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 attending: chief complaint: cc: major surgical or invasive procedure: s/p 8 coils in gastroduodenal artery perfomrmed by interventional radiology s/p failed egd attempts x 2 due to esophageal diverticulum history of present illness: hpi: 85 y/o m w/recent micu admission for gi bleed, discharged to rehab, who was admitted to icu on from rehab with brbpr. during his prior hospitalization , he was admitted to with weakness, and a hct of 21. patient underwent an egd x 2, which both times revealed a large duodenal ulcer with overlying clot. interventional was unable to be completed due to techinical difficulties. patient subsequently failed to respond to transfusion appropriately without a significant drop in his hct. he required a total of 12u prbcs and 4u ffp. he was transferred to on for further management and question of surgical intervention. before transfer, his course at was complicated by hypoxemic respiratory failure requiring intubation (felt to be due to volume overload from the transfusions vs aspiration pna), and hypotension requiring pressors (which occurred after receiving propofol for sedation). * upon arrival here on , he was extubated and weaned off pressors. he required no further prbc transfusions as his hct remained stable. gi service evaluated the patient and felt that there was no diagnostic or interventional need for antoher endoscopy. he was treated with ceftriaxone, vancomycin, and flagyl for sepsis (presumed source aspiration pna). he was transferred to the floor on . on the floor, he had an attempted thoracentesis as he had a pleural effusion seen on both cxr and chest ct, but they were unable to get any fluid. he remained hypoxic, requiring 2l o2 to saturate 95% and desaturated quickly with any movement. he was discharged to rehab on with instructions to complete a 14-day course of levo and flagyl. * patient at rehab on , developed bright red blood in his bowel movements and was sent to . no records from the are available. in the ed, he was initially hypotensive to 108/53 but otherwise hemodynamically stable. patient proceeded to have brbpr, and his initial hct was 23 (was 28 prior to d/c). the ed resident and attending were unable to place an ngt. he was transfused 2u prbcs, given 1l ns, protonix 40 iv, and was transferred to the micu. . in the micu, gi evaluated him and performed egd on . they were able to advance the scope pass the upper esophageal sphincter but there after it entered a broad cavity without exit, presumably a zenker's diverticulum with large opening. it was presumed to be zenker's diverticulum in the crico-pharyngeus, preventing passage of the scope into the esophagus. other techniques to document bleeding site and intervene, such as angiography were considered and patient underwent one on . there was no evidence of active bleeding seen on initial angiogram. with the prior known location of duodenal ulcer, it was decided to proceed with gastroduodenal artery embolization. patient had a 8 coil embolization of the gastroduodenal artery. on this subsequent arteriogram, a small branch arising from the proximal gastroduodenal artery was still perfused. patient's hct subsequently was stable. his last transfussion was on (for a total of 2+2 units over ). patient was transfered to regular floor for further care. . patient is alert and oriented to place. he denies any fevers/chills, no lightheadedness, no abdominal pain, no nausea, or vomiting, no chest pain, no shortness of breath, no chest pain, no dysuria/hematuria, no myalgias/arthralgias. past medical history: hypothyroidism duodenal ulcer as above afib anemia alcohol abuse social history: sh: large etoh use, 2 shots of bourbon per night with a few glasses of wine. never had etoh w/d. no cigarette use - quit after 15 year smoking x 4 ppd. lives @ home w/wife who he takes care of. he does the cooking in the house. married x 55 years. no children but have a friend, , whom they consider to be their son. is the next in line after his wife per the durable power of attorney form. - (their home #) - - family history: fh: nc physical exam: pe: t: 101.1 bp: 136/44 p: 75 r: 25 o2 sat: 97% on gen: elderly male lying in bed under 5 blankets, shivering, coughing heent: pale sclerae, mm dry neck: supple lungs: rhonchorous anteriorly cv: tachycardic, irregular, no m/r/g abd: soft, nt/nd. +bs. ext: chronic venous stasis changes of ble with 1-2+ ble edema neuro: oriented to person, place (hospital), but not time (thinks it is ) pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:15am 7.6 3.27* 9.6* 28.8* 88 29.4 33.5 15.8* 434 06:15am 8.0 3.47* 10.2* 30.4* 88 29.4 33.6 15.9* 463* 04:30am 9.7 3.33* 10.0* 29.0* 87 30.2 34.7 15.9* 427 06:10am 9.0 3.50* 10.4* 30.6* 88 29.6 33.8 16.0* 449* 06:55pm 29.6* 08:25am 11.5* 3.43* 10.1* 30.5* 89 29.6 33.3 16.0* 437 07:23pm 30.1* 08:44am 10.4 3.43* 10.2* 30.5* 89 29.6 33.3 16.1* 425 07:40pm 28.6* 06:25am 11.9* 3.29* 10.0* 28.8* 88 30.3 34.6 15.9* 370 08:30pm 29.8* 11:30am 11.8* 3.59* 10.5* 31.4* 87 29.4 33.6 15.9* 360 03:09am 11.6* 3.34* 10.0* 29.2* 88 30.0 34.3 16.1* 327 07:43pm 27.6* 02:42pm 28.0* 10:55am 27.3* 04:46am 12.5* 3.02* 9.2* 26.2* 87 30.6 35.3* 16.2* 280 02:12am 26.1* 08:00pm 26.1* 05:11pm 10.2 2.64* 7.8* 23.6*1 89 29.7 33.3 