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: darvocet-n 50 attending: chief complaint: hemmorhagic gastritis congestive heart failure major surgical or invasive procedure: colonoscopy history of present illness: 66 year old male with pmhx of cad s/p icd placement in , metallic aortic valve replacement, s/p mi, cvax4 who presents with acute hematocrit drop due to hemmorhagic gastritis. the patient has had recurrent bleeding over the last 8 months, and was just discharged from the micu on after episodes of melena and hypotension. the patient has had a total of 29 blood transfusion since due to this. he has been on warfarin since and had only been having problems since middle of last year. he said that he has had an recently and it did not show any source of bleeding. he has not had a recent colonoscopy or capsule study. he has been having increasing dyspnea and cough over the past week and was started on a z-pack empirically. he also has noticed some increased weakness and black stool over the past week. in the ed his vitals were hr: 91, bp: 95/52, rr: 29, 98% ra, guaiac positive stool. lasix 20mg iv x1 and tranfused 2 units of prbc. he was then transferred to the floor for further management. past medical history: - cva x 4 (most recent while on warfarin, asa and plavix - though this cva was not proven on mri; last mri in ' showed microvascular disease but no signs of embolic stroke) - benign hypertension - cad - single vessel distal lad - mi - in , 3 stents unknown type unknown date - s/p icd implantation parciology pc - diastolic chf - preserved ef, diastolic - avr - mechanical valve - type 2 diabetes - copd - low back pain - nephrolithiasis - duodenal ulcer on egd social history: smoking/tobacco: 60 pack years, quit 2 years ago. -etoh: seldom. -illicits: iv drugs once in his life when young, never again. -lives at/with: daughter and her family. she assists with his medications. independent with adls and ambulates with cane. from - he lived in and so we have no records of his care at that time. he states that he has never been in the military, never been incarcerated although he has been around individuals who have. he is not currently sexually active and has had female partners in the past. family history: there is diabetes mellitus, hypertension and dyslipidemia in several immediate family members. his sister had chf/?mi begining in her late 40s. his mother had breast cancer and chf. physical exam: ros: gen: - fevers, - chills, - weight loss eyes: - photophobia, - visual changes heent: - oral/gum bleeding cardiac: - chest pain, - palpitations, - edema gi: - nausea, - vomitting, - diarhea, - abdominal pain, - constipation, - hematochezia, + melena pulm: + chronic dyspnea, - cough, - hemoptysis heme: + bleeding, - lymphadenopathy gu: - dysuria, - hematuria, - incontinence skin: - rash endo: - heat/cold intolerance msk: - myalgia, - arthralgia, - back pain neuro: - numbness, - weakness, - vertigo, - headache physical exam: vss: 99.1, 106/58, 95, 20, 95%ra gen: nad pain: 0/10 heent: eomi, mmm, - op lesions pul: bibasilar rales, ee wheezes cor: rrr, s1/s2, iii/vi sem abd: nt/nd, +bs, - cvat, - rebound/guarding ext: - cce neuro: caox3, non-focal pertinent results: 01:13pm blood wbc-5.1 rbc-2.82* hgb-8.9* hct-26.3* mcv-93 mch-31.4 mchc-33.7 rdw-18.4* plt ct-147* 03:47am blood wbc-5.3 rbc-2.44* hgb-7.8* hct-23.0* mcv-94 mch-32.1* mchc-34.0 rdw-18.2* plt ct-154 04:30pm blood wbc-4.3 rbc-2.09* hgb-6.6* hct-20.1* mcv-96 mch-31.7 mchc-33.0 rdw-18.2* plt ct-152 04:30pm blood neuts-50.2 lymphs-26.8 monos-10.1 eos-12.0* baso-0.8 03:47am blood pt-28.7* ptt-43.0* inr(pt)-2.8* 04:30pm blood pt-28.8* ptt-42.5* inr(pt)-2.8* 03:47am blood glucose-75 urean-18 creat-0.8 na-140 k-3.4 cl-110* hco3-24 angap-9 04:30pm blood glucose-166* urean-18 creat-0.9 na-139 k-4.0 cl-111* hco3-22 angap-10 04:30pm blood ctropnt-<0.01 04:30pm blood probnp-696* 03:47am blood calcium-8.0* phos-3.4 mg-1.8 03:47am blood cortsol-4.3 4:30 pm blood culture #1 r ac. blood culture, routine (pending): chest (portable ap) study date of 4:52 pm impression: mild congestive heart failure with small bilateral pleural effusions and bibasilar airspace opacities, likely atelectasis. infection, however, is not completely excluded. ekg: nsr@90, qtc 456, q ii, avf, v4-v6, flattened st v5-6 portable tte (complete) done conclusions the left atrium is moderately dilated. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the distal septum may be hypokinetic. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. a bileaflet aortic valve prosthesis is present and appears well-seated. the transaortic gradient is normal for this prosthesis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. tricuspid regurgitation is seen (views suboptimal for quantification). there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. compared with the report of the prior study (images unavailable for review) of , findings are similar. egd findings: esophagus: normal esophagus. stomach: mucosa: abnormal vascularity of the mucosa was noted in the antrum and stomach body. these findings are compatible with avm's. no active bleeding. other gastritis resolved duodenum: normal duodenum. impression: gastric avm's no blood/active bleeding in upper gi tract. otherwise normal egd to third part of the duodenum. recommendations: follow up with in-patient gi team additional notes: final diagnoses are listed in the impression section above. estimated blood loss = zero. no specimens were taken for pathology. patient's home medication list was reconciled. colonoscopy findings: excavated lesions multiple diverticula were seen in the sigmoid colon, descending colon, transverse colon, ascending colon and cecum. diverticulosis was severe but no active bleeding from diverticulum. other no active bleeding/blood in the colon impression: colonic diverticulosis. no active bleeding/blood in the colon. otherwise normal colonoscopy to cecum recommendations: follow up with inpatient gi team additional notes: final diagnoses are listed in the impression section above. estimated blood loss = zero. no specimens were taken for pathology patient's home medication list was reconciled brief hospital course: 65yom with h/o chronic diastolic chf (ef > 55%), nyha class iii, cad w/ rca stent and distal lad occlusion w/ apical akinesis, s/p avr on warfarin, dm, htn, cva, and with gastritis and gastric avms who was initially admitted on for gib c/b chf exacerbation, transferred to the ccu for hypotension in setting of diuresis, called out to . . 1. chronic blood loss anemia due to gastrointestinal bleeding: patient presented with a hct drop of 10. he has been admitted multiple times for recurrent hemorrhagic gastritis. his inr on admission was 2.8. his coumadin was stopped and he was monitored while waiting for his inr to trend down for possible egd. surgery was also consulted for possible gastrectomy given these recurrent episodes and recommended biopsies to rule out malignancy. a heparin drip was started once his inr was below 2.5 given his risk of stroke with his aortic valve replacement. he received a total of 6units of prbc during his time on the general medicine floor. his h/h stabilized and he underwent egd and colonoscopy which revealed multiple gastric angiectasias, but no clear signs of bleeding. he subsequently underwent a capsule study that revealed one angiectasia in the distal jejunum, but no other sources of active bleeding. his warfarin was restarted (with heparin and then lovenox bridge) and titrated to goal inr 2.5-3.5. on the cardiology service, his hcts ranged from 20-23 and he was transfused 1 unit with goal hct >21. he was started on iron, vitamin b12, and vitamin c. he was transferred to the ccu on for chest pain, hypotension, and hct that did not respond appropriately to blood transfusions. on , he was transfused 3u prbcs for a hct of 19.6. on the evening of , he had an episode of hematemesis w/ 125 cc's of bright red blood. gi and ir were notified. he was managed conservatively with iv protonix and close monitoring of his hct. hct remained fairly stable for the subsequent 2 days, though he did require 1u prbc on . gi deferred further intervention. coumadin was held briefly and he was started on a heparin gtt in case of further gi bleeding. he continued to have hematocrit drop on which stabilized again. heparin gtt was discontinued. gi was reconsulted who determined he would only be a candidate if he has significant acute hematocrit drop or large volume hematemesis. he required an additional 1u prbc on and was called out of the icu on . coumadin