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: no known allergies / adverse drug reactions attending: chief complaint: gi bleed major surgical or invasive procedure: left internal jugular central vein line placement history of present illness: mr. is a 46 year old gentleman with a pmh etoh cirrhosis c/b multiple prior ugibs and past possible hrs, continued alcohol abuse c/b seizures, ckd (had been on hd until ), now being transferred from for management of hypovolemic shock secondary to gi bleed, and possible tips procedure. history obtained from omr and osh records, as well as conversation with icu nurse, as patient is intubated and sedated. girlfriend reported to osh that patient had filled four "buckets" of bloody emesis at home, and was then convinced to go to the ed at on . on arrival, patient was only able to speak in short sentences, but was making little sense. vs on arrival were bp 91/37 hr 160 rr 20 (temperature and sao2 not recorded). he became obtunded, and was intubated shortly thereafter, with fentanyl boluses, followed by propofol drip. labs were notable for: h/h 2.8/8.2, plts 64, cr 3.9, inr 2.6, urine tox positive for oxycodone, etoh level 238, and ucx with 100,000 coag negative staph. og tube was placed, and this prouced another container full of bloody emesis. massive transfusion protocol was initiated in the ed, and patient was given 4 units ffp, 2 units of prbc and 4 liters of ns. egd that evening showed erosive esophagitis, barrett's esophagus, coffee grounds in stomach, and a suggestion of duodenal varices. gastroenterologists at hypothesized that the patient may have been chronically bleeding from his esophagitis/varices, as they could find little evidence of active bleeding. during his admission at , he received a total of 10 units prbcs, 7 units ffp, and two 6-packs of platelets. he was kept on octreotide drip (began ) and pantoprazole 40 mg iv bid (). he was also treated with zosyn for possible aspiration pneumonia (starting on ). for sedation, he was kept on propofol for sedation with lorazepam iv boluses as needed. prior to transfer to labs h/h , and plt 25 @ 1200 today. for access, he had a right triple lumen cvl and a left a-line. he also had an og tube, and fully matured rue av fistula (not used since /). he was transferred to for further management, including possible capsule endoscopy, balloon enteroscopy and/or tips. on arrival to the micu, patient was intubated and sedated, but appeared comfortable. past medical history: 1. multiple admissions to for upper and lower gi bleeds. most recently at ugib, admitted : transfused 9u prbc, 8u ffp and 10u plts. no noted varices on egd . thought to be secondary to erosive esophagitis. 2. etoh cirrhosis: acute etoh hepatitis in (was not started on corticosteroids due to gi bleed, uti and ); was started on pentoxyphyline to prevent hrs with a planned 4 week course from (last day ); negative hepatitis a, b and c serologies. complicated by gi bleeds as above in the past (but no varices), and possible history of hrs. 3. ckd: cr baseline around 3.0. was hd-dependent via rue fistula until . diagnosis was multifactorial from atn +/- nsaids +/- hrs 4. mrsa bacteremia treated with vancomycin 5. etoh abuse with h/o seizures in the setting of heavy alcohol consumption 6. gastroesophageal reflux disease 7. mva : right femur fracture with placement, pelvic fracture 8. asthma social history: has never smoked. drank vodka daily until recently, but denies drinking in the past 4 months (last drink first week of ). never has used iv drugs. lives with girlfriend, . has 2 children, daughter 17, son, 16 who live with their mother who the patient is still very close to. pt formerly worked at mass electric. family history: mother - deceased alcoholic liver disease father - deceased cancer, diagnosed in his 40s. no other family history of cancer. physical exam: admission physical exam vitals: t: 97.8 nbp: 100/56 abp: 136/66 p: 74 r: 18 sao2: 100% on ac tv 500 rr 12 fio2 50% peep 5 general: intubated/sedated, appears comfortable heent: scleral icterus, perrl, no head trauma. neck: unable to assess jvp due to habitus. right ij in place without surrounding hematoma or erythema. cv: regular rate and rhythm, normal s1/s2, ii/vi systolic murmur loudest at the llsb. lungs: upper airway sounds of ventilation transmitted throughout. breath sounds throughout anterior lungfields. abdomen: distended with tense subcutaneous edema worse on flanks bilaterally. unclear whether distention is primarily from anasarca vs. underlying ascites. unable to assess for hepatosplenomegaly due to distention. slight erythema on lower abdomen. minimal scrotal edema and erythema. gu: + foley ext: onchonychia. 