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: history of present illness: this is a 46-year-old male with known metastatic renal cancer and known portal vein thrombosis and biliary obstruction with esophageal varices, diagnosed in , who was transferred from an gastrointestinal bleed. the patient was admitted to hospital on . at that time, he complained of nausea and vomiting times three days, hematemesis, and melena times two days. he was noted to have hematemesis in the emergency department and his admission hematocrit was 20.1. he was started on sandostatin drip. + esophageal varices without acute bleed and without stigmata of bleed. a red clot was seen on the greater curve of the fundus without an active bleed. there was an adherent clot with normal underlying mucosa. no - tears and patient had received nine units of packed red blood cells with an increase in hematocrit to 23.5. patient also received eight units of ffp for inr of 1.5. he also received 10 mg of subcutaneous vitamin k and was then transferred to for further management. patient was witnessed to have around 500 cc of bright red blood with clots in route. also, had bright red blood per rectum at that time. patient had not been hemodynamically stable at any time prior to admission. past medical history: 1. metastatic renal cell carcinoma, status post right nephrectomy in , status post high dose il-2 therapy in , status post right pulmonary nodule resection in and status post high dose il-2 therapy in , then status post il-12 with il-2 in to . went through one and a half cycles and stopped secondary to personal reasons, status post thalidomide from to present. 2. biliary obstruction, status post biliary stent in which was replaced by a new biliary stent in . 3. portal vein thrombosis, diagnosed . 4. peripheral neuropathy secondary to thalidomide. medications on admission: thalidomide 300 mg po q.d., propranolol 60 mg po b.i.d., xanax 0.5 mg po b.i.d., oxycontin 20 mg po q.d. allergies: no known drug allergies. medications on transfer: octreotide 100 mg intravenous, protonix 40 mg intravenous b.i.d. and ativan prn. social history: this is a machinist, married with two children. no tobacco and no alcohol. physical examination: vital signs: temperature 100.1. pulse 130. blood pressure 154/66. general: pale jaundiced man. pulmonary: clear to auscultation bilaterally, except rales at the bases. cardiovascular: tachycardic with regular rhythm, no murmurs. abdomen: soft, nontender, nondistended, positive bowel sounds. extremities: no cyanosis, clubbing or edema, warm, 2+ distal pulses and pale (that was the physical examination from the first progress note on , no physical examination from the night float admission note). laboratories on : white blood cell count of 4.3, hematocrit 33.6 and platelets 139,000. electrolytes were all within normal limits. uric acid 4.6, alt 17, ast 16, ldh 130, alkaline phosphatase 101 and t bilirubin 0.5. abdominal ct on masses at pancreatic and peripancreatic region, masses of adrenals bilaterally, splenomegaly with a splenic mass, splenic vein obliterated by tumor with collateral varices, status post right nephrectomy, lesion of left kidney, inguinal and pelvic lymph nodes, no free fluid and persistent extrinsic occlusion of the portal vein. endoscopic retrograde cholangiopancreatography from : limited exam of the esophagus, stomach, duodenum all normal. malignant looking common bile duct stricture with multiple filling defects and a 7 cm stent was placed. esophagogastroduodenoscopy from : grade 2 varices at 30 cm from the incisor. laboratories from the outside hospital on : all electrolytes were within normal limits. hematocrit 21.3. coags: pt was 14.9, ptt 22.2, inr of 1.5. d dimer was positive, fibrinogen 424 and the fdp was less than 10. alkaline phosphatase was 257 but otherwise normal liver function tests. electrocardiogram on at outside hospital with sinus tachycardia at 122, axis 61, intervals 125.84.419 corrected. no st elevation or depression. t wave inversion in iii. assessment and plan: this was a 46-year-old man with metastatic renal cancer with known esophageal varices and portal hypertension, secondary to extrinsic compression of the portal system by the mass and portal vein thrombosis who presented to an outside hospital with an upper gastrointestinal bleed thought to be secondary to gastric varices. 