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: shortness of breath major surgical or invasive procedure: none history of present illness: this year old male presents with shortness of breath. he has a history of congestive heart failure with ef of 35%, coronary artery disease with most recent pci in w/ des in proximal lad and stent in rca, atrial fibrillation, and a history of abdominal aortic aneurysm (dimensions unknown). he presents with several weeks of shortness of breath that is more significant than his baseline dyspnea, characterized by long pauses between sentences. he has been instructed to use oxygen at night but does not do so. on morning prior to admission, his visiting nurse noted an o2 sat of 78% with atrial fibrillation to rates in the 150s. he presented to the ed. in the ed he was initially placed on a non-rebreather which was quickly weaned to 2 l nc. saturations were near 100%. chest x-ray revealed no pulmonary edema; lower extremities were not edematous. a hematocrit was obtained at 24% which is 10 points below his normal - 5 days ago his hct was 32%. over the past several months, his mcv has decreased and his platelet count has trended up. he has been constipated for the past week until this morning when he had a milk of magnesia enema; he moved lots of stool but unclear if blood was noted. also of note - he has been having difficulty swallowing water - such that he feels it gets stuck halfway down his esophagus, at times causing him to choke or regurgitate. he no longer swallows solids. these symptoms have been present for > 1 week but probably less than 1 month. for this reason, he has been eating canned soups with high salt load - his shortness of breath has worsened over this period with intermittent orthopnea and lower extremity edema. recently he was in the ccu for iv diuresis - he was discharged on an increased dose of lasix and his lisinopril was held in the setting of hypotension; a beta blocker was also considered given his pacs which were potentially contributing to his hypotension however this was held because of his recent hypotension as well. currently upon transfer to the micu he is feeling well, with no dyspnea that he reports, although between sentences he must pause. denies orthopnea, pnd, lower extremity swelling, syncope, dizziness, chest pressure or palpitations. no cough, hemoptysis, hematemesis, melena, abdominal pain. review of systems only positive as above (dysphagia, resolved constipation, intermittent shortness of breath). his vitals at time of transfer are bp of 78/40, hr 120, rr 16, o2 sat 95% on 2 l, and temp 98. past medical history: diabetes mellitus cad s/p stenting rca and lad, last cath 4 yrs ago hypercholesterolemia hypertension senile purpura colon cancer s/p colon resection and s/p splenectomy macular degeneration, left eye osteoarthritis mild aortic stenosis (valve area 1.2-1.9) squamous cell carcinoma osteoarthritis bph abdominal aortic aneurysm social history: lives at home alone in ; he has a visiting nurse r that comes once a week. he has been married for 63 years. he is a retired newspaper printer. remote history of smoking 20pack years. no alcohol. has a daughter and has a son who is an ophtamologist in ct. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission physical exam bp of 78/40, hr 120, rr 16, o2 sat 95% on 2 l, and temp 98. gen: caucasian male, sitting up in bed, pleasant, alert and oriented x 3, appropriate to conversation heent: conjunctival pallor, skin looks somewhat pale as well to family members, oropharynx clear cardiac: to level of jaw, no murmurs appreciable, tachycardic, irregular rate pulm: dry crackles at bases bilaterally abd: soft and nontender with no distension, normal bowel sounds ext: no edema appreciable discharge physical examination vitals: t: 98.2, bp: 99/66, hr 96 (88-114), rr 16-20, o2: 97% ra. admit wt 66.7 kg gen: pleasant, calm, nad, charming, heent: no conjunctival pallor. no icterus. mmm. op clear. neck: supple, no lad. 10 cm. normal carotid upstroke. cv: rrr. normal s1,s2. iii/vi harsh mid peaking crescendo/decrescendo murmur with preserved s2 at the rusb with radiation to the neck. ii/vi blowing hsm at the llsb and apex. lungs: breath sounds bilaterally, no rhonchi, fine inspiratory crackles. abd: nabs. soft, nt, nd. ext: wwp, 1+ le edema. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. non-focal pertinent results: i) admission labs 12:27pm blood wbc-11.2* rbc-2.99* hgb-6.9* hct-24.5* mcv-82 mch-23.2* mchc-28.3* rdw-22.4* plt ct-426 12:27pm blood neuts-83.1* lymphs-10.5* monos-6.0 eos-0.1 baso-0.3 12:27pm blood pt-13.8* ptt-23.8* inr(pt)-1.3* 12:27pm blood glucose-319* urean-84* creat-1.5* na-140 k-5.0 cl-100 hco3-26 angap-19 04:23am blood ck(cpk)-41* 12:27pm blood probnp-* 12:27pm blood ctropnt-0.03* 12:27pm blood iron-13* 03:45pm urine color-straw appear-clear sp -1.014 03:45pm urine blood-neg nitrite-neg protein-neg glucose-tr ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg 03:45pm urine ii) imaging: resting data ekg: sinus freq. isolated abps and vpbs. heart rate: 73 blood pressure: 110/60 protocol stage time speed elevation heart blood rpp (min) (mph) (%) rate pressure 1 0-4.5 5mcg/ kg/min 114 96/56 total exercise time: 4.5 % max hrt rate achieved: 89 symptoms: none st depression: none interpretation: this year old man with a pmh of old mi, pci, as, chf, dm2 and af was referred to the lab for evaluation of aortic valve function. the patient was infused with 5 mcg/kg/min of dobutamine over 4.5 minutes as was stopped for achieving target