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: coumadin attending: chief complaint: variceal bleed, brbpr major surgical or invasive procedure: tips balloon history of present illness: 84 y.o male with pmhx of cryptogenic cirrhosis presenting with gastric/esophageal variceal bleeding from . his admission hct was 25.5, he was noted to have bright red blood per rectum (admitted today ) and was initially hemodynamically stable. his hemodynamics worsened and he had increased brbpr. hct nadir was 22, and he got 3 units of prbc, 1 units ffp, 1 unit of plt at and in . egd at revealed avm's, esophageal/gastric varices with esophageal varices being injected with epinephrine. copious amounts of blood was noted in the esophagus and stomach. the patient was started on levophed.he is on home pradaxa for hx of a fib with last dose per family given around 20 hours ago. he was also given 1 unit of factor 9, 4 liters of fluid. . he was noted to have noted to have a wbc ct of 27.2 at , he was started on vanco/zosyn and a paracentesis was performed showing: 557 wbcs, 16% polys. 53% monos, 22% other, rbcs. he was intubated at prior to transfer. he was also noted to have aspirated during intubation. on arrival to the micu, the patient is intubated, unresponsive with stable hemodyanmics. was placed with the ge junction baloon inflated but not the esophageal baloon itself. review of systems: cannot be obtained given intubated status (+) 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: 1. hypertension. 2. sick sinus syndrome with atrial fibrillation status post permanent pacemaker, and off coumadin for gastrointestinal bleed, now on pradaxa. 3. complications of pacemaker insertion in the past history. 4. fatty liver disease. 5. cryptogenic cirrhosis with portal hypertension and varices. 6. upper gastrointestinal bleed from av malformations in the duodenum in . most recently noted a duodenum avm which is likely source of the current gastrointestinal bleed. 7. chronic anemia, bone marrow suppression, baseline hematocrit is low.previously darbepoetin dependent. 8. prostate cancer status post radiation therapy. 9. colon cancer status post colectomy incompletely, this is now treated. 10. neuroendocrine tumor of the liver diagnosed in per dr. and dr. at . 11. orthostatic hypotension. 12. benign prostatic hypertrophy. 13. hypothyroidism. 14. cataracts. 15. rotator cuff repair. 16. status post inguinal hernia. 17. diverticulosis. 18. asthma. social history: lives independently with his wife here in assisted-living facility. he is an professor. he stopped smoking 40 years ago. has a 30 pack year history of smoking. takes 2 ounces of alcohol a week. he uses a cane to ambulate. family history: father had a stroke at age 63, mother died of unknown causes at 83. physical exam: admission exam: vitals: t:99.0 bp: 90/40 p:65 r:12 18 o2:99% intubated cmv fio2 100% general: alert, intubated, unresponsive heent: sclera anicteric, neck: supple, jvp not elevated, no lad , 2 central lines in rihgt ij cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: no wheezes, rales, insp and exp ronchi diffusely abdomen: soft, distended, bowel sounds hypoactive diffusley, has large llq soft 4cmx5cm mass could be hernia . surgical scar midline. gu: foley yellow urine ext: warm, well perfused, 1+ pulses b/l, no clubbing, no cyanosis or 2+ pitting edema in left lle up to knee, nonpitting edema on rle. neuro: pupils 3mm b/l sluggish reactivity to light discharge exam: t-98.4 bp-110/53 hr-67 rr-20 o2-96%ra general: oriented x3. conversive and responds to questions. joking about politics heent: sclera anicteric. mmm neck: supple, no jvp cv: rrr. ns1&s2. holosystolic murmur at apex lungs: ctab. good air flow. abdomen: non-tender. soft, mildly distended, bs+4, has large llq soft 4cmx5cm mass could be hernia. surgical scar midline, well healed. ext: rue asymmetrical edematous compared to lue. warm, well perfused, 1+ pulses b/l, no clubbing, no cyanosis. 1+ pitting edema of all extremities. 