1. upper gastrointestinal bleed: the patient with endoscopy at outside hospital, negative for stigma of variceal bleed, most likely secondary to gastric varices. the patient was put on octreotide and protonix. despite this, patient continues to have active bleeding. patient was planned to have abdominal ultrasound and then gastrointestinal and interventional radiology to evaluate. hematocrit will be followed and transfusion prn. hospital course: gastrointestinal was consulted and an emergent abdominal ultrasound was done which showed limited portal vein flow distally. a multiphasic ct showed unchanged metastases with portal vein flow distally but minimal flow proximally. interventional radiology was contact and a portal vein stent was placed along with an external-internal biliary drain which drained percutaneously in one direction and also into the duodenum. patient received a total of 28 units of packed red blood cells and 23 units of ffp. during the procedure, which the patient was stented by interventional radiology, he went under general anesthesia. there was some difficulty extubating the patient and he was ultimately extubated two days later. he developed a left lower lobe pneumonia, believed to be due to an aspiration pneumonia during patient's intubation. he was put on a ten day course of levaquin and clindamycin. enterococcus also grew out from patient's bile which was sensitive to levaquin and thus treated with a ten day course of levaquin, also used for the pneumonia. difficult with extubation, secondary to low oxygen saturation. patient was later found to have an abnormally high aa gradient and also a vq mismatch. this was believed to possibly be secondary to small pulmonary emboli being sent from patient's existent left popliteal deep vein thrombosis. interventional radiology was again consulted and an ivc filter was attempted to be placed secondary to patient's inability to be anticoagulated. during the procedure, it was discovered that patient's inferior vena cava was abruptly tapered secondary to extrinsic compression by tumor. therefore, a filter was not placed at that time. patient remained on a 100% nonrebreather for two to three days and ultimately his oxygen was weaned as his pneumonia resolved. on , on the day of discharge, patient was saturating between 92 and 99% on room air and was not experiencing any dyspnea on exertion with ambulation and denied any cough. during patient's intubation, he was agitated on his vent, and, therefore, started on propofol at which time he became hypotensive and required neo-synephrine in order to maintain blood pressure. patient also experienced acute renal failure likely secondary to the dye load given during a ct and angio procedure during the admission. patient maintained good urine output and creatinine rose to 1.8, then resolved on its own. the patient's diet was slowly advanced from npo to a full regular diet. patient at time of discharge was able to tolerate all foods. his hematocrit remained stable for five to six days around 30. patient's total bilirubin also rose to a peak of 20. once the total bilirubin had peaked, it began to drop status post drainage procedure a few points a day. in the days prior to discharge it had dropped from 16.6, 12.7 to 10.6, 10.0, 9.5 and on the day of discharge to 8.4. interventional radiology was again consulted and it was decided that patient could have the drain capped and be discharged home with visiting nursing assistant and follow-up one week later with dr. and the interventional clinic. also, during the admission, patient with a liquid diet for which stool studies were sent. all cultures and fecal leukocytes were negative. ova and parasites was never sent. patient was finally discharged on . discharge diagnoses: 1. upper gastrointestinal bleed secondary to gastric varices. 2. portal vein thrombosis. 3. renal cell cancer with metastases. 4. deep vein thrombosis, status post internal and external biliary stent, status post portal vein stent and peripheral neuropathy. discharge medications: 1. clindamycin 300 mg po q.i.d. until . 2. protonix 40 mg po q.d. 3. ativan 1-2 mg po q. 8 hours prn. 4. propranolol 60 mg po b.i.d. 5. levofloxacin 500 mg po q.d. until . 6. patient was sent home with an extra biliary drainage bag so that patient may attach the bag if it becomes obstructed and call his oncologist or interventional clinic. follow-up: patient to follow-up with dr. and also with interventional clinic on . a vna was set up to flush the catheterization with 10 cc of saline and dressing changes q.d. the patient was sent home on a regular diet. addendum: patient developed moderate abdominal discomfort shortly after arrival home and was told by dr. to uncap the biliary drain and resume external drainage. this relieved the patient's symptoms. jwm , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube angioplasty of other non-coronary vessel(s) insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) other percutaneous procedures on biliary tract diagnoses: pneumonia, organism unspecified acute kidney failure with lesion of tubular necrosis secondary malignant neoplasm of other specified sites pulmonary collapse personal history of malignant neoplasm of bladder esophageal varices with bleeding varices of other sites obstruction of bile duct 

Answer: The patient is high likely exposed to