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: somnolence major surgical or invasive procedure: bipap history of present illness: the patient is a 63 y/o man with a history of diabetes, schizoaffective disorder, chronic renal failure c/b chronic hyperkalemia, chronic obstructive pulmonary disease, peripheral vascular disease, hypertension, and rheumatoid arthritis who was admitted to the medical service after presenting to the emergency department with a mechanical fall in the setting of pre-syncope. . the patinet is a resident at assistted living. due to a long standing history of ra, he is wheelchair bound at baseline. per report, it was on the toilet, when . . in the ed, initial vs: 98.1, 124/86, 16, 100% on 4l. the patients ekg was at baseline, and he remained hemodynamically stable. he was admitted to the medicine team for further evaluation. . on arrival to the floor, the patinet was found unresponsive. he was difficult to arouse, and only able to answer questions in sentence fragments. an abg was checked, showing a ph of 7.19 pco2 90 po2 99 hco3 36. the patient was admitted to the icu for initation of bipap. . ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: coronary artery disease hypertension type 2 dm peripheral vascular disease h/o pe, on coumadin rheumatoid arthritis copd depression bipolar disorder schizophrenia glaucoma social history: lives in with roommate, smoked 1 ppd for 35 years, still smoking, quit drinking 4-5 years ago, used to drink socially, no ivdu, but has tried cocaine once. is wheelchair dependent family history: father died of heart disease and also had cancer, mother had cancer. physical exam: on admission - vitals - t:97.0 bp:179/94 hr:99 rr:21 02 sat: 93% 1 l general: pleasant, well appearing gentleman in nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. jvp at clavicle. cardiac: regular rhythm, tachycardic. normal s1, s2. no murmurs, rubs or . lungs: diffuse wheezes throughout. poor air movement with decreased bs in l base>r. pursed lip however no increased resp effort. abdomen: nabs. soft, nt, nd. no hsm extremities: 1+ edema to the knee, non-painful to palpation. dp/pt pulses not appreciated. chronic vs changes bilaterally in les. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 intact. preserved sensation throughout. strength grossly intact with no focal weaknesses. psych: listens and responds to questions appropriately, pleasant . on discharge: vitals - t:97.8 bp:142/84 hr82 rr:22 02 sat: 93% 1 l general: pleasant, well appearing gentleman in nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. jvp at clavicle. cardiac: regular rhythm, tachycardic. normal s1, s2. no murmurs, rubs or . lungs: improved aeration, diffuse wheezes throughout at expiration. pursed lip however no increased resp effort. abdomen: nabs. soft, nt, nd. no hsm extremities: 1+ edema to the knee, non-painful to palpation. dp/pt pulses not appreciated. chronic vs changes bilaterally in les with weeping wounds. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 intact. preserved sensation throughout. strength grossly intact with no focal weaknesses. psych: listens and responds to questions appropriately, pleasant pertinent results: ============== labs ============== admission labs 03:40pm blood wbc-5.9 rbc-4.12* hgb-11.5* hct-39.1* mcv-95 mch-27.8 mchc-29.3* rdw-15.7* plt ct-248 03:50pm blood pt-40.5* ptt-37.8* inr(pt)-4.3* 03:50pm blood glucose-85 urean-45* creat-2.9*# na-143 k-5.4* cl-105 hco3-27 angap-16 03:50pm blood ck-mb-5 probnp-4310* 04:07am blood cortsol-21.1* 07:44pm blood type-art po2-99 pco2-90* ph-7.19* caltco2-36* base xs-3 intubat-not intuba 04:45am blood freeca-1.19 . discharg labs: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:45am 5.2 3.70* 10.5* 34.5* 93 28.3 30.4* 15.4 236 differential neuts bands lymphs monos eos baso atyps metas myelos 04:30am 65.1 22.0 10.0 2.3 0.7 red cell morphology hypochr anisocy poiklo macrocy microcy polychr 03:40pm 2+ normal normal normal normal normal basic coagulation (pt, ptt, plt, inr) pt ptt plt smr plt ct inr(pt) 06:45am 236 06:45am 21.2* 110.8*1 2.0* chemistry glu urean creat na k cl hco3 angap 93 31* 1.3* 146* 4.6 104 37* 10 ============== micro ============== **final report ** urine culture (final ): no growth. ============= radiology ============= ct head 1. mucosal thickening of the left maxillary and ethmoid sinuses with an air-fluid level in the left maxillary sinus. 