20g iv in right hand. neuro: pupils 3mm b/l reactive to light, confused. baseline ptosis of l eyel skin: multiple echymotic lesions of torso, and extremities pertinent results: admission labs: 05:30pm blood wbc-31.6*# rbc-3.36* hgb-10.7* hct-32.4* mcv-96 mch-31.8 mchc-33.0 rdw-20.5* plt ct-127* 05:30pm blood neuts-70 bands-9* lymphs-3* monos-18* eos-0 baso-0 atyps-0 metas-0 myelos-0 05:30pm blood pt-13.2* ptt-29.2 inr(pt)-1.2* 05:30pm blood glucose-150* urean-36* creat-1.0 na-141 k-4.4 cl-110* hco3-22 angap-13 05:30pm blood alt-29 ast-45* ld(ldh)-253* alkphos-96 totbili-1.6* 05:30pm blood albumin-3.0* calcium-7.6* phos-4.8* mg-1.9 06:11pm blood lactate-1.2 06:11pm blood freeca-1.03* discharge labs: 06:25am blood wbc-9.0 rbc-3.02* hgb-9.6* hct-30.3* mcv-100* mch-31.8 mchc-31.6 rdw-19.6* plt ct-165 05:15am blood neuts-67 bands-1 lymphs-5* monos-20* eos-0 baso-0 atyps-0 metas-7* myelos-0 nrbc-1* 06:25am blood pt-13.2* ptt-42.0* inr(pt)-1.2* 06:25am blood glucose-97 urean-17 creat-1.0 na-139 k-4.1 cl-107 hco3-26 angap-10 06:25am blood alt-58* ast-76* alkphos-208* totbili-0.8 06:25am blood calcium-8.5 phos-3.2 mg-1.8 other labs: 06:31am blood vitb12-1744* folate-14.2 07:30pm blood tsh-7.6* 03:53am blood tsh-0.91 07:30pm blood free t4-1.1 03:06am blood fibrino-200 04:35am blood fibrino-183 04:31am blood %hba1c-5.4 eag-108 12:07am blood lactate-1.3 calhco3-25 05:44pm blood freeca-1.11* 10:35 am urine site: catheter source: catheter. **final report ** urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- =>16 r vancomycin------------ =>32 r imaging: cxr : the device is in place. the tip of the device is not visualized. there is an endotracheal tube with its tip projecting approximately 7 cm above the carina. a right internal jugular venous introduction sheath and right internal jugular catheter is in situ. moderate parenchymal opacity in the left perihilar lung areas. mild atelectasis at the left lung base. minimal atelectasis at the right lung base, otherwise unremarkable right lung. borderline size of the cardiac silhouette. left pectoral pacemaker with correct position of the wires. abd u/s dopp : 1. multiple right and left lobe hepatic masses consistent with metastatic disease. 2. extensive non-occlusive portal thrombosis in the right, left and main portal veins extending to the smv. cxr : the fundic balloon, previously inflated in standard position, has now been deflated. the tube has not migrated in position. et tube, right internal jugular line and introducer are in standard placements. transvenous right atrial pacer lead in standard placement. ventricular lead has a relatively short ventricular excursion and may not be accurate. right basal edema has improved. considerable left perihilar consolidation, presumably aspiration pneumonia, is unchanged. no pneumothorax or appreciable pleural effusion is present. heart size is normal. doppler le: no evidence of deep thrombosis. the deep peroneal veins are not visualized. cxr : since the prior study there has been slight interval improvement in pulmonary edema which is still present associated with bilateral large pleural effusions and bibasal atelectasis. ng tube tip is in the stomach. et tube tip is in unchanged appropriate position. apices were not included in the field of view. echo : suboptimal image quality. normal biventricular cavity sizes with preserved global biventricular systolic function. moderate tricuspid regurgitation. pulmonary artery hypertension. mild mitral regurgitation abd doppler : patent tips shunt. nonocclusive thrombus is seen within the main portal and in the left portal . multiple hepatic masses are again seen throughout the liver consistent with metastatic disease as was seen on prior imaging. scant trace of ascites seen in the right upper quadrant. the study and the report were reviewed by the staff radiologist rue venous u/s : nonocclusive thrombus in the right internal jugular . nonocclusive thrombus in the right cephalic . ct head : no acute intracranial process. brief hospital course: 84 yo m with pmh cyptogenic cirrhosis and afib who presented with variceal bleeding, hypotension, and leukocytosis. intubated and sedated upon arrival from osh. bleed stabilized in icu with and tips. transferred from icu to floor. noted to have multiple ue clots, and started on lovenox. egd positive for bleeding avm x5, s/p ablation. course c/b by ams thought to be icu delirium . active issues: # variceal bleed: hct drop down to 22 at . received 1 unit prbcs after transfer to . balloon placed to stabilize bleed in micu. pt underwent tips on and portal thrombectomy also done for non-occlusive clot present. hct stabilized after tips and removed the next day. pt had large bm with blood of varying shades mixed in on . his hct did not drop but he was given 1 unit prbc to be safe. hct remained stable with no further bleeding noted in house. treated with ctx 1g daily for 7 days for prophylaxis. transferred to floor after hct stable. egd several days after initial bleed significant for grade 2 non-bleeding esophageal varices and several oozing gastric avm's. ablated 5 avm on repeat egd. pt had already undergone tips, so nadolol not given. discharged with stable hct. . # aspiration pna: pt noted to have aspirated during intubation