15.7* 387 05:26am 9.7 3.15* 9.4* 28.8* 91 29.8 32.7 15.7* 268 differential neuts bands lymphs monos eos baso atyps metas 05:11pm 84.1* 10.1* 3.8 1.3 0.6 basic coagulation (pt, ptt, plt, inr) pt ptt plt ct inr(pt) 06:15am 434 chemistry renal & glucose glucose urean creat na k cl hco3 angap 06:15am 91 13 1.0 132* 4.2 96 26 14 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 06:10am 11 15 227 46 0.4 other enzymes & bilirubins lipase 06:10am 17 chemistry totprot albumin globuln calcium phos mg uricacd iron 06:15am 7.5* 3.2 1.7 . urine: 01:15pm yellow clear 1.018 12:37pm yellow clear 1.030 02:12am amber1 clear 1.023 1 abn color affect dipstick dipstick urinalysis blood nitrite protein glucose ketone bilirub urobiln ph leuks 01:15pm neg neg tr neg neg neg neg 9.0* neg 12:37pm neg neg neg neg neg neg neg 6.5 neg 02:12am neg neg neg neg neg neg neg 6.5 tr microscopic urine examination rbc wbc bacteri yeast epi transe renalep 01:15pm 0-2 0-2 few none 0-2 02:12am 0-2 0-2 few none 0-2 * ekg: rate 72, afib, nl axis, nl intervals, no st-t changes * cxr upon d/c: the previously identified left lower lobe opacity has been slightly decreasing. there is continued small bilateral effusion. there is mild congestive heart failure with cardiomegaly. no pneumothorax is identified. . impression: slightly improving left lower lobe pneumonia. mild congestive heart failure with cardiomegaly and bilateral pleural effusion. * chest ct from : impression: 1. multifocal pneumonia of the left lower lobe, lingula, and left upper lobe. two small wedge-shaped pleural-based opacities of the right upper and middle lobes may represent spread of pneumonia. 2. moderate bilateral layering pleural effusions with associated posterobasal atelectasis of the lower lobes bilaterally. 3. probable component of congestive heart failure given pleural effusions, fissural fluid, and interstitial prominence. 4. multiple small bilateral apical blebs. * tte : 1. the left atrium is markedly dilated. the left atrium is elongated. the right atrium is moderately dilated. 2. 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 normal (lvef>55%). 3.right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic root is mildly dilated. 5.the aortic valve leaflets are mildly thickened. mild (1+) aortic regurgitation is seen. 6.the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 7.moderate tricuspid regurgitation is seen. 8. there is mild pulmonary artery systolic hypertension. 9.there is a trivial/physiologic pericardial effusion. * video swallow study: . mild oral and pharyngeal dysphagia with no evidence of aspiration. a large diverticulum is noted in the pharynx. difficult to determine type of diverticulum (zenker's versus killian-). solid and liquids were observed to collect within diverticulum along with backflow swallow following throat clearing. for further details, please refer to the video swallow evaluation from . . coiling procedure: : procedure: following written informed consent with the patient's daughter and son-in-law, the patient was positioned supine on the angiography table. preprocedure timeout was performed to confirm patient, procedure and site. standard sterile prep and drape of the right inguinal region. local anesthesia with 7 cc of 1% lidocaine subcutaneously. using a combination of palpatory and fluoroscopic guidance, a single wall puncture of the right common femoral artery was performed. a 0.035-inch guidewire was advanced through the needle into the abdominal aorta using fluoroscopic guidance. needle was exchanged for a 5-french vascular sheath, however, due to marked tortuosity of the iliac arteries this did not provide adequate stability for catheter manipulations in the aorta. as such, the sheath was exchanged for a long 6-french vascular sheath. a cobra catheter was used to select the superior mesenteric artery and superior mesenteric arteriography was performed. attempts were made to catheterize the celiac artery with cobra catheter, sos omni catheter, catheter, but these were all unsuccessful. finally, a catheter was successful at selecting the celiac artery. celiac arteriography was performed. based on the patient's clinical presentation and the findings of the diagnostic arteriograms, it was determined that the patient was a suitable candidate for and may benefit from embolization of the gastroduodenal artery. a 3-french microcatheter was advanced with a 0.018-inch guidewire through the catheter and used to select the gastroduodenal artery. gastroduodenal arteriography was performed. coil embolization of the gastroduodenal artery was then performed through the microcatheter using a total of four 2 mm x 2 cm microcoils and four 4 mm x 4 cm microcoils. the catheter was displaced into the common hepatic artery and common hepatic arteriography was performed post- embolization. based on the findings of this post-embolization arteriogram, we attempted to regain access to the proximal stump of the gastroduodenal artery, however, these attempts were unsuccessful. all catheters, wires, and the sheath were removed and hemostasis was ensured with direct manual compression. there were no immediate complications. moderate sedation was provided by administering divided doses of intravenous versed (total of 2 mg) and intravenous fentanyl (total of 200 mcg). there was a total intraservice time of 2 hours, during which the patient's hemodynamic parameters were continuously monitored. total of 150 cc of optiray radiographic contrast was utilized. findings: superior mesenteric arteriography demonstrated patency of the superior mesenteric artery and its major branches. a replaced right hepatic artery arises from the proximal portion of the superior mesenteric artery. no source of bleeding or active extravasation was identified in the visualized portions of the superior mesenteric artery territory. celiac arteriography demonstrates the splenic artery, left gastric artery and common hepatic artery to arise from the celiac artery. the left hepatic artery arises from the common hepatic artery. the gastroduodenal artery arises from the common hepatic artery. the celiac artery and its major branches are patent. active extravasation or potential source of bleeding from the celiac artery territory was not identified. the imaging was carried out into the venous phase and the splenic vein, main and right and left main portal veins are patent. gastroduodenal arteriography demonstrates patency of the right gastroepiploic artery and the superior pancreaticoduodenal arteries. common hepatic arteriography post-embolization demonstrates ongoing patency of the downstream portion of the common hepatic artery and the left hepatic artery. the proximal stump of the gastroduodenal artery is patent. the coil embolization was performed from the origin of the gastroepiploic artery back to near the origin of the gastroduodenal artery. on this arteriogram, a small branch arising from the proximal gastroduodenal artery was still perfused. attempts to reenter the gastroduodenal artery stump to embolize this branch were unsuccessful. there were no immediate complications. impression: no arterial source of bleeding identified on celiac arteriography and superior mesenteric arteriography (with imaging focused on the superior half of the bowel). based on the history of a duodenal ulcer with blood clot at a prior upper endoscopy at an outside hospital and the findings of the diagnostic arteriograms, it was determined that the patient may benefit from and was a suitable candidate for gastroduodenal artery embolization. this was performed with a residual small branch of the proximal gastroduodenal artery not occluded. at the time of the final angiographic run, there was still some perfusion through the superior coils into another branch of the gastroduodenal artery as well. . egd: indications: melena previously documented duodenal ulcer, presumably bleeding, documentation of bleeding source and potential therapy needed procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. the physical exam was performed. conscious sedation was initiated by the physician. pulse oximetry and cardiac and blood pressure monitoring were used throughout the procedure. the patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the crico-pharyngeal region was reached. the vocal cords were visualized. there were no complications. findings: esophagus: excavated lesions on each attempt to intubate the patient, the scope passed the upper esophageal sphincter and entered a broad cavity without exit, presumably a zenker's diverticulum with large opening. multiple attempts were made, with the neck flexed and hyperextended, the patient supine and left lateral decubitis, and after failed attempts to pass dilator as a guide. although a previous endoscopy had successfully entered the esophagus, we were unable to do so. impression: presumed zenker's diverticulum in the crico-pharyngeus, preventing passage of the scope into the esophagus recommendations: in order to intubate the esophagus, we will need some guide into the esophagus. consider passing an ng tube with the aid of flouoroscopy, anesthesia, or thoracic surgery. in the meantime, consider other techniques to document bleeding site and intervene, such as angiography (and if appropriate, a bleeding scan). brief hospital course: a/p: 85 y/o m w/recent duodenal ulcer and pneumonia who presents with brbpr and anemia. * #. gi bleed: with a known source of duodenal ulcer, it was most likely source of patient's brbpr. unfortunately ng lavage or egd could not confirm an active bleeding. lower source (ischemic colitis from hypotension, colon ca given longstanding anemia etc) remains in the differential. pt. was transfused a total of 4 units prbcs . after failed egd esophageal diverticulum, patient underwent ir embolization of gastroduodenal artery but also without visualization of active bleeding. of note there was partial vascularization of gastroduodenal (one of the branches) that remained in tact. patient's hct remained stable since the procedure with a range of 28-30 and patient's stools were guiac negative. patient was initially continued on iv protonix and then switche to po bid. patient was also given vitamin k for reversible coagulopathy. patient will need an outpatient colonoscopy to r/o ca and r/o other causes of lower gi bleed. * #. multilobar pneumonia - patient with no evidence of aspiration on video swallow. patient with chest ct showing multifocal opacities as well as sputum culture growing pan-sensitive klebsiella. patient completed a 14 days course