workload. no arm, neck, back or chest discomfort was reported by the patient throughout the study. there were no significant st segment changes during the infusion or in recovery. the rhythm was sinus with frequent isolated apbs, vpbs and several ventricular couplets. appropriate hemodynamic response to low dose dobutamine infusion. impression: no symptoms, ischemic ekg changes or sustained ectopy. echo report will be sent separately. dse: the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef= 20-25%). right ventricular chamber size and free wall motion are normal. there is critical aortic valve stenosis (valve area <0.8cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. impression: severely depressed left ventricular systolic function - only the basal segments have appreciable systolic function. the aortic valve is likely severely stenotic. prior to dobutamine gradient across the valve was as high as 60mm hg peak and 33mm hg mean after an atrial premature contraction with consequent prolonged ventricular filling. this suggested that the valve was intrinsically stenotic. this was confirmed with low-dose dobutamine when average lvot velocities increased from 0.5 m/s to 0.7m/s and average av velocities from 2.7m/s to 3.5m/sec. again, after a vpc, peak gradient was as high as 73 mm hg and mean 41mm hg. us doppler: history: 82-year-old man with right upper extremity dvt, picc line removed, assess progression of dvt. comparison: right arm ultrasound . findings: grayscale, color and doppler images were obtained of the right ij, subclavian, axillary, brachial and basilic veins. note is made that the right cephalic vein could not be identified. occlusive thrombus is seen again within the right axillary vein and in one of the two right brachial veins. additionally, on today's exam the right basilic vein demonstrates occlusive thrombus. these veins do not compress and do not demonstrate vascular flow on color doppler imaging. no thrombus is seen within the right subclavian vein or within the right ij. impression: continued appearance of deep vein thrombosis within the right axillary vein and within one of the two right brachial veins. additionally dvt is seen today within the right basilic vein. discharge: 07:27am blood wbc-10.6 rbc-2.92* hgb-8.2* hct-27.4* mcv-94 mch-28.2 mchc-30.1* rdw-24.1* plt ct-260 01:15pm blood hct-27.3* 03:09pm blood ret man-3.4* 07:27am blood glucose-130* urean-31* creat-1.0 na-139 k-4.1 cl-110* hco3-21* angap-12 07:27am blood calcium-8.3* phos-2.9 mg-2.0 03:55am blood hapto-108 03:09pm blood folate-18.6 12:27pm blood caltibc-347 vitb12-489 ferritn-25* trf-267 pending: none brief hospital course: m with cad, ischemic cardiomyopathy, aortic stenosis, atrial fibrillation, chronic occult bleed, who presented to with hypoxia and shortness of breath in the setting of afib with rvr and anemia who has an ongoing bleed of probable gi pathology. year old male with a past medical history signficant for colon cancer resection and splenectomy (), aaa, cad, ischemic cardiomyopathy, atrial fibrillation, and severe aortic stenosis who presented to with hypoxia and shortness of breath in the setting of atrial fibrillation with rvr and anemia. initially the patient was admitted to the micu secondary for concern for hypotension. in the micu, a picc was placed for central access and he was started on pressors. he was asymptomatic with blood pressures in the 70s-80s. he was noted to be anemic. he was transfused 2 units. following a small amount of diuretics the patient was no longer in atrial fibrillation. he was subsequently sent to the cardiology service for workup of his aortic stenosis. dobutamine stress echo showed a valve area of .8 and an ef of 25%. the patient patient continued to have an on-going bleed. his stools were guiac positive but negative for melena or bright red blood. for this reason, gi believed that it was highly unlikely that his bleeding was gi in nature as he was receiving approximately one unit per day. losing more than 100cc of blood in a day results in frank melena or blood in the stool. however, this was moot point as the patient did not want invasive procedures (i.e. colonoscopy). the patient was noted to have an upper extremity dvt secondary to his picc line. the picc line was pulled and he was started on anticoagulation which resulted in more rapid bleeding. of note, there was no hemodynamic instability. anticoagulation was held and plavix was reduced to 81mg. a goals of care meeting was held with the family (please see omr notes for full detail). the patient and his family decided that he did not want further workup for his anemia, cardiac disease, or ue dvt. he wanted to enjoy the rest of his productive life at home with his family. after stopping the various blood thinning medications, his hct remained stable and he was discharged home with the instructions to follow up with his pcp for possible transfusions in the future to manage his symptoms. anemia: patient with hct of 24 without anticoagulation. one week ago his hct was 33. patient is guaic positive. patient with guiac positive stool on dre and stool sample x 2. no signs of frank melena or hematochezia. patient has required 5 units and continues to drop hct. gi bleed is certainly a culprit, however, anemia likely multifactorial. suboptimal reticulocyte count indicating an insufficient marrow response. patient is currently transfusion dependent. given his cardiovascular status, it is diffult to ascertain if patient could even safely undergo bowel prep and colonoscopy with severe heart