was restarted on as the patient had relative stability in his hct and no further hematemesis. his hct continued to fluctuate, however, ranging from 24 to 27 and he received additional transfusions prn hct <25. he will need to have serial hcts as an outpatient with goal hct of 25. he will f/u with gi as an outpatient with plan for repeat scope and consideration of apc in the future. he is set up with pheresis unit at to receive weekly blood transfusions as needed. he will have hct checked prior to his weekly appointments at the pheresis unit and his pcp will place an order for blood transfusion if needed. he will follow-up closely with his cardiologist/np to monitor fluid status in the setting of transfusions. at this time, we recommend goal hct 25 (ie. 1 unit if hct <25, 2 units if <23, send to ed if <21) and would suggest considering an extra dose of torsemide 20 mg with each transfusion. he will be seen in clinic on where he can have a hct check and will f/u with his cardiology-np on where a decision regarding extra diuretic dose can be made as his first pheresis unit appointment is afternoon. thereafter he will have weekly pheresis appointments (scheduled) and should have additional f/u appointments with pcp and cardiology. he will be discharged with a picc line in place for access which should be removed (tentatively in 4 weeks) to avoid risk of infection. would recommend type and screen with hct checks so that he always has an active type and screen. this plan has been reviewed with his pcp, , gastroenterologist, pheresis unit nurse coordinator and case manager. **hct on discharge is 27.4** 2. dyspnea: initially thought to be an acute copd exacerbation in the outpatient setting for which the patient was placed on a z-pack that was completed in-house. he was given nebulizers around the clock as well as guaifenesin and tesslon pearls for his cough. his breathing remained labored and his cough persisted despite treatment. his lasix, lisinopril and metoprolol had been held in the setting of gi bleed and he became volume overloaded. metoprolol was restarted and he was treated with iv lasix. initially he was diuresing well with lasix boluses 40mg iv but developed hypotension to sbp 80s. he was transferred to the cardiology service for treatment of acute on chronic chf exacerbation. on the cardiology floor, he was placed on a lasix drip at 7mg/hr and uptitrated to 10mg/hr. his bp was stable in the 80s-90s systolic, without symptoms. he was started on metolazone. he diuresed 500ml-1l per day. his weight trended down to dry weight and he clinically improved with resolution of dyspnea and improvement in lower extremity edema. on , he was transferred to the ccu. in the ccu, diuresis was continued in hopes of relieving high venous pressure to help slow the upper gi oozing. he started on a lasix gtt and was diuresed 4l over the course of 3 days. lasix gtt was changed to torsemide 20 mg daily with good response. he will have close follow-up with dr. . he should have outpatient blood pressure monitoring and we recommend close follow-up with his pcp. **weight on discharge is 78 kg** 3. cad: s/p avr, icd and and has been medically managed. no acs sx. his metoprolol, lisinopril and lasix were initially held, but were slowly restarted as described in the plans above. aspirin was held in the setting of gi bleed. he will be discharged on metoprolol and torsemide. recommend restarting aspirin in the future, when hcts have been stabilized. . 4. dm2: last a1c was 6.4, fsg were well controlled throughout the course of his stay. 5. aortic valve replacement: patient had avr in . he is on coumadin with goal inr 2.5-3.5. in prior notes, it was mentioned that he had recurrent cvas on coumadin, though from mri in , it appears that the cvas were microvascular in origin and not embolic from valve or apical hypokinesis. due to his persistent gi bleeding, he may benefit from inr goal of 2.0-3.0. . 6. chronic low back pain: currently stable, was not an issue during this hospitalization. 7. cva: patient had many strokes in the past. his coumadin was managed as described above. 