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: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue, black stools major surgical or invasive procedure: upper endoscopy , hemodialysis tunneled hemodialysis line ij central venous catheter placement and removal history of present illness: this is a 69 y/o f dm, cad s/p nstemi, nash cirrhosis who had melena x1 month with abdominal pain and fatigue. she came to the ed to be evaluated for fatigue. on initial presentation, she had bp down to 89/50, not responsive to fluids. additionally had hyperkalemia. liver was concerned about hrs so initiated treatment with midodrine and octreotide with albumin. renal was consulted as well. she was found to have a decreased hct to 22 from baseline of 26 to 27. of note patient had recent admission for shortness of breath found to have nstemi. cath demonstrated single vessel disease - no intervention. patient was actively diuresed. for anemia work-up patient had colonoscopy and egd which demonstrated esophageal varices and gastritis. cta to rule out pe demonstrated nodular liver, splenomegaly and ascites. patient is now follewed by dr. who felt liver disease is secondary to nash. patient was planning to have banding of esophageal varices one week prior which was delayed. given her hct drop and abnormal labs as well as hypotension to the 60s requiring pressors she was admitted to the micu for further work up. in the micu, she received 3 units prbcs, octreotide gtt, ctx for sbp ppx, and her aspirin, nadolol, lasix, ace, spironolactone were held. she was treated with albumin, midodrine, octreotide for presumed hrs as well. the octreotide gtt was discontinued as banding was performed (4 cords of grade 3 varices with stigmata of recent bleeding, no overt bleeding; banded x 3). no blood in esophagus, stomach, duodenum. a diagnostic paracentesis was performed without sbp. renal initially recommended running patient positive 1-2l. she required restarting of her neo for persistent hypotension. echo was performed that showed volume overload with mild depressed systolic function (likely 50%) however it was a poor study. on , a temporary hd access was placed and patient was placed on cvvh given volume overload and pressor dependence. she subsequently had a v/q scan which was intermediate prob, but given concerns for massive gi bleed from varices on anticoagulation, this was not initiated. of note, she required bipap for several days for respiratory distress given volume overload. she was initiated on hd on without complication. on review of prior records, she was found to have a new pelvic mass with elevated ca 125 to 400 concerning for ovarian malignancy (ovaries could not be visualized on prior us). outpatient mri has not yet been completed. currently, the patient is breathing well on room air and feels well. she continues to be weak from her hospital stay. she reports occasional coughing with phlegm productive which is not bothersome to her. no bm today despite lactulose. she denies chest pain, sob, abdominal pain, fevers, chills or myalgias or other symptoms. review of systems: (+) per hpi past medical history: after 5 years w/o medical care she presented in with new afib, nstemi, new cirrhosis, elevated ca 125 (400), nonvisualized ovaries on ct or us, 2.5 cm hypoechoic pelvic mass c/w fibroid vs ovarian pathology. was admitted , cath demonstrated single vessel disease - no intervention. patient was actively diuresed. for anemia work-up patient had colonoscopy and egd which demonstrated esophageal varices and gastritis. cta to rule out pe demonstrated nodular liver, splenomegaly and ascites. was to have outpatient pelvic mri to characterize uterine mass. other studies showed significant cirrhotic stigmata (varices, splenomegaly, ascites), and her breathing improved with aggressive diuresis. patient is now followed by dr. who felt liver disease is secondary to nash. patient was planning to have banding of esophageal varices one week prior to this admission but this was delayed due to the snow. diabetes-- x 10 years, denies complications hypertension-- since the age of 16 years old hyperlipidemia appendectomy as a child s/p c-section denies prior transfusions, liver disease, exotic travel past gyn history: one c-section, no hormone replacement therapy, underwent menopause at 50 years old and has not had post-menopause vaginal bleeding, menarche at 12 years old