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: penicillins / zocor / ace inhibitors attending: chief complaint: biliary obstruction major surgical or invasive procedure: endoscopic retrograde pancreaticogram (ercp)x 2 endoscopic ultrasound transjugular liver biopsy history of present illness: the patient is a 59 year old male with a history of cad, moderate to severe mitral regurgitation, paroxysmal atrial fibrillation not on coumadin, hodgkin's disease in remission, hypercholesterolemia, hypertension, and ventricular tachycardia s/p icd implant in . he was transferred from for possible ercp after having an elevated tbili and ruq ultrasound showing borderline intrahepatic biliary dilation and borderline cbd dilation 6 cm. . he was recently discharged home from rehab on after a one month stay following a brief hospitalization for a chf exacerbation. on the day he returned home, he developed severe bilateral neck pain and stiffness which prompted him to present to the ed. the pain was constant, worsened with palpation or head movement, and not exertional. on exam in the ed, it was localized to the scm muscles and thought to be muscle spasm. he was given ativan 5 mg po x2 and tylenol 975 mg po. his neck pain improved, and he was about to be discharged, but he became hypotensive with sbp down to 66/34. he was given iv fluids with improvement in his pressures. he was found to be guaiac positive and his hct was down about 6 points from his prior admission. labs showed creatinine 1.5, hct 27.3, and d-dimer 906. there was concern for both pe and gi bleeding, so he was admitted. . he had a v/q scan on which was negative. he was transfused a total of 3 units prbcs with his hct remaining at 34-35 afterwards. cardiology felt that his troponin leak was due to demand ischemia. he had several episodes of rapid afib requiring rate control. he did report some chest pain during one episode, and noted that he had been having intermittent chest discomfort over the last few weeks at rehab which was attributed to gerd. his blood pressure was labile and would drop to the 80s-90s systolic at night. . labs on showed alt 51, ast 33, alk 75, tbili 4.4, dbili 3.4, and inr 1.7 not on coumadin. subsequent abdominal us on showed borderline intrahepatic biliary dilation and cbd dilation 6.5 mm. abdominal ct on showed stranding and inflammatory changes adjacent to the pancreatic head. he denied any abdominal pain or other gi symptoms, but did note several days of diarrhea at rehab ust before discharge which was worked up for c diff but negative. mrcp was not possible due to his icd. he was treated with empiric flagyl and levofloxacin given the concern for colitis noted on ct. he was transferred to for further evaluation and possible ercp. prior to transfer, he reportedly looked clinically well. . once in the icu, he reported feeling fairly well with few specific complaints besides his chronic medical issues. he reports that the neck pain that initially brought him to has completely resolved. he has not noticed any bloody, black, or tarry stool. he does not have any abdominal pain or recent change in bowel habits. he denies any chest pain, pressure, palpitations, cough, or sob. he denies any lightheadedness or dizziness. he has chronic lower extremity edema which he thinks is slightly increased from baseline. he has several decubitus ulcers which developed during his recent rehab stay. he denies ever having similar skin issues in the past. he has chronic weakness of the left arm from his inclusion body myositis. . 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 new arthralgias or myalgias. denies rashes or skin lesions except as above. past medical history: # cad # ptca at () -- des to rca # ventricular tachycardia s/p icd implant () # atrial fibrillation # paroxysmal svt # mitral regurgitation () # hypertension # hypercholesterolemia # rhematoid arthritis () -- treated with methotrexate # hodgkin's lymphoma s/p chemo and radiation () -- currently in remission # shingles () # inclusion body myositis () -- weakness primarily of left arm # left foot and ankle fusions social history: he is single and lives alone. he is not currently working. he uses a walker or motorized wheelchair at baseline. his home is handicap accessible. he was recently in rehab and had returned home on the day of his admission to osh. # tobacco: quit in , previously smoked 1 ppd # alcohol: occasional social alcohol # illicits: none family history: # father: died from leukemia when patient was 5 years old # mother: stroke at age 89, lived to age # maternal grandfather: heart disease and died at age 84. physical exam: admission physical exam: vitals: t 97.7, bp 122/83, hr 102, rr 19, spo2 100% on ra general: alert, oriented, no acute distress, pleasant heent: sclera anicteric, no conjunctival injection, eomi, perrl, mmm, oropharynx clear neck: supple, full rom, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular tachycardia, soft s1 and s2. blowing holosystolic murmur at llsb and apex. abdomen: bowel sounds present. resolving ecchmoses at heparin injection sites. soft, non-tender, non-distended. no rebound tenderness or guarding. no organomegaly. gu: no foley ext: warm, well perfused. digital cap refill ~2 sec. lower extremity edema 2+ bilaterally. dp pulses 1+ bilaterally. left arm weakness. deformity of left foot. skin: folliculitis of back and trunk. decubitus ulcers. *** exam on discharge: -- continued to have 2+ lower extremity edema, though improved, also has had + left upper extremity edema, though also improved pertinent results: tte (complete) done conclusions the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with normal free wall contractility. there is abnormal septal motion/position (suggestive of rv pressure overload). 