2. no acute bleed or masses present. ============= cardiology ============= echo suboptimal image quality. overall left ventricular systolic function cannot be reliably assessed (it does appear depressed in certain views with possible infero-lateral hypokinesis). there is abnormal septal motion/position. the diameters of aorta at the sinus, ascending and arch levels are normal. trivial mitral regurgitation is seen. tricuspid regurgitation is present but cannot be quantified. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , no definite change. if indicated, a repeat study with echo contrast (definity) may assist in assessment of lv function. brief hospital course: 63 yo m with bipolar disorder, schizophrenia, rheumatoid arthritis, copd, chf, diabetes mellitus, peripheral vascular disease, hypertension, ckd and questionable pulmonary embolism admitted for syncope now s/p micu for for acute on chronic respiratory acidosis. . # hypercarbic respiratory failure: unrespeonsive upon arrival on the floor. likely related to a h/o sleep apnea and hx of copd, however no pfts on record. minimal emphysema on ct scan, but exam consistent with copd given wheezing, pursed lip , decreased breath sounds. started treatment for copd flare. patient also underwent a sleep study in house which showed cheynes- pattern, with intermittent desaturation. the recommendation was night time oxygen and slide sleeping. had an echo that was a poor quality but systolic chf was not thought to be a significant contributor. continued albuterol, ipratropium, advair in house but resumed home inhalers prior to discharge. continuous o2 sats, titrate to o2 sats to range 88-92% given chronic co2 retention. encouraged incentive spirometry. resumed 10mg po lasix per home regimen. patient should have outpatient pfts. . # somnolence: most likely due to co2 retention in the setting of obesity hypoventilation/copd. pt showed significant improvement with initiation of bipap. mental status cleared in the morning with bipap and did not require respiratory support for the rest of the day. tsh, utox, lfts normal. ct head was negative. on hd#2, bipap trial while patient somnolent and after bipap x 1 hour abg 7.23 / 89 / 90. switched to nasal cpap x 10-15 minutes abg 7.27 / 78 / 51. thought to be multifactorial in the setting of renal failure, uremia and hypercarbia. confirmed with pharmacy that psych meds are hepatically cleared, so unlikely to have worsened mental status in the setting of acute renal failure. patient was trialed on cpap at night and tolerated this well in the icu. somnolence improved throughout hospitalzation. . # htn: improved today. amlodipine was initiated in icu, also given labetolol prior to transfer. resumed patient beta blocker prior to discharge. . # acute on chronic renal failure: patinet followed by dr. here at in evaluation of cri w/ baseline creatinine of 1.5. the etiology of his chronic kidney disease is felt to be multifactorial, including lithium toxicity, renal hypperfusion from chf, nsaids in setting of ra, pvd with ras, diabetic/ hypertensive nephropathy. patient now presents with acute on chronic renal failure. improved with fluids and feurea consistent with possible pre-renal azotemia. limited evidence of chf on cxr. bnp elevated from baseline. no new medications as possible offenders. lasix were held in the icu, and ua and lytes were unremarkable. currently better than baseline. avoid nephrotoxic meds. cont home lasix. . # hyperkalemia: potassium high throughout admission. received polysterene x1 in micu. no adrenal insufficiency by serum cortisol. has a history of this in the past. repeated kayexelate on floor which the patient tolerates well. put on renal diet. cont 10mg lasix per home regimen. pcp can consider further w/u as out-pt with trans-tubular k gradient, aldosterone, renin. . # tachycardia: on admission, concerning for volume depletion given pre-renal state and in the setting of recent confusion with likely poor po intake. no recent ecg. ecg was nsr, not tachy. resumed patient home beta blocker at lower dose. . # le chronic venous stasis changes: seen by vascular in the past, c/w chronic venous insufficiency. wound consult saw patient and recommendations included in discharge paperwork. . # ra: appears from last rheumatology note more consistent with burnt out disease. cont home hydroxychloroquine. disabling, pt wheelchair bound at baseline, cont home hydroxychloroquine. . # pre-syncope and fall: clarify events in am regarding events of fall. no focal neurologic deficits on exam. no fractures on pelvic xray. unclear history however concerning for mechanical etiology vs confusion in the setting of hypercarbia. no fractures on pelvic xray. pt saw and assessed patient. he should be on fall percautions. . # enlarged thyroid on prior ct: tsh normal. patient should be set up with thyroid imaging as outpatient. tsh wnl. pcp could consider