with regular periods. no ocp use. social history: had a desk job prior; retired now. she is an ex-smoker (quit 30 years ago); denies etoh, ivdu family history: denied malignancy including breast and ovarian ca; mother recently passed after a leg infection c/b stroke; both parents had htn physical exam: admission physical: tmax: 36.2 ??????c (97.1 ??????f) tcurrent: 35.9 ??????c (96.6 ??????f) hr: 73 (70 - 78) bpm bp: 111/65(76) {63/41(46) - 111/79(76)} mmhg rr: 15 (15 - 20) insp/min spo2: 100% heart rhythm: af (atrial fibrillation) general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, moderately distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema rectal: dark black loose stool, guaiac positive pertinent results: admission labs: 04:10pm blood wbc-7.7 rbc-3.55* hgb-6.4* hct-23.7* mcv-67* mch-17.9* mchc-26.8* rdw-21.0* plt ct-260 04:10pm blood neuts-80.5* lymphs-13.2* monos-5.5 eos-0.7 baso-0.1 04:10pm blood pt-13.3 ptt-25.0 inr(pt)-1.1 04:10pm blood glucose-145* urean-133* creat-3.6* na-137 k-5.7* cl-98 hco3-25 angap-20 04:10pm blood alt-33 ast-53* ck(cpk)-407* alkphos-74 totbili-0.8 04:10pm blood lipase-77* 04:10pm blood ck-mb-14* mb indx-3.4 12:57am blood calcium-8.9 phos-5.9* mg-2.4 10:30am blood type-art po2-68* pco2-56* ph-7.25* caltco2-26 base xs--3 10:30am blood glucose-179* lactate-1.1 k-5.5* 10:34am blood o2 sat-88 10:30am blood freeca-1.17 05:59pm urine color-yellow appear-clear sp -1.013 05:59pm urine blood-neg nitrite-neg protein-25 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 05:59pm urine rbc-0-2 wbc-0-2 bacteri-many yeast-none epi- 05:59pm urine castgr-0-2 05:59pm urine eos-positive 05:59pm urine hours-random urean-613 creat-159 na-less than 02:21pm ascites wbc-120* rbc-2385* polys-6* lymphs-48* monos-25* mesothe-15* macroph-6* 02:21pm ascites totpro-2.8 glucose-174 ld(ldh)-99 albumin-1.4 discharge labs: 06:45am blood wbc-4.6 rbc-3.18* hgb-7.3* hct-24.7* mcv-78* mch-23.0* mchc-29.6* rdw-23.6* plt ct-210 07:30am blood wbc-4.0 rbc-2.83* hgb-6.2* hct-21.1* mcv-74* mch-21.8* mchc-29.4* rdw-24.9* plt ct-139* 08:30am blood pt-14.7* ptt-39.7* inr(pt)-1.3* 07:30am blood plt ct-139* 07:30am blood pt-14.3* ptt-42.5* inr(pt)-1.2* 07:30am blood ret man-3.0* 06:45am blood glucose-142* urean-48* creat-4.8* na-138 k-4.0 cl-96 hco3-27 angap-19 07:30am blood glucose-114* urean-46* creat-4.5*# na-139 k-4.1 cl-101 hco3-27 angap-15 07:20am blood alt-130* ast-214* ld(ldh)-297* alkphos-124* totbili-1.0 07:30am blood alt-122* ast-228* ld(ldh)-307* alkphos-94 totbili-0.8 dirbili-0.4* indbili-0.4 11:33am blood ck-mb-14* mb indx-4.6 ctropnt-0.32* 04:57am blood ck-mb-11* mb indx-3.6 ctropnt-0.36* 04:10pm blood ctropnt-0.44* 04:10pm blood ck-mb-14* mb indx-3.4 06:45am blood calcium-9.0 phos-3.4 mg-1.9 07:30am blood calcium-8.4 phos-2.4* mg-1.8 07:00am blood caltibc-382 ferritn-38 trf-294 07:30am blood hapto-147 05:27pm blood cortsol-48.8* 05:42am blood type-art po2-86 pco2-38 ph-7.38 caltco2-23 base xs--1 micro: ucx: negative ucx: negative ucx: negative bcx: negative x2 bcx: negative bcx: negative peritoneal fluid: no growth. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. studies: cxr: stable severe cardiomegaly. no acute cardiopulmonary process. ecg: atrial fibrillation with a single wide complex beat. rightward axis. borderline low voltage. st-t wave abnormalities. since the previous tracing of the axis is more vertical and st-t wave abnormalities may be more prominent. clinical correlation is suggested. tte: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is probable basal inferoseptal akinesis and probabel basal inferior akinesis but views are suboptimal for assessment of regional wall motion. overall left ventricular systolic function is probably mildy impaired (lvef 50%?). the right ventricular cavity is dilated there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. at least mld to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , unable to compare regional wall motion due to poor image quality. renal u/s: 1.no evidence of obstruction. 