2+ distal pulses. 2+ pitting edema in ue bilaterally. rue with prominent fistula, +thrill. lower extremities with 4+ pitting edema to halfway up thighs. neuro: opens eyes to voice. opens and closes eyes on command, but does not squeeze hands. withdraws to pain. discharge exam vs: 99.8 98.8 89 130/60 20 92% ra general: nad. heent: ncat. icteric sclera. mmm. cards: rrr no mrg pulm: ctab. decreased breath sounds right base. abd: nabs. soft nt/nd. ext: 2+ edema bl to knees pertinent results: admission labs 07:49pm blood wbc-5.4# rbc-2.90* hgb-9.1* hct-27.1* mcv-93 mch-31.4 mchc-33.7 rdw-16.7* plt ct-36* 07:49pm blood neuts-87.6* lymphs-6.9* monos-5.4 eos-0.1 baso-0 07:49pm blood pt-14.8* ptt-30.9 inr(pt)-1.4* 03:11am blood fibrino-173* 07:49pm blood glucose-184* urean-93* creat-4.2* na-139 k-4.3 cl-107 hco3-21* angap-15 07:49pm blood alt-60* ast-97* ld(ldh)-171 ck(cpk)-159 alkphos-90 amylase-207* totbili-6.2* 07:49pm blood ck-mb-4 ctropnt-0.15* 02:15am blood ck-mb-4 ctropnt-0.14* 07:49pm blood albumin-3.1* calcium-7.9* phos-5.8*# mg-2.1 uricacd-12.6* cholest-94 07:49pm blood triglyc-134 hdl-31 chol/hd-3.0 ldlcalc-36 ldlmeas-<50 07:49pm blood osmolal-330* 07:49pm blood tsh-0.76 08:09pm blood type-art temp-36.7 tidal v-500 peep-5 fio2-50 po2-104 pco2-38 ph-7.36 caltco2-22 base xs--3 -assist/con intubat-intubated 08:09pm blood lactate-1.1 images and procedures: cxr findings: portable semi-upright chest radiograph was obtained. endotracheal tube terminates at the level of the carina and should be withdrawn 2-3 cm. orogastric tube courses into the stomach and out of view. right ij catheter likely terminates in the right atrium and can be withdrawn 4 cm for more optimal positioning. consider repeat radiograph after repositioning. bilateral pleural effusions and dense retrocardiac opacity are noted, with low lung volumes and possible mild pulmonary edema. moderate cardiomegaly noted. cxr findings: in comparison with study of , the degree of pulmonary vascular congestion has somewhat decreased, though part of this may be due to the upright position. substantial enlargement of the cardiac silhouette persists with large right pleural effusion with atelectasis involving the right middle and lower lobes. blunting of the left costophrenic angle is seen but the left chest is otherwise clear. echo the left atrium is moderately dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: mild symmetric left ventricular hypertrophy with near hyperdynamic left ventricular systolic function. dilated and hypokinetic right ventricle with mild tricuspid regurgitation and mild to moderate pulmonary hypertension. compared with the prior study (images reviewed) of , the right ventricle appears dilated and hypokinetic with elevated pulmonary pressures. colonoscopy normal colonic mucosa from rectum up to the cecum. no signs of active bleeding. one small diverticula seen in the ascending . retroflexed view revealed small internal hemorrhoids otherwise normal colonoscopy to cecum egd severe esophagitis in lower esophagus with what appeared 2 tongues of salmon colored mucosa left undisturbed.moderate to severe diffuse portal gastropathy without signs of active bleeding. normal duodenum bulb, second portion and normal small bowel mucosa up to proximal jejunum otherwise normal egd to second part of the duodenum cxr a radiograph centered at the thoracoabdominal junction was obtained to assess for placement of an orogastric tube, which terminates within the stomach. within the chest, endotracheal tube and central venous catheter are unchanged in position, and there remains marked enlargement of the cardiac silhouette, now accompanied by mild pulmonary vascular congestion. worsening homogeneous opacity in the right mid and lower lung region likely represents a combination of a large right pleural effusion and atelectasis involving the right middle and right lower lobes. portable cxr small left pleural effusion has minimally increased. moderate right pleural effusion is probably unchanged allowing the difference in positioning of the patient, decreased though from . there is no evident pneumothorax. cardiomegaly