ultrasound. # schizophrenia: continued risperidone, oxcarbamazapine, divalproex . # h/o pe: remote history. inr supratherapeutic, held coumadin but then became subtherapeutic so needed a heparin bridge. coumadin continued and therapeutic at discharge. . # dm: no oral hypoglyemics at baseline. hemoglobin a1c of 6.1 in . iss while in house. cont asa 81mg daily. . # bph: cont flomax . # glaucoma: cont home gtts # general care: ppx: ranitidine, therapeutic on coumadin, bowel regimen, access: piv, code: full code, contact: fen: replete lytes prn / low k diet. discharged to rehab. medications on admission: risperidone 3 mg qhs latanoprost 0.005 % 1 drop hs oxcarbazepine 300 mg aspirin 81 daily hydroxychloroquine 200 mg divalproex 500 mg albuterol puff q 4 hours prn fluticasone 110 mcg 2 puffs acetaminophen 325 mg 1-2 tablets po q6h prn pain ranitidine hcl 150 mg daily furosemide 10 mg daily warfarin 6 mg daily aledronate 70 mg q week calcitriol 0.25 mg daily flomax 0.4 mg daily spiriva 1 cap daily vitamin d daily discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. risperidone 1 mg tablet sig: three (3) tablet po hs (at bedtime). 3. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 4. oxcarbazepine 150 mg tablet sig: two (2) tablet po bid (2 times a day). 5. hydroxychloroquine 200 mg tablet sig: one (1) tablet po bid (2 times a day). 6. divalproex 500 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po bid (2 times a day). 7. furosemide 20 mg tablet sig: 0.5 tablet po daily (daily). 8. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 9. senna 8.6 mg tablet sig: one (1) tablet po twice a day. 10. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 13. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 14. colace 100 mg capsule sig: one (1) capsule po twice a day. 15. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 16. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 17. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 18. alendronate 70 mg tablet sig: one (1) tablet po once a week. 19. bacitracin 500 unit/g ointment sig: one (1) application topical once a day. 20. flomax 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. 21. flovent hfa 110 mcg/actuation aerosol sig: one (1) ih inhalation twice a day. 22. hydrocortisone 1 % cream sig: one (1) apply to skin topical twice a day. 23. proair hfa 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation twice a day. 24. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation once a day. 25. azithromycin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 3 days: start am of . disp:*3 tablet(s)* refills:*0* 26. prednisone 20 mg tablet sig: as directed tablet po once a day: please take 2 tablets on and then take 1 tablet on . 27. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical tid (3 times a day) as needed for itching. discharge disposition: extended care facility: discharge diagnosis: primary: obesity hypoventilation syndrome copd exacerbation acute renal failure hyperkalemia hypertension . secondary: depression diabetes schizoaffective disorder rheumatoid arthritis 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 after an episode of lightheadedness resulting in a fall. once you arrived on the floor you were unresponsive and we believe this was because you were not enough in combination with your copd. you were also evaluated by the sleep doctors . you were seen by the wound care nurses for your leg wounds. . you are being discharged to rehab which you should be in for less than 30 days. . the following changes have been made to your medication regimen: 1)we started you on prednisone taper for the next 4 days. 2)we started you on azithromycin for the next 3 days. 3)we changed your metoprolol to 25mg by mouth twice a day. 4)we added amlodipine 10mg daily for your blood pressure. . you will need to be seen by your nephrologist, the sleep doctors and your primary care doctor when you leave rehab. followup instructions: provider: , md phone: date/time: 2:00 provider: , md phone: date/time: 9:00 . please call the dr. , the sleep doctor, for a follow up appointment at( within the next 2 weeks. procedure: non-invasive mechanical ventilation diagnoses: acidosis acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified obstructive chronic bronchitis with (acute) exacerbation depressive disorder, not elsewhere classified chronic kidney disease, unspecified pulmonary collapse long-term (current) use of anticoagulants rheumatoid arthritis personal history of venous thrombosis and embolism obesity, unspecified schizoaffective disorder, unspecified other hyperalimentation 

Answer: The patient is high likely exposed to