2.stable right upper pole renal cyst. 3.small amount of ascites. v/q scan: at least three segmental perfusion defects, consistent with an intermediate probability for pulmonary embolism, in the setting of no ventilation images and clear lungs. in the absence of additional studies, given the pattern of findings, clinical treatment for pulmonary embolism would be warranted. lenis: no evidence of dvt of in either lower extremity tunneled dialysis line placement: satisfactory placement of tunneled dual-lumen 23-cm tip-to-cuff dialysis catheter in the left internal jugular vein with fluoro and ultrasound guidance. the lumens were flushed and the catheter is ready to use with the tip in the right atrium. the temporary left ij hemodialysis catheter was removed. chest xray: new diagnosis of arf and cirrhosis, needs specific cxr to rule out tuberculosis for outpatient hd initiation. mri pelvis w/o contrast: single fibroid within the left posterior uterine body correlates with the lesion seen on ultrasound. the ovaries are atrophic and there is no evidence of adnexal mass. large pelvic ascites, presumably related to the history of cirrhosis. abdominal ultrasound: patent hepatic vasculature, gallstones and sludge within the gallbladder, ascites, splenomegaly, right pleural effusion. egd : findings: esophagus: protruding lesions 1 cords of grade i varices were seen in the distal esophagus proximal to site of previous banding. excavated lesions two ulcers were found in the distal esophagus at the sites of previous banding. no stigmata of recent bleeding noted. stomach: mucosa: erythema, congestion, abnormal vascularity and mosaic appearance of the mucosa were noted in the whole stomach. these findings are compatible with portal hypertensive gastropathy. duodenum: normal duodenum. impression: ulcers in the esophagus esophageal varices erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy otherwise normal egd to third part of the duodenum recommendations: ulceration at site of previous band ligation, grade i varix proximal compressed with air. no area suitable for banding at this time. continue sucralfate 1 gram liquid, protonix. repeat egd with banding in 2 weeks. no active bleeding noted or etiology for anemia. please consider starting ferrous sulfate and heme consult if indicated. brief hospital course: on the patient arrived in the emergency department complaining of fatigue and melena, in the setting of known esophageal varices scheduled for elective banding. she was noted to have a rising creatinine, an elevated (but not rising) troponin, a hematocrit below her baseline, hyperkalemia for which she received kayexalate. her pressures dropped from an initial 120/58 to 89/50, non-responsive to fluids. she had an ij placed, was started on pressors and admitted to the icu for presumed gib, started on octreotide, and had an upper endoscopy in the early morning of . no active variceal bleeding was noted, although there was potentially some slow oozing. three of her four known varices were banded, and she was started on a 5-day course of antibiotics. sulcrafate was started, and she was started on a soft diet given the new bands. for her asicites she had a diagnostic paracentesis that showed no evidence of sbp. an echo showed some mild tricuspid and mitral regurgitation, moderate pulmonary hypertension, and an ef of 50%. a renal ultrasound showed no evidence of obstruction and a stable right upper pole renal cyst. she seemed to have an obstructive sleep apnea picture overnights, and on she was put on bipap overnight. the hepatology team considered her potentially a hepatorenal syndrome case so she was treated with midrodine, octreotide, albumin. a temporary hd line was placed and cvvhd initiated. she also had a v/q scan performed to evaluate for pulmonary embolus that came back as intermediate risk for pe. she had lenis as well that were negative for dvts. however, given her freshly banded varices, after discussion with the gi service, it was decided she would be too high risk for anticoagulation given very high risk of rebleeding. her pressures stabilized off vasopressors and she was able to be initiated on hemodialysis on . she continued to tolerated hemodialysis during the rest of her stay. in the micu while on cvvh, 20 kg of fluid were able to be removed. her hrs treatment was discontinued as this was not felt to be the etiology of her renal failure (more likely atn and pre-renal from hypotension in the setting of acute blood loss anemia from variceal bleed). she was continued on midodrine as below. she was transferred out of the medical icu to the medical floor for further management. # anemia: she continued to be anemic after her initial bleed and resuscitation. she received 2 additional units of blood that did not bump