at osh. treated with clindamycin and ctx x7 days for presumed aspiration pna and infection ppx as above. resolved by the time he wsa on the floor, and pt had no additional cough, purulent sputum or fever . # multiple thrombi and h/o pe: on pradaxa which was stopped due to gib. obtained lle doppler to r/o dvt and it was negative. pt developed asymmetrical edema of lue while on the floor. u/s demonstrated non-occlusive thrombi of rij and cephalic . although pt had recent h/o gib, decision made to place on chronic anticoagulation as chance of stroke or other embolic/thrombotic event very high. pt is allergic to coumadin and pradaxa irreversible, so started on lovenox 90mg . monitored for worsening of gib for several days prior to discharge and hct remained stable. . #leukocytosis: elevated between 20-40 throughout icu stay despite treatment of pna, sbp ppx, and resolution of gib. had diagnostic para at osh which had high wbc count but not enough pmn to satisfy criteria for sbp. c. diff neg during admission. contact oncologist who reproted a baseline wbc of 4 in this pt. heme/onc was consulted and believed that given the acuity in onset, this represented leukemoid reaction rather than malignancy/dyscrasia. wbc monitored throughout stay, and gradually trended down. wbc of 9 on discharge. . # hypoxia: intubated at osh. extubated on . several liters up at that time aggressive volume resuscitation and was also being treated for pna, which were the likely causes of his hypoxia. also had bilateral pleural effusions. diuresed with lasix and resp status improved. abx as above. obtained echo to eval cardiac function in setting of effusions and it showed "normal biventricular cavity sizes with preserved global biventricular systolic function. moderate tricuspid regurgitation. pulmonary artery hypertension. mild mitral regurgitation." he was satting in high 90s on face tent at time of transfer out of micu. hypoxia resolved on the floor after lasix administration . #vre bacteruria: pt grew vre from urine several times, however, symptom free and ua not suspicious for infection. treated this as contaminant after consulting id and confirming this does not need treatment. . chronic issues: #cryptogenic cirrhosis: s/p tips as above. started lactulose and rifaximin for ppx against hepatic encephalopathy. mental status waxing and after extubation but he was oriented for the most part with some mild confusion. per wife pt had been confused a lot at home prior to procedure. at time of calloout pt aa&ox3. shortly after hitting the floor he became very agitated/confused and oriented x0. would attempt to pull out iv lines and drains. temporarily placed in restraints, for several hours at a time. full encephalopathic workup was negative. likely component of hepatic encephalopathy in setting of new tips. delirium resolved after 3-4 days of hitting the floor. thought to have component of icu delirium. . # afib: off diltiazem on admission due to bleeding. went into afib with rvr to 140s on and became hypotensive to sbp 80s while in rvr. at same time was more agitated, hypoxemic to mid 80's on psv. converted spontaneously back to nsr once restarted on home diltiazem dosing. pressures normalized at that time as well. this happened again on (rvr to 150s + hypotension to sbp 80s). he was asymptomatic at that time. interrogated pacer and it was normal. tsh wnl. went into one additional episode of afib w/rvr on the floor with hypotension, however, reverted to nsr after 5mg metoprolol iv x3. was in nsr at time of discharge. . #chf: history of ?diastolic chf. volume overloaded in the icu and started on iv lasix on floor. became euvolemic and continued on home dose of lasix. echo on demonstrated ef >60% . # bph finasteride held in setting of bleeding and hypotension. no urinary retention throughout inpatient course. should be re-evaluated upon discharge. . transitional issues: #be aware of vre colonization #needs -weekly monitoring of electrolytes and hct to ensure stability #continue lovenox. #follow up with gastroenterology/hepatology medications on admission: lasix 20 mg levothyroxine 150mg daily vit d 2000mg daily nadolol 20mg daily lipitor 5mg daily prilosec 20mg metamucil 1 teaspoom daily zantac 300mg daily finasteride 5mg daily iron asa 81mg daily pradaxa 150mg daily calcium citrate advair 2/500 daily diltiazem 240mg daily discharge medications: 1. enoxaparin sodium 90 mg sc q12h 2. diltiazem 60 mg po q6h hold for sbp<100 3. ferrous sulfate 325 mg po daily 4. furosemide 20 mg po bid 5. lactulose 30 ml po q8h notify md < 0 after 6 hours. if improvement, ask md to change to tid dosing. if not, discuss