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 probably mitral valve prolapse (not well seen but suggested). an eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is at least mild pulmonary artery systolic hypertension. there is no pericardial effusion. venous dup upper ext unilateral left study date of impression: no left upper extremity deep vein thrombosis liver or gallbladder us (single organ) study date of impression: 1. patent hepatic and mesenteric vasculature as described above. 2. gallbladder adenomyomatosis. 3. coarsened hepatic echotexture suggests underlying parenchymal disease. 4. bilateral pleural effusions. ct abd & pelvis with contrast study date of impression: 1. no evidence of hepatic lesion. 2. indistinct lobulated appearance of the pancreatic head may represent focal pancreatitis (correlate with labs), differential diagnosis includes cystic neoplasm such as ipmn ; correlation with prior imaging is recommended and mr may be considered if further work-up is indicated. 3. enlarged right iliac lymph node with calcification consistent with treated lymphoma, thus no evidence for recurrence. however, comparison with prior studies would be helpful to deternime stability. ercp (): impression: biliary stricture in the lower third of the cbd. otherwise normal cholangiogram. a biliary stent was placed. moderate esophagitis in the gastroesophageal junction eus (): impression: eus: fatty pancreas, but no evidence of pancreatic mass lesion or chronic pancreatitis. stent in the cbd without adjacent mass seen. small amount of peri-gastric ascites was noted. ercp (): impression: biliary stent in good position appropriately draining bile. normal limited cholangiogram through the stent. no cause of rising bilirubin found. liver biopsy pathology: 1. mild canalicular and hepatocellular cholestasis with focal bile duct damage and proliferation with associated neutrophils (immunostains for cytokeratins ae1/ae3 and cytokeratin 7 are examined to better highlight biliary epithelium). 2. mild mixed steatosis with focal ballooning degeneration; no intracytoplasmic hyalin seen. 3. minimal lobular mixed inflammation including lymphocytes, neutrophils and rare eosinophils. 4. mild sinusoidal fibrosis demonstrated with trichrome stain without portal fibrosis. 5. no stainable iron on iron stain. 6. red stain for amyloid is negative. brief hospital course: 60 yo man with chf, ra with hx of methotrexate, cad, vt s/p icd, admitted from rehab for neck pain, found to be hypotensive, went to icu where he was found to have anemia and cbd stricture and significant lft abnormalities. . # acute hepatitis with hyperbilirubinemia/multiple lft abnormalities: he was noted to have an elevated conjugated bilirubin during his osh stay, with workup showing intrahepatic ductal dilatation and a borderline dilated common bile duct. ct abdomen showed inflammatory changes adjacent to the pancreatic head as well as abnormal wall-thickening of the ascending and proximal transverse colon which may reflect colitis. mrcp could not be performed due to the patient's icd and he was transferred to for possible ercp. ct scan showed "indistinct lobulated appearance of the pancreatic head may represent focal pancreatitis (correlate with labs), differential diagnosis includes cystic neoplasm such as ipmn ; correlation with prior imaging is recommended and mr may be considered if further work-up is indicated." ercp at showed a biliary stricture in the lower third of the cbd concerning for malignancy. sphincterotomy and brushings were not performed at that time given clinical instability. a stent was placed however. after stent placement, his bilirubin (total and direct) continued to rise. repeat ercp/eus on showed a patent stent and no evidence of pancreatic mass or chronic pancreatitis. ciprofloxacin and flagyl had been given empirically given the colitis and biliary involvemnt, these were stoppped on . mtx was held given his acute liver dysfunction; this may be restarted prn as an outpatient. a ct abdomen was performed, which did not show any evidence of recurrence of his lymphoma, and did not reveal an etiology of his liver dysfunction. . repeat ercp is scheduled for later this month for stent removal. eus with brushings/biopsy will be done at that time to evaluate for malignancy as etiology of the stricture. . the liver service was consulted and patient underwent transjugular liver biopsy on . pathology results revealed a cholestatic injury. the results of the biopsy were discussed with the ercp team as well as the liver service. the exact cause of his liver dysfunction is not completely clear but it is likely that much of his liver injury was from the biliary