is obscured by the pleural effusions. right lower lobe and right middle lobe atelectases have improved. there are increasing atelectases in the left lower lobe. pa and lateral cxr findings: pa and lateral views of the chest are obtained. since the prior study, there is interval improvement of right pleural effusion. there is also evidence of right middle lobe atelectasis with associated volume loss. the previously seen left lower lobe atelectasis is improved since the prior study. there is no pneumothorax. cardiac size is unchanged. conclusion: improved right pleural effusion and left lower lobe atelectasis with persistent right middle lobe atelectasis and volume loss. no pneumothorax. key lab studies: pleural fluid () analysis wbc rbc polys lymphs monos meso macro other 17:51 1000* * 2* 48* 0 1* 49*1 02 pleural chemistry totprot glucose ld(ldh) albumin cholest 17:51 1.5 89 172 < 1.0 24 gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. urine cultures negative blood cultures negative discharge labs: 06:15am blood wbc-2.9* rbc-2.87* hgb-9.2* hct-27.0* mcv-94 mch-31.9 mchc-33.9 rdw-17.1* plt ct-85* 06:15am blood pt-14.3* ptt-38.5* inr(pt)-1.3* 06:15am blood glucose-86 urean-22* creat-4.2*# na-134 k-3.6 cl-97 hco3-34* angap-7* 06:15am blood alt-14 ast-27 ld(ldh)-165 alkphos-122 totbili-3.2* 06:15am blood totprot-5.3* albumin-2.9* globuln-2.4 calcium-8.1* phos-2.5* mg-1.9 brief hospital course: mr. is a 46 year old gentleman with a pmh etoh cirrhosis c/b multiple gi bleeds, ckd with baseline and ongoing alcohol abuse, transferred to for further evaluation of gi bleed. # gi bleed: unclear source, as egd revealed no prominent active bleed; most likely sources include erosive esophagitis and duodenal varices, although these may not account for the amount of blood loss evidenced by blood counts at osh. hematemesis, melena, brisk tempo of bleeds and precipitous in counts would also be more consistent with upper gi source. he was transferred for further exploration with possible egd/ vs. capsule study, with consideration of tips, based on findings. patient was hemodynamically stable (normal hr and bp) on admission to micu, with h/h increased to after massive blood product repletion at osh. on egd showed no sign of active bleeding, severe esophagitis, moderate gastropaty and colonoscopy was unremarkable. this raised the possibility of a portal gastropathy. his cvl from osh was removed and new line placed in lij. octreotide and pantoprazole now since , octreotide discontinued on . he was started on zosyn for the possibility of an aspiration pna (see below) which also doubled as sbp prophylaxis and he completed a 7 day course on . capsule endoscopy on floor did not function properly, perhaps secondary to body habitus. patient thereafter monitored, with stable hematocrit for nearly 2 weeks thereafter as patient awaited placement in rehab. ultimately, his blood losses were thought to be secondary to gastropathy. # cirrhosis: meld 27 on discharge(mortality over 3 months = 20%). secondary to alcholic liver diseases, with prior decompensations from gi bleeds and possible hrs. no known hepatic encephalopathy, ascites or variceal bleeds. patient was removed from transplant list in for failure to keep appointments and relapse with alcohol use. octreotide, pantoprazole and zosyn were continued as above. after completion of his egd/colonoscopy and following his extubation on , he was started on lactulose and rifaximin for prevention of hepatic encephalopathy. these medications were continued on discharge. # pleural effusion: patient found to have pleural effusion on cxr. per prior reports and notes, has been longstanding and likely volume overload and was previously characterized as hepatic hydrothorax following pleural effusion analysis several months prior to admission. patient offered thoracentesis, but was initially very against the idea and declined, preferring instead to allow dialysis to take off fluid. patient ultimately agreed to the procedure, and it was performed on . extended light's criteria suggested transudative effusion. post-procedure portable xr raised concern of trapped lung, but repeat pa and lateral xr was unremarkable. he may require periodic thoracentesis if fluid reaccumulates and he develops dyspnea or coughing. # acute on chronic kidney disease: creatinine elevated on admission to 4.2 from baseline in the low 3 range, with urine electrolytes