrence of sepsis while on the floor. he was almost complete with his vancomycin and zosyn course for which he will complete on . his white count remained stable and his fever curve remained afebrile throughout his course on the floor. however, his vancomycin trough was elevated and plans were to hold vancomycin until trough drops below 15. also of note was increasing fluid boluses for blood pressure support and hyperalbuminemia from his chronic illness and recent exacerbation of his illness. the patient became more anasarcic with weeping through his upper and lower extremities. this was slightly improved upon discharge from the intensive care unit but, however, persisted on the floor. he did continue to have signs of skin breakdown in his sacral and back region and was placed on a kainair mattress and seen by the wound care nurses to help evaluate his sacral skin breakdown. his altered mental status was most likely attributed to his toxic metabolic state from sepsis versus hepatic encephalopathy. currently, he is awake, alert, and oriented to his name but not to place and occasionally to time and this waxes and wanes throughout the day. this will continue to be followed and continue to use lactulose, titrating to at least four bowel movements a day to help with his hepatic encephalopathy. 2. respiratory failure: as addressed before. this was stable after extubation on . he remained stable, oxygenating with his nasal cannula; however, at the time of this dictation did have a chest x-ray showing bilateral lower lobe atelectasis and possible bilateral pleural effusions which is consistent with his cirrhotic hyperalbuminemic state. his respiratory status remained stable and he continued to be followed as his condition improve. the patient does have the known left upper lobe lung mass which is concerning with a cancer; however, although was scheduled to have a ct-guided endobronchial biopsy done, the patient's change in medical condition prevented completion of that test. this workup will be deferred for now as the patient will likely be unable to tolerate treatment for the mass at this time. we will continue to follow. 3. asthma: the patient's respiratory wheezes were stable and clinical asthma was stable in-house while on his combivent and fluticasone regimen. 4. diabetes: it was diet-controlled at home. however, he did have some lability here, likely secondary to his end-stage liver disease but was stable and only continued on sliding scale insulin regimen. 5. anemia/thrombocytopenia: the patient did have a negative workup for hemolysis but possibly a low-grade dic with rising inr and ptt and dropping fibrinogen in light of initial sepsis; however, this has been stabilized and his thrombocytopenia is likely secondary to his chronic liver disease and anemia likely secondary to malnutrition. continue supportive care with goal platelets at least greater than 20,000 and hematocrit greater than 30. 6. electrolytes: the patient initially came in hyponatremic and this resolved with normal saline hydration and eventually corrected to hypernatremia in light of recent dehydration, especially intravascularly. the patient was started on free water boluses through his ng tube and also started on iv free water repletion. his rising chloride and low bicarbonate were also consistent with dehydration and contractions and continued to try to replete free water as above. 7. peritonitis: initially with abdominal distention and elevated white count on ascites fluid concern for microperforation versus peritonitis, especially with dilated loops of bowel. the patient had c. difficile times three which remained negative and were stable. the patient's flagyl was discontinued. the patient also had a ct, as described above. however, as the patient was n.p.o. and concerned for microperforation, tube feeds were held and the patient was started on ppn and had a stable lumen picc placed and eventually his peritonitis and small bowel improved. 8. code: the patient's family was updated daily with progress and prognosis in terms of the patient's condition. eventually, at the time of discharge from the icu after a family meeting on , it was decided that the patient should be dnr/dni with no pressors and no icu stays. however, continue supportive care in terms of fluid boluses and family is still to be updated daily on any changes and on progress and will continue to treat infection and hypotension as previously. will continue with physical therapy and supportive comfort care. 9. nutrition: the patient's ppn was discontinued once his small bowel dilatation seemed resolved and he was started on tube feeds through his ng tube to be titrated up slowly. the patient's albumin was most recently 2.1, consistent with his poor nutrition and chronic disease. will continue tube feeds and try to improve the patient's nutritional status as possible. the remainder of the hospital course to be dictated at the time of discharge. , m.d. dictated by: medquist36 procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube percutaneous abdominal drainage arterial catheterization diagnoses: alcoholic cirrhosis of liver unspecified septicemia sepsis pulmonary collapse acute respiratory failure chronic obstructive asthma, unspecified hepatic encephalopathy 

Answer: The patient is high likely exposed to