stricture itself, with possible contribution from drug injury, specifically from antibiotics that he received at the outside hospital. the liver specialists feel confident that methotrexate was not at fault and they do not think that mr. is contraindicated from receiving methotrexate in the future. . # gi bleeding: his hct was reportedly 27.3 on presentation to osh with guaiac positive stool. because of his nstemi /demand ischemia with troponin leak, he was transfused prbcs for a goal hct >30 and remained stable during the remainder of his stay at the outside hospital. his hct on arrival to was 34.7 without evidence of frank bleeding. ercp showed evidence of esophagitis, which may explain the patient's anemia and guaiac positive stools. he will need repeat outpatient egd at some point to re-assess esophagitis. he will also need an outpatient colonoscopy to evaluate his anemia with guaic positive stool. his hematocrit again drifted down to 25 and he received 1 unit of packed red blood cells during his stay at . his hematocrit remained stable after this transfusion. . # rheumatoid arthritis: the patient has a history of rheumatoid arthritis and was on nsaids and methotrexate at the time of admission to the hospital. these were held in the setting of his acute illness. in this setting, he developed increasing severe left hip pain; which improved with physical therapy. his methotrexate may be restarted on an outpatient basis. he should follow up with his rheumtologist upon discharge from rehab. . # leukocytosis: the patient was noted to have leukocytosis to 13 on . blood and urine cultures were drawn and stool was sent to c. diff. the leukocytosis resolved by ; no etiology was found. . # coagulopathy: he was noted to have an elevated inr 1.7-2.0 without anticoagulation. he was given vitamin k at osh without significant improvement in his inr. fibrinogen was checked given concern for a consumptive coagulopathy, but the level was high, which would not be consistent with such a process. the cause of his coagulopathy is unclear, but the lack of response to vitamin k suggests a synthetic defect in the liver or an acquired condition such as antiphospholipid antibody syndrome or factor inhibitor. 2 units of ffp were administered prior to ercp per ercp team request. ultimately, his inr did normalize and was normal at the time of discharge. suspect, the elevated inr was due to acute liver dysfunction. . # metabolic acidosis: he was noted to have a non anion gap metabolic acidosis at osh with bicarb . subsequent abg showed partial compensation. the etiolology of his acidosis is unclear, as the patient denies any diarrhea or vomiting. medication effect or renal tubular acidosis is a possibility. his serum bicarb gradually improved and stabilized and was within normal limits at the time of discharge. . # cad/ demand ischemia/ nstemi: he has a significant history of cad with des to the rca in . he had several episodes of rapid afib at osh with mild troponin elevation to 0.16 and to 0.36 which were thought to be from demand ischemia. he denied any chest discomfort or palpitations during his stay. patient was monitored on telemetry and his troponin was trended and found to decrease. asa was continued. atenolol was changed to metoprolol. no statin given acute hepatitis. patient appears to have a history of intermittent rbbb. . # hypotension: he was hypotensive to the 60s systolic on presentation to osh, with improvement after receiving blood and iv fluids. his bp continued to be labile, however, with bp dropping to the 80s-90s at night. he was transferred with a regimen of atenolol 12.5 mg po bid and losartan 12.5 mg po daily with strict holding parameters. his bp continued to be labile, dropping to the 60s systolic while sleeping, but increasing back to the 110s when awakened. bps were closely monitored through the day, and he maintain sbps 110s, with maps ranging from 70-90. his home anti-htnsive were held and he was given multiple ivf boluses to maintain bp in the early part of his hospitalization. his am cortisol level was normal and tte showed an ef of 50-55% (though has diastolic dysfunction). ultimately, his blood pressure stabilized, however, and he tolerated continued beta blockade as well as diuretics (see below). . # atrial fibrillation: he was in sinus rhythm on arrival to with rate ~100 bpm. he had several episodes of afib with rvr while at osh leading to demand ischemia as discussed above. asa 325 daily was continued while in the medical intensive care unit. patient was intermittently in afib w/rbbb while in the icu, requiring iv lopressor for rate control. he was evaluated by cardiology on due to recurrence of afib with rvr. he was treated with iv metoprolol, which was subsequently transitioned to oral metoprolol with good hr control. it was decided to not anticoagulate him given the risk for gi bleeding. he eventually converted to nsr, and he was continued on metoprolol to help suppress ectopy. . # peripehral edema- the patient developed significant edema in his lower extremities followed by his left arm. this was likely multifactorial--he appeared to have low oncotic pressure (albumin low of 2.2) and received large amounts of iv fluids due to his low blood