disease. discussion with the patient is that he would not want a gi procedure and as long as his bleed were to slow down enough to to the point where he could safely receive transfusions as an outpatient, he would greatly prefer that. -symptomatic transfusions -iron supplementation rue swelling: patient with picc in the rue. new onset right sided swelling compared to left. ultrasound confirmed rue dvt. patient has not had any increased swelling. positive radial pulses, no distal parathesias. given the patients ongoing bleed and greatly elevated ptt will hold heparin for this morning until repeat crit. discussion with patient is that he does not want ongoing anticoagulation secondary to the frequent blood tests. chronic chf: patient appears well compensated from a volume standpoint. he is euvolemic. given his ischemic cardiomyopathy with depressed ef the patient could benefit from a beta blocker for his tachycardia and decreased ef. however, we are currently limited by his hypotension. currently holding beta blocker/ace inhibitor in order to avoid symptomatic hypotension. holding heart failure medications in the setting of hypotension. note date: signed by , md on at 5:38 pm affiliation: today, i met with mr. and discussed treatment options and goals of care and i also met with the patient and his 3 children (health care proxy present) to discuss goals of care going forward. mr. has coronary artery disease, severe aortic stenosis, with an lvef of 25%. he has worked with physical therapy extensively and he is able to ambulate on room air 25 to 50 feet (which has been his baseline). he is currently very comfortable on room air and prior to this hospitalization, reports having a very good quality of life and enjoys the company of his family and is very high functioning in his adl's with given the severity of his as. during this hospitalization, the patient has had transfusion dependent anemia. he likely is bleeding from a gi source but this is unclear. unfortunately, during this hospitalization, he has developed a rue dvt associated with picc line. the risks vs. benefits of anticoagulation for this patient (who has a chronic slow bleed) were discussed. the family was informed that there was a definite risk of life threatening pulmonary embolus without anticoagulation. they were also informed that anticoagulation has risks of major bleeding. with regards to the dvt the patient and his family wanted to treat this very conservatively. it was mutually decided upon that the risks of anticoagulation are high. therefore, an ultra-sound would be preformed to monitor for the evolution of the clot. if this clot was progressing or symptomatic (causing swelling, numbness, ect) then anticoagulation would be re-considered. however, if the clot appeared stable the patient and family would like to not anticoagulate and take the risk that the patient might develop complications from the dvt (such as pe or swelling, numbness ect). the patient's anemia was also adressed. he has an ongoing bleed of unclear etiology (probably gi related). the patient and his family did not want colonoscopy. the patient and his family want for the patient to be able to go home and carry-on with his life. the patient and family and health care provider would like to be sure that the rate of bleeding was slow enough that he could safely go home and would have his hct followed up in 48 hours by his pcp. was also the understanding that the patient may require transfusions down the road. all the patient's questions were answered. the patients family's questiosn were answered. senior resident dr. confirmed these wishes. md pgy1 note date: signed by , md on at 7:25 pm affiliation: dr. i hope all is well. following up on our last conversation. mr. looks spectacular. his hct is 27. we gave him 1 u of rbc for a hct of 24 yesterday and then it was 27 this am and this afternoon. we talked it over with mr. and his daughter/hcp and i wanted to relay to you the upshot. obviously, though, a full dc summary shall be available for your review shortly. 1. he wanted to go home and avoid a colonoscopy. as you know, we believe that he was bleeding from an unknown source exacerbated by aspirin and plavix and later heparin (for his upper dvt). we believe and explained to him that he will continue to bleed but we are hopeful that this will be slow enough such that iron supplementation and transfusions prn can help. i confronted him with the possibility that he might bleed quickly and not make it to a transfusion, that this might "result in his death" - he understood that and was at peace with the possibility. he understood that this condition limits his life expectancy. we discharged him on asprin 81 - for your upcoming appt, please consider checking a hct, adjusting his iron regimen (iv?) and arranging transfusions. perhaps you could also consider bridging him to a hospice vna 2. the dvt. he had a picc associated dvt and was heparinized. we discussed it with him and laid out the risks and benefits. giving the bleeding experience, we supported his choice to forego anticoagulation. we took serial ultrasounds and discussed the matter with a vascular specialist who recommended following the ue dvt for extension. i explained to mr. that extension meant that a clot could go to his lungs and "kill you". again, i supported his choice to forego anticoag on account of the bleeding risk. he has been a true pleasure to care for and has been very appreciative and satisfied with his hospitalization. he will see you on thursday. thanks again et md senior resident, internal medicine medication changes 1. please start iron 325mg once a day 2. please start colace 200mg once a day 3. please start senna 1 tab twice a day 4. please take miralax on an as needed basis but it is important that you have at least one to two bowel movements per day. 4. start a multivitamin once a day 5. stop furosemide 40mg. 6. stop plavix 7. decrease aspirin to 81mg per day. 8. restart metformin 850 mg twice a day 9. restart glipizide 2.5mg once a day transitional issues: 1. consider initiating discussion of hospice care with the patient. 