of ceftriaxone and flagyl during his hospitalization. he remained afebrile throughout his course and his wbc was within normal limits and with a downward trend. patient did have low grade fevers 24 hours prior to discharge and was pancultured again. his ua was unremarkable, his foley was changed, and his bcx were negative and cxr prior to discharge only showed resolving pna. low grade fevers may also be due to grade 2 sacral ulcer or atelectatisis. * # esophageal/pharyngeal diverticulum - large diverticulum is noted in the pharynx. difficult to determine type of diverticulum (zenker's versus killian-). solid and liquids were observed to collect within diverticulum along with backflow swallow following throat clearing during video swallow. gi service also had similar findings during their two failed egds when the scope ended up in the blind pharyngeal pouch below first esophageal sphincter. with consultation of ent and gi service it was felt that the patient may f/u with ent, dr. , for potential outpatient esophagoscopy and there was no acute need for surgical intervention due to no evidence of aspiration and patient poor but improving pulmonary status. . # urinary retention - patient with trouble voiding completely after removal of the foley resulting in 1000 cc urinary retention. patient's symtpoms were relieved with foley insertion. patient may improve with further conditioning and may benefit from flomax initiation. he may need a future urology evaluation and should f/u with them. . # afib: currently well-controlled, tolerating metoprolol well. patient cannot have anticoagulation due to his history of severe gib.ecg without ischemic changes. * #. hx alcohol abuse: was on ciwa scale while in here before, currently out of withdrawal window. -thiamine, folate * #. elevated inr: has been during this and prior admission (generally between 1.3-1.4). received vitamin k for inr >1.5. pt. received ffp last night in the setting of ongoing bleed. etiology felt to be nutritional deficiency (+/- liver disease from alcoholism.) likely also compounded by abx use. * #. full code. complex social situation: his wife is apparently an alcoholic, and he is her caregiver. they have neighbors with whom they are very close, and the is the primary contact who will communicate with the wife. is . medications on admission: meds at rehab: levofloxacin (to finish 14-day course) flagyl (to finish 14-day course) levothyroxine thiamine folate metoprolol 50 multivitamin albuterol/atrovent nebs prn discharge medications: 1. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 4. multivitamin capsule sig: one (1) cap po daily (daily). 5. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 6. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for sbp<100, hr<55 . 10. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 11. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po qam. 12. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po at bedtime for 2 months. discharge disposition: extended care facility: medical center - discharge diagnosis: upper gi bleeding due to presumed duodenal ulcer s/p gastroduodenal artery coiling resolving multilobar pna - l lower lobe, lingula, l upper lobe; r upper and middle lobes esophageal diverticulum urinary retention atrial fibrilation anemia - chronic etoh abuse hypothyroidism discharge condition: stable hct, guiac negative stool, patient requiring assistance with ambulation, oxygenating well on ra. discharge instructions: please take all your medications as instructed. please seek immediate medical attention if you have fevers/chills, nausea, increasing cough or chest pain or shortness of breath. please watch for any signs of bleeding. if you have recurrent bright red blood per rectum, or bloody emesis/vomit you will need to seek immediate medical attention. you may need hct check next week and then in a month while patient is on protonix. please follow up with ent, dr. , to evaluate potential surgical intervention regarding your esophageal diverticulum. you may also need to see urology if your symtpoms of urinary retention don't improve despite medical management such as flomax. followup instructions: please follow up with in weeks after your discharge from rehab. please call . . follow up with gastroenterology. you will need op colonoscopy. gastroenterology clinic number is (. you can also ask your pcp for gi offices closer to your home. . follow up with ent as an outpatient for zenker's repair. dr. can be reached @ (. . follow up with urology for urinary retention. clinic @ number is (. procedure: other esophagoscopy arteriography of other intra-abdominal arteries transcatheter embolization for gastric or duodenal bleeding transfusion of packed cells transfusion of other serum diagnoses: congestive heart failure, unspecified acute posthemorrhagic anemia acquired coagulation factor deficiency unspecified acquired hypothyroidism atrial fibrillation alcohol abuse, unspecified retention of urine, unspecified pressure ulcer, lower back hypovolemia pneumonia due to klebsiella pneumoniae pain in joint, ankle and foot pain in joint, shoulder region acute duodenal ulcer with hemorrhage, without mention of obstruction diverticulum of esophagus, acquired 

Answer: The patient is high likely exposed to