consistent with prerenal azotemia. there was concern for developing hrs, especially in setting of gi bleed, but the patient was still making urine so it was considered less likely. clincially, he was total body volume overloaded with extensive peripheral edema. patient was briefly trialed on furosemide drip, but experienced worsening creatinine and after discussion with renal it was decided to move forward with ultrafiltration in order to remove his excess fluid (5l off on ). thereafter, patient was initiated on hemodialysis and will continue a mwf course via his rue avf. a small pseudoaneurysm was appreciated- he was evaluated by transplant surgery who will follow him as an outpatient. # urinary tract infection: on , patient developed low grade fevers. continued to cough, but cough was slightly improved s/p thoracentesis mentioned above. patient also with chills, some sweats. ua suggestive of urinary tract infection, so patient was started on levaquin with dosing to also cover a potential pulmonary source as well. will complete roughly 5d of treatment. # aspiration pneumonia: based on retrocardiac opacity on cxr, as well as concern for aspiration reported from osh. treated with zosyn as mentioned previously, remained afebrile without leukocytosis while in icu. # alcohol abuse: continued through current admission, with etoh level 238 on admission. initially patient was on midazolam drip as well. because of history of seizures during alcohol intoxication, and patient was closely monitored. patient did well and did not show evidence of withdrawal. received counseling and sw consultation with a focus on rela # uti: noted at osh, treated with total 7 days of zosyn. was coag negative staph. repeat cultures were negative. # supraventricular tachycardia: he developed a narrow-complex tachycardia during dialysis session on with pulse instantaneously rising to 130 from 80. was asymptomatic. ekg appeared consistent with avnrt. failed vagal maneuvers. broke with iv metoprolol and he maintained sinus rhythm for the remainder of the hospitalization after we re-initiated his home-dose metoprolol tartrate . transitional issues: - patient to continue levaquin with a dose of 500 mg on and (500 mg q48hr) to complete ~5 day course for uti - patient to continue hemodialysis once discharged from hospital - patient may need repeat thoracentesis for hepatic hydrothorax. please evaluate with cxr if he has increased coughing or shortness of breath. - followup/workup of microhematuria seen repeatedly on ua - watch phos level (decreased sevelamer from 1600tid to 800tid b/c phos on low side) - watch potassium level (patient has required replacement) - f/u in liver clinic follow up: - patient will need pcp followup after /c from rehab - outpatient nephrology f/u - transplant surgery f/u for avf pseudoaneurysm - aggressive social work support for alcohol relapse prevention pending studies: - pleural fluid culture (ngtd) - pleural fluid cytology - urine culture (ngtd) - blood culture (ngtd) medication regimen: - continue metoprolol as previously - start new meds lactulose, rifaximin, pantoprazole, sucralfate, nephrocaps, sevelamer, miconazole powder, multivitamins, thiamine, folic acid - discontinue spironolactone medications on admission: the preadmission medication list is accurate and complete. 1. metoprolol tartrate 25 mg po bid 2. spironolactone 25 mg po daily discharge medications: 1. metoprolol tartrate 25 mg po bid rx *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 2. folic acid 1 mg po daily rx *folic acid 1 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*3 3. multivitamins 1 tab po daily rx *multivitamin 1 tablet(s) by mouth daily disp #*30 tablet refills:*2 4. thiamine 100 mg po daily rx *thiamine hcl 100 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*2 5. lactulose 30 ml po tid please titrate to bowel movements a day rx *lactulose 10 gram/15 ml 30 cc by mouth three times a day disp #*3 liter refills:*1 6. miconazole powder 2% 1 appl tp tid rx *miconazole nitrate 2 % rash :prn disp #*1 container refills:*3 7. nephrocaps 1 cap po daily rx *b complex-vitamin c-folic acid 1 mg 1 capsule(s) by mouth daily disp #*30 capsule refills:*2 8. pantoprazole 40 mg po q12h rx *pantoprazole 40 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 9. rifaximin 550 mg po bid rx *rifaximin 550 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 10. sevelamer carbonate 1600 