2. check hct for blood transfusions prn medications on admission: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 5. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: do not take more than 4g in 24 hours. 8. glipizide 2.5 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 9. metformin 850 mg tablet sig: one (1) tablet po twice a day. 10. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual prn as needed for chest pain. 11. polyethylene glycol 3350 17 gram powder in packet sig: one (1) powder in packet po daily (daily) as needed for constipation. discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*2* 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. miralax 17 gram powder in packet sig: one (1) po once a day as needed for constipation. disp:*30 packets* refills:*1* 7. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 8. glipizide 2.5 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 9. metformin 850 mg tablet sig: one (1) tablet po twice a day. 10. outpatient lab work please check cbc on and fax results to , md. 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). discharge disposition: home with service facility: mauel home care agency, inc discharge diagnosis: 1. critical aortic stenosis 2. chronic systolic heart failure with lvef of 25% 3. anemia 4. lower gi bleed 5. right upper extremity dvt 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. , you were found on this admission to have on going gi bleeding which is causing you anemia (low blood count). per your wishes we did not pursue the gi bleeding with a colonoscopy. over the past 24 hours your bleeding has slowed down to the point where your blood levels are stable. it is very important that you follow up with dr. for rechecking your blood levels in 48 hours. you may continue to have ongoing bleeding and require transfusions in the future. it is very important that you talk with your primary care doctor about your anemia going forward and the most appropriate ways in which to manage it. in addition, you have severe aortic stenosis and your heart dose not pump very well. we have been holding your cardiac medications in the setting of your low blood pressure. please discuss this with your pcp when you follow up with him. since we are starting you on oral iron, a medication which causes constipation, it is extremely important that you take your bowel medications everyday so that you do not become constipated. you also have a blood clot in your arm. we are not going to start you on anticoagulation according to your wishes. anticoagulation can cause signficant bleeding. if you wish to start anticoagulation for this blood clot please discuss this with your pcp. we have made the following changes to your medications: 1. please start iron 325mg once a day 2. please start colace 200mg once a day 3. please start senna 1 tab twice a day 4. please take miralax on an as needed basis but it is important that you have at least one to two bowel movements per day. 4. start a multivitamin once a day 5. stop furosemide 40mg. 6. stop plavix 7. decrease aspirin to 81mg per day. 8. restart metformin 850 mg twice a day 9. restart glipizide 2.5mg once a day -you need to talk with your cardiologist and primary care physician about resuming cardiac medications 8. please check your laboratory values to see if your blood count is low before you see your primary care doctor. weigh yourself every morning, md if weight goes up more than 3 lbs. if you experience any of the danger signs listed below please go to the nearest emergency department. followup instructions: department: when: thursday at 2:10 pm with: , md building: (, ma) campus: off campus best parking: free parking on site department: cardiac services when: thursday at 3:20 pm with: , md building: sc clinical ctr campus: east best parking: garage department: orthopedics when: wednesday at 11:25 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: wednesday at 11:45 am with: , md building: sc clinical ctr campus: east best parking: garage procedure: venous catheterization, not elsewhere classified diagnoses: coronary atherosclerosis of native coronary artery pure hypercholesterolemia congestive heart failure, unspecified unspecified essential hypertension acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified aortic valve disorders hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) percutaneous transluminal coronary angioplasty status other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure other complications due to other vascular device, implant, and graft osteoarthrosis, unspecified whether generalized or localized, site unspecified personal history of malignant neoplasm of large intestine abdominal aneurysm without mention of rupture hemorrhage of gastrointestinal tract, unspecified acute on chronic systolic heart failure acute venous embolism and thrombosis of deep veins of upper extremity acquired absence of intestine (large) (small) 

Answer: The patient is high likely exposed to