8. hypergammaglobulinemia: is being monitored in the outpatient setting. recommend close pcp f/u. medications on admission: bactroban nasal 2% ointment intranasally lipitor 80mg po daily citracel 250mg-200unit tab 3 tabs am/ 2 tabs pm pantoprazole 40mg po delayed release po q12h combivent 18mcg-103mcg 1 puff inh ns nasal spray 2 sprays inh furosemide 20mg po daily lisinopril 5mg po daily glyburide 5mg 2 tabs daily nitro 0.3 sl prn for chest pain colace 100mg po bid oxycodone 10mg po q6-8h:prn pain azithromycin 250mg po q24h x3 days albuterol 90mcg inh 2 puffs q4h:prn sucralfate 1gm qid folic acid 1mg po daily flovent 110mcg inh metoprolol 25mg 0.5tab daily polyethylene glycol 1 packet daily:prn warfarin 2.5mg po daily discharge medications: 1. atorvastatin 80 mg tablet sig: one (1) tablet po hs (at bedtime). 2. citracal + d petites 200 mg calcium -250 unit tablet sig: three (3) tablet po every morning. 3. citracal + d petites 200 mg calcium -250 unit tablet sig: two (2) tablet po at night. 4. bactroban nasal 2 % ointment sig: one (1) application nasal twice a day. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 6. combivent 18-103 mcg/actuation aerosol sig: one (1) puff inhalation twice a day. 7. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 8. sodium chloride 0.65 % aerosol, spray sig: sprays nasal (2 times a day). 9. oxycodone 5 mg tablet sig: 1-2 tablets po q8h (every 8 hours) as needed for pain. 10. glyburide 5 mg tablet sig: two (2) tablet po once a day. 11. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 12. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tab sublingual prn as needed for chest pain: please call your doctor if you use this medication. 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). 16. miralax 17 gram powder in packet sig: one (1) packet po once a day as needed for constipation. 17. metoprolol succinate 25 mg tablet extended release 24 hr sig: 0.5 tablet extended release 24 hr po once a day. 18. warfarin 1 mg tablet sig: two (2) tablet po once a day: please have your inr checked weekly to adjust dose of warfarin. your goal inr is 2.0-3.0. :*90 tablet(s)* refills:*2* 19. iron 325 mg (65 mg iron) capsule, extended release sig: one (1) capsule, extended release po once a day. :*30 capsule, extended release(s)* refills:*2* 20. vitamin b-12 1,000 mcg tablet extended release sig: one (1) tablet extended release po once a day. :*30 tablet extended release(s)* refills:*2* 21. vitamin c 500 mg capsule, extended release sig: one (1) capsule, extended release po once a day: please take with iron to increase absorption. :*30 capsule, extended release(s)* refills:*2* 22. torsemide 20 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 23. outpatient lab work please check inr and hct weekly. goal inr is 2.0-3.0. goal hct is 25. notify md if patient is less than goal. send results to: name: , location: , division of general medicine address: , e/cc-6, , phone: fax: email: and name: , md location: division of cardiology address: , e/rw-453, , phone: fax: email: 24. outpatient lab work please check hct and inr on , . send results to: name: , location: , division of general medicine address: , e/cc-6, , phone: fax: email: and , np building: sc clinical ctr 25. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous once a day: for inr < 1.8. 26. picc picc line care per protocol discharge disposition: home with service facility: discharge diagnosis: primary: upper gi bleed acute on chronic diastolic heart failure secondary: diabetes type ii copd 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: mr. , it was a pleasure taking part in your care. you were admitted to for a bleed in your gastrointestinal tract. you required blood transfusion because your blood count had dropped. your blood counts stablized and the gi doctors performed , small bowel capsule study, and colonoscopy which was negative for active bleeding. it showed irritation in your stomach that was likely the site of your bleeding, however it was not bleeding at the time of the procedure. during your hospitalization you had cough and shortness of breath, as well as fluid accumulation in your legs and lungs because of your heart failure. your blood pressures were low, and caused you to be dizzy when you had intravenous doses of lasix (a diuretic). you were transferred to the cardiology service to give you a continuous intravenous infusion of lasix to help remove the excess fluid. your blood pressures remained stable and