her hematocrit appropriately. repeat egd did not show any stigmata of bleeding, only appropriate ulcerations at the sites of prior banding. her stools were tested on several occasions and were negative for occult blood. she was found to be iron deficient. this, in addition to her renal failure, are the likely etiology of her persistent anemia. her hct remained stable over her last several days of admission at around 25. she is receiving epoeitin at dialysis. she was started on daily iron supplementation. # cirrhosis: in terms of her liver disease, she had some increase in her lfts several days before discharge. an abdominal us was performed that showed patent hepatic and portal vasculature and no etiology for her transaminitis. the hepatology team did not feel that any further work up was needed. however, she should follow up with the liver clinic with dr. and have liver function tests repeated one week after discharge. additionally, she should have a repeat egd one month after discharge as well to follow her varices. nadolol could be restarted if her blood pressures tolerate. initially she was not thought to be a candidate for liver transplantation because of her pulmonary hypertension, but she should have a repeat echo to reevaluate given her clinical improvement and reassess her candidacy for transplantation. # hypotension: her blood pressures have been low while here. after her hrs treatment was discontinued, she was continued on midodrine as her pressures did not allow her to tolerate hemodialysis. midodrine was changed to dialysis days only which the patient tolerated without difficulty. this has been stable for the last several days. # pelvic mass: found on prior admission. reportedly had elevated ca-125 which was checked as she had new ascites. initial imaging with pelvic ultrasound was concerning for ovarian mass. mri abdomen was performed which showed the mass to be consistent with a fibroid. outpatient gynecology follow up can be arranged if the patient requests removal or is symptomatic. # diabetes type 2: her metformin was discontinued given her renal failure and she was placed on a humalog insulin sliding scale. she tolerated this without difficulty. she would like to see a physician at the clinic on discharge from rehabilitation. # atrial fibrillation: was rate controlled here without intervention. nadolol may help with this in addition to secondary prevention of variceal bleed when it is appropriate to restart this medication. # coronary artery disease: recent nstemi in of this year with catheterization showing one vessel disease. patient has a follow up appointment with cardiologist dr. for further management. # renal failure: likely multifactorial: acute blood loss anemia causing hypotension with pre-renal and atn features. also, patient had been recently started on acei and diuretics (lasix, spironolactone) during prior admission which likely exacerbated her renal failure. she is tolerating hd and has had negative dedicated cxr to rule out tuberculosis, a negative ppd as well as negative hepatitis serologies. she was not hep b immune so she received her initial vaccine here on . she will need to complete the remaining two vaccines in the series as an outpatient. she will need to be followed for any signs of renal recovery as an outpatient. medications on admission: per recent discharge summary 1. diazepam 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety/insomnia. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for rash. 4. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. nadolol 40 mg tablet sig: one (1) tablet po once a day. 7. metformin 500 mg tablet sig: one (1) tablet po once a day. 8. flurazepam 15 mg capsule sig: one (1) capsule po at bedtime as needed for insomnia. 10. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 11. lasix 20 mg tablet sig: three (3) tablet po twice a day. 12. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 13. spironolactone 50 mg tablet sig: one (1) tablet po once a day. * pt states she stopped taking iron several weeks ago * discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 5. heparin (porcine) 1,000 unit/ml solution sig: 4000- unit dwell injection prn (as needed) as needed for line flush: dialysis catheter (tunneled 2-lumen): dialysis nurse only: withdraw 4 ml prior to flushing with 10 ml ns followed by heparin as above according to volume per lumen. . 