pressure, he also has a history of right sided heart failure. as his blood pressure gradually stabilized, he was carefully started on low dose lasix with good diuresis. lasix was gradually increased in dose and frequency to , and his edema gradually improved. he continues to have significant edema at the time of discharge and he should continue to receive diuretics. renal function should also be closely monitored with his diuresis. . ***transitional issues **** -- will require outpatient colonoscopy and endoscopy in the near future -- f/u with ercp team for removal of stent, eus to evaluate ?pancreatic head mass, and brushings of stricture later this month -- continued diuresis medications on admission: medications on transfer: metronidazole 500 mg iv q8h levofloxacin 500 mg iv q24h acyclovir 400 mg po bid aspirin 325 mg po daily atenolol 12.5 mg po bid losartan 12.5 mg po daily nitroglycerin 0.4 mg sl prn duoneb (2.5-0.5 mg) q4h prn sob fluticasone propionate nasal spray daily methotrexate 17.5 mg po weekly on saturday leucovorin 5 mg po weekly 8-12 hours after methotrexate citalopram 10 mg po daily neurontin 100 mg po bid buspar 5 mg po tid pantoprazole 40 mg po bid multivitamin 1 tab po daily discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day) as needed for constipation. 3. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 4. buspirone 5 mg tablet sig: one (1) tablet po tid (3 times a day). 5. gabapentin 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. ranitidine hcl 150 mg tablet sig: two (2) tablet po bid (2 times a day). 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 8. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). 9. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. tablet, delayed release (e.c.)(s) 10. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp<90. 11. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 12. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 13. outpatient lab work check cbc, bmp, ast, alt, alk phos, t , pt/inr every tuesday and thursday. results to md on call. 14. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. discharge disposition: extended care facility: nursing & therapy center - ( center for rehabilitation and sub-acute care) discharge diagnosis: hypotension atrial fibrillation cad with nstemi bile duct obstruction due to common bile duct stricture acute hepatitis ?pancreatic head mass anasarca/edema discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were transferred from an outside hospital due to need for an ercp. you had low blood pressures at the outside hospital as well as here in the beginning of your admission; these improved as you got better. you also had a rapid heart rate with atrial fibrillation, this was likely due to being ill. there was a blockage of your bile duct and the ercp team opened this area up with a stent. they went back a looked a second time to make sure this remained open since your bilirubin was going up and it remained open. they also looked at your pancreas and did not see evidence of chronic pancreatitis. at the outside hospital you had a decrease in your red blood cell count and were found to have microscopic blood in the stool. you should have a colonoscopy and repeat upper endoscopy as an outpatient. you underwent a liver biopsy, which showed cholestatic injury, likely due to the stricture mentioned above, perhaps with a contribution of a drug injury. you have an appointment with the ercp doctors (listed below) for repeat ercp. it is very important to keep this appointment for stent removal, endoscopic ultrasound, and brushings to check for cancer. you had a lot of swelling of your legs and left arm and this was likely from all the fluids you received when your blood pressure was low. this improved with medicines to make you urinate. you still have a lot of extra fluid and this will need to be removed with ongoing diuresis when you are at the rehab facility. followup instructions: ** you will need to get an endoscopy and colonoscopy by your gastroenterologist for anemia with blood in your stool. ** ** you will need to see your primary care doctor when you are discharged from the rehab facility ** ** ercp follow-up ** department: endo suites when: thursday at 8:00 am department: digestive disease center when: thursday at 8:00 am with: , md building: building (/ complex) campus: east best parking: main garage procedure: endoscopic sphincterotomy and papillotomy endoscopic insertion of stent (tube) into bile duct endoscopic retrograde cholangiopancreatography [ercp] transjugular liver biopsy diagnoses: acidosis coronary atherosclerosis of native coronary artery pure hypercholesterolemia mitral valve disorders congestive heart failure, unspecified unspecified essential hypertension acute and subacute necrosis of liver acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) atrial fibrillation hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites automatic implantable cardiac defibrillator in situ rheumatoid arthritis esophagitis, unspecified obstruction of bile duct chronic diastolic heart failure other acute and subacute forms of ischemic heart disease, other inclusion body myositis 

Answer: The patient is high likely exposed to