converting to enemas q2hrs 6. levothyroxine sodium 150 mcg po daily 7. multivitamins 1 tab po daily 8. rifaximin 550 mg po bid 9. pantoprazole 40 mg po q12h 10. atorvastatin 5 mg po daily 11. artificial tear ointment 1 appl both eyes prn dry eyes 12. fluticasone-salmeterol diskus (250/50) 1 inh ih daily discharge disposition: extended care facility: for the aged - macu discharge diagnosis: primary diagnosis: bleeding gastric arteriovenous malformations cryptogenic cirrhosis atrial fibrillation w/ rapid ventricular response congestive heart failure internal jugular venous thrombus thrombophilia altered mental status discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure caring for you at . you were admitted to the intensive care unit from an outside hospital. you had extensive bleeding from your stomach and esophagus. you were transfused several units of blood and a balloon was temporarily placed in your esophagus to prevent further bleeding. to take some of the pressure of your esophageal veins, a shunt was made that connects your portal to your jugular , that blood doesn't pool behind your cirrhotic liver. after you stopped bleeding you were sent to the - service where you were monitored for several days we took a small camera to look at your esophagus and stomach. we gound several sites of bleeding in your stomach. these were destroyed with a laser. you may have more sites of bleeding i your colon or bowel that we could not find with the camera we used. we also found several nodules on your esophagus. this should be followed up by the liver doctor. you have an appointment scheduled for this. several clots were detected in your veins. this can be life-threatening because the clots could move to your heart or brain. we started you on lovenox to stop these clots from worsening. you will need to take this twice a day. you had several episodes of atrial fibrillation that resulted in temporary lowering of your blood pressure. this was treated with iv medication. your home diltiazem was continued in-house and should be continued when you leave. medication changes stop nadolol stop omeprazole stop dabigatran stop finasteride start pantoprazole (to prevent intestinal bleeding) start rifaximin (to prevent encephalopathy) start lactulose (to prevent encephalopathy) start enoxaparin ( to treat blood clot) followup instructions: name: , address: ,, , phone: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. name: , when: wednesday at 1:45pm address: , , phone: md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours other endoscopy of small intestine enteral infusion of concentrated nutritional substances percutaneous abdominal drainage endoscopic control of gastric or duodenal bleeding other endovascular procedures on other vessels injection of anesthetic into spinal canal for analgesia intra-abdominal venous shunt insertion of sengstaken tube phlebography of the portal venous system using contrast material phlebography of the portal venous system using contrast material central venous catheter placement with guidance diagnoses: anemia, unspecified esophageal reflux congestive heart failure, unspecified toxic encephalopathy unspecified essential hypertension cirrhosis of liver without mention of alcohol portal hypertension unspecified acquired hypothyroidism atrial fibrillation personal history of malignant neoplasm of prostate asthma, unspecified type, unspecified personal history of tobacco use hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) acute respiratory failure pneumonitis due to inhalation of food or vomitus other shock without mention of trauma personal history of malignant neoplasm of large intestine cardiac pacemaker in situ other ascites anticoagulants causing adverse effects in therapeutic use esophageal varices in diseases classified elsewhere, with bleeding hyperosmolality and/or hypernatremia personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health diverticulosis of colon (without mention of hemorrhage) leukocytosis, unspecified chronic diastolic heart failure angiodysplasia of stomach and duodenum with hemorrhage nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] portal vein thrombosis personal history of pulmonary embolism angiodysplasia of intestine (without mention of hemorrhage) acute venous embolism and thrombosis of internal jugular veins acquired absence of intestine (large) (small) euthyroid sick syndrome acute venous embolism and thrombosis of superficial veins of upper extremity malignant carcinoid tumor of other sites secondary neuroendocrine tumor of liver 

Answer: The patient is high likely exposed to