mg po tid w/meals rx *sevelamer carbonate 800 mg 2 tablet(s) by mouth three times a day disp #*180 tablet refills:*2 11. sucralfate 1 gm po qid rx *sucralfate 1 gram 1 tablet(s) by mouth four times a day disp #*120 tablet refills:*2 12. levofloxacin 500 mg po 2x duration: 1 doses dose on and after dialysis discharge disposition: extended care facility: - discharge diagnosis: gi bleed alcholic cirrhosis aspiration pneumonia acute tubular necrosis secondary to hypovolemic shock volume overload urinary tract infection discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , it was a pleasure being involved in your care. you were admitted first to the icu at hospital for for concern of severe bleeding into your gi tract and then transferred here. it was reported that you had vomited several buckets of blood. when your blood counts were done, they were found to be extremely low. the bloody vomit is certainly related to alcohol abuse. an endoscopy and a colonoscopy were done to look for a site of bleeding. when we did not find one, we did a capsule endoscopy (you swallowed a pill with a camera) to look for bleeding in your small intestine. this was also unrevealing. the bleed likely originated from gastric (stomach) inflammation which was seen on the scope study. during this episode you were noted to be very confused. this can happen with severe liver disease. we gave you lactulose and rifaximin to make you have bowel movements. your mental status eventually cleared on these medicines. there was a high suspicion that you had inhaled stomach contents while you were confused because you were not clearing your airway properly. we treated you with an 8 day course of the powerful iv antibiotic zosyn. also since you had low blood pressures, the icu had to give you many liters of fluid to keep your blood pressure high enough. unfortunately, this caused your tissues to swell up. after your episodes of low blood pressure resolved, the nephrologists (kidney doctors) took 10 liters of fluid out of your body with ultrafiltration and then gave you dialysis on to support your kidney function, which remains extremely poor. you will be continuing hemodialysis on an outpatient basis. prior to discharge, on , you were found to have a low grade fever. we looked at your urine, which suggested a urinary tract infection. we are treating you with antibiotics. it is important that you take the medicines we prescribe after discharge exactly as prescribed. please see them attached. briefly: - please continue metoprolol as previously - please start new meds levofloxacin, lactulose, rifaximin, pantoprazole, sucralfate, nephrocaps, sevelamer, miconazole powder, multivitamins, thiamine, folic acid - please discontinue spironolactone followup instructions: please follow up with your pcp after discharge from rehab: name: , p. location: medical associates address: , , phone: fax: department: liver center when: thursday at 9:20 am with: building: lm campus: west best parking: garage name: , location: medical associates address: , , phone: appointment thursday 3:10pm department: transplant center when: monday at 10:45 am with: , md building: lm bldg () campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours other endoscopy of small intestine hemodialysis thoracentesis colonoscopy central venous catheter placement with guidance diagnoses: acidosis thrombocytopenia, unspecified acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified acute posthemorrhagic anemia alcoholic cirrhosis of liver chronic kidney disease, stage iv (severe) asthma, unspecified type, unspecified acute respiratory failure other specified cardiac dysrhythmias pneumonitis due to inhalation of food or vomitus other shock without mention of trauma hepatic encephalopathy hemorrhage of gastrointestinal tract, unspecified varices of other sites other specified disorders of stomach and duodenum other and unspecified alcohol dependence, unspecified diverticulosis of colon (without mention of hemorrhage) internal hemorrhoids without mention of complication other esophagitis family history of malignant neoplasm of gastrointestinal tract ventral, unspecified, hernia without mention of obstruction or gangrene personal history of methicillin resistant staphylococcus aureus other fluid overload unspecified pruritic disorder other specified forms of effusion, except tuberculous 

Answer: The patient is high likely exposed to