we were able to remove the excess fluid that had accumulated. your shortness of breath was improved. you began having bleeding again, however, with dropping blood counts. you were transferred to the cardiac care unit where you were closely monitored and diuresed. you again received several transfusions. when your blood levels were stabilized, you were transferred to the regular cardiac floor. on the cardiac floor, you continued to intermittently require blood transfusions. when you receive blood however, you retain fluid and need to have the fluid removed. currently, your blood levels are at a normal level and your volume status is normal. we believe that you may require blood transfusions and extra diuretics to remove fluid over the next several weeks. for this reason, we have arrange for you to have weekly appointments at the pheresis unit at - where you can receive blood transfusions if you need it. you will need to have blood work to check your blood count prior to these appointments. you will also need to have your inr checked weekly to adjust your warfarin dose. goes up more than 3 lbs. limit your fluid intake to 1-2 liters per day. you may need an extra dose of torsemide (a diuretic) with blood transfusions to prevent fluid accumulation. we made the following changes to your medications: continue: - bactroban nasal 2% ointment intranasally twice a day - atorvastatin 80 mg daily - citracel 250mg-200unit tab 3 tabs in the morning and 2 tabs at night - pantoprazole 40mg twice a day - combivent 18mcg-103mcg 1 puff inhaled twice a day - ns nasal spray 2 sprays twice a day - glyburide 10 mg daily - nitroglycerin 0.3 mg sublingual as needed for chest pain - colace 100 mg twice a day - oxycodone 10 mg every six to eight hours as needed for pain - albuterol 90 mcg 2 puffs as needed every 4 hours for shortness of breath - sucralfate 1 g four times a day - folic acid 1 mg daily - flovent 110 mcg inhaled twice a day - metoprolol succinate 12.5 mg daily - polyethylene glycol 1 packet daily as needed for constipation stop: - warfarin 2.5 mg daily - furosemide 20 mg daily - lisinopril 5 mg daily start: -warfarin 2 mg daily -iron 325 mg daily -vitamin b12 1000 units daily -vitamin c 500 mg daily take with iron to increase absorption -torsemide 20 mg daily followup instructions: the following appointments have been made for you. it is crticial that you attend these appointments. department: when: at 10:00 am with: md/ post clinic building: sc clinical ctr campus: east best parking: garage **this appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. this visit, you will see your regular primary care doctor in follow up.** ****have your hct and inr checked at this visit**** department: cardiac services when: wednesday at 10:30 am with: , np building: sc clinical ctr campus: east best parking: garage ****have your torsemide dose adjusted at this visit**** department: pheresis unit when: wednesday at 1:00 pm with: pheresis unit for blood campus: east best parking: garage ****this appointment is for your blood transfusion**** after these appointments, you will need to have weekly appointments to see cardiology, have your hct checked, and receive blood transfusions. it is critical that you attend all appointments and have your blood levels monitored closely. procedure: venous catheterization, not elsewhere classified other endoscopy of small intestine colonoscopy diagnoses: coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled iron deficiency anemia secondary to blood loss (chronic) obstructive chronic bronchitis with (acute) exacerbation percutaneous transluminal coronary angioplasty status heart valve replaced by other means old myocardial infarction long-term (current) use of anticoagulants unspecified gastritis and gastroduodenitis, with hemorrhage automatic implantable cardiac defibrillator in situ personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits anticoagulants causing adverse effects in therapeutic use diverticulosis of colon (without mention of hemorrhage) angiodysplasia of stomach and duodenum without mention of hemorrhage acute on chronic combined systolic and diastolic heart failure benign essential hypertension other specified diseases of blood and blood-forming organs 

Answer: The patient is high likely exposed to