6. sucralfate 1 gram tablet sig: one (1) tablet po bid (2 times a day). 7. midodrine 5 mg tablet sig: 1.5 tablets po qhd (each hemodialysis). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 10. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion/heartburn. 11. insulin glargine 100 unit/ml solution sig: thirteen (13) units subcutaneous at bedtime. 12. humalog 100 unit/ml cartridge sig: as directed units subcutaneous four times a day: as per sliding scale. 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob, wheeze. 14. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed for nasal congestion. 15. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 16. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 17. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). discharge disposition: extended care facility: northeast - discharge diagnosis: esophageal variceal bleed acute renal failure requiring hemodialysis hypotension anemia from acute blood loss and iron deficiency anemia cirrhosis, likely nash iron deficiency coronary artery disease atrial fibrillation diabetes mellitus type 2 uterine fibroids 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: you were admitted with acute renal failure and a bleed from varices in your esophagus. these are a complication of your cirrhosis. you required an extended stay in the medical icu during which time you had your varices banded and required blood to bring your blood pressures up. you also stopped urinating and had kidney failure which required the initiation of dialysis. it is unclear as to how long you will continue to need dialysis. for now, you will have this three days weekly and this can be arranged when you leave your rehab facility as well. you will need to have follow up of your varices by the liver team in one month and this appointment was made for you. additionally, you will need to have your liver function testing rechecked in one week to ensure that it remains stable. you also need to complete the hepatitis b vaccine series. you need to have your next vaccine after and then the last in the series should be 6 months after the first. you had a mass in your pelvis evaluated. this turned out to be a benign tumor called a fibroid. this can be followed by gynecology as an outpatient if you find that you are having symptoms from it. you are also iron deficient and we started you on iron supplementation. this may make you constipated. you should monitor for any black or tarry looking stools as this could be a sign of another bleed from your varices. we have made a number of changes to your medications which are outlined on the following pages. please take these medications as directed. your outpatient doctor can decide when to make any changes. followup instructions: appointment #1 dr. in liver center: . , on at 10:30am. ( appointment #2 dr. , md phone: date/time: 1:00pm. appointment #3 upper endoscopy procedure at , 3th floor building on at 11:30 am. . appointment #4 dr. , gynecology, at to arrange follow up for fibroids. appointment #5 before leaving rehab, please call for a primary care doctor to arrange follow-up care regarding your anemia. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified other endoscopy of small intestine hemodialysis hemodialysis venous catheterization for renal dialysis percutaneous abdominal drainage non-invasive mechanical ventilation arterial catheterization arterial catheterization endoscopic excision or destruction of lesion or tissue of esophagus diagnoses: acidosis hyperpotassemia obstructive sleep apnea (adult)(pediatric) coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified cirrhosis of liver without mention of alcohol acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled portal hypertension atrial fibrillation constipation, unspecified other and unspecified hyperlipidemia iron deficiency anemia, unspecified other ascites acute systolic heart failure esophageal varices in diseases classified elsewhere, with bleeding diverticulosis of colon (without mention of hemorrhage) internal hemorrhoids without mention of complication chronic pulmonary heart disease, unspecified personal history of colonic polyps nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] acute myocardial infarction of unspecified site, subsequent episode of care leiomyoma of uterus, unspecified shock, unspecified 

Answer: The patient is high likely exposed to