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 / morphine / keppra / acetylcysteine attending: chief complaint: back pain major surgical or invasive procedure: thoracic embolization t8/9 corpectomy with cage and instrumented fusion and bone marrow aspiration transfusions thoracentesis bronchoscopy and bal history of present illness: dr. is a 58 year old female with a history of metastatic renal caricnoma to the brain, spine and lungs s/p multiple thoracic procedures for resesection of pulmonary metastases who was admitted to the neurosurgical service on for planned vertebrectomy and reconstruction of t8 and t9. she underwent this procedure on . the procedure was uncomplicated and she has been healing well from a surgical perspective. she was extubated on the 9th. she notes that she has had a cough since extubation but has not been bringing up significant secretions. she notes that she feels as if she has a weak cough. she spiked a fever to 102 degrees on and was noted to have wheezing. she had a portable cxr which was suggestive of pneumonia and was started on levofloxacin. she spiked again on and had cultures drawn. she had a ct t-spine to evaluate post-operatively and although not protocoled to evaluate the lungs, lung windows revealed a moderate-to-large left pleural effusions, small right pleural effusion with bibasilar dependent consolidations, left greater than right, concerning for pneumonia and pleural effusions. her pulse was in the high 90s on and has risen gradually to the 120s. a trigger was called on the floor at 16:29 on when she developed worsening respiratory status. she was noted to appear anxious with labored breathing with respiratory rates in the 30s and hr in the 130s. she reports that her acute respiratory distress started shortly after receiving acetylcysteine she received 1 mg po ativan and a micu evaluation was called. abg was 7.46/41/64. she received a nebulizer treatment which she says improved her symptoms and was also placed on 50% by facemask. she was started on vancomycin and cefepime. she was transferred to the micu for further management. on arrival the micu she reports that her respiratory symptoms have dramatically improved. she is no longer coughing. she has mild pain with deep inspiration but is able to take a deep breath. she has cough productive of minimal sputum and feels as if her cough is weak. she feels chills but is not currently febrile. her appetite is poor. she has no nausea, vomiting, abdominal pain, diarrhea, dysuria, hematuria, leg pain or swelling. she has not had a bowel movement for 3 days. past medical history: metastatic renal cell carcinoma - diagnosed in - s/p left radical nephrectomy with pathology consistent with clear cell carcinoma - s/p right upper lobe wedge resection for pulmonary metastasis - right frontal lobe brain metastasis s/p resection with sterotactic radiosurgery to resection site - s/p high dose il-2 - s/p right bilobectomy (right upper and right middle lobe) - s/p right chest wall resection - s/p right lower lobe wedge resection - t8 s/p cyberknife - s/p sunitinib complicated by hand foot syndrome, mucositis - rad001 trial to present - s/p t8 and t9 vetebrectomy and recontruction hypertension peptic ulcer disease (h. pylori positive) hyperglycemia social history: works as a pediatrician in a private practice. she will be returning to work during her weeks that she is feeling well. family history: non-contributory physical exam: vitals: t: 100.3 bp: 135/55 p: 123 r: 16 o2: 94% on 4l general: alert, oriented, no acute distress heent: sclera anicteric, mm dry with evidence of mucocytis neck: supple, jvp not elevated, no lad lungs: coarse breath sounds throughout. scarce expiratory wheezes througoug with bronchial breath sounds at left base. no egophony. no clear decrease in tactile fremitus. cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining clear yellow urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema back: well healing surgical incision with staples in place, no erythema, warmth pertinent results: 09:00am blood wbc-10.6 rbc-3.97* hgb-7.6* hct-25.9* mcv-65* mch-19.1* mchc-29.2* rdw-17.8* plt ct-226 09:00am blood plt ct-226 09:00am blood pt-11.2 ptt-24.4 inr(pt)-0.9 09:00am blood glucose-142* urean-16 creat-1.0 na-140 k-4.1 cl-102 hco3-27 angap-15 09:00am blood calcium-8.7 phos-3.3 mg-1.9 06:45am blood glucose-108* urean-6 creat-0.7 na-138 k-4.7 cl-105 hco3-27 angap-11 03:40am blood glucose-115* urean-11 creat-0.8 na-136 k-4.2 cl-99 hco3-29 angap-12 07:30am blood glucose-137* urean-17 creat-0.8 na-139 k-4.5 cl-98 hco3-31 angap-15 06:25am blood caltibc-152* vitb12-326 folate-6.9 ferritn-595* trf-117* . cbc trend: 02:27am blood wbc-7.2 rbc-3.49* hgb-8.8* hct-25.5* mcv-73* mch-25.1* mchc-34.3 rdw-19.9* plt ct-174 05:10am blood wbc-11.5*# rbc-3.19* hgb-8.2* hct-24.5* mcv-77* mch-25.6* mchc-33.3 rdw-20.2* plt ct-213 06:25pm blood wbc-14.9* rbc-3.20* hgb-8.2* hct-24.9* mcv-78* mch-25.5* mchc-32.8 rdw-20.6* plt ct-238 04:42am blood wbc-12.7* rbc-3.17* hgb-7.9* hct-24.2* mcv-76* mch-24.8* mchc-32.5 rdw-22.2* plt ct-340 05:00am blood wbc-10.3 rbc-3.05* hgb-7.7* hct-23.7* mcv-78* mch-25.2* mchc-32.4 rdw-22.1* plt ct-368 03:40am blood wbc-9.3 rbc-3.36* hgb-8.6* hct-26.2* mcv-78* mch-25.7* mchc-32.8 rdw-21.8* plt ct-432 06:30am blood wbc-9.8 rbc-3.23* hgb-8.1* hct-25.4* mcv-79* mch-25.2* mchc-32.0 rdw-22.2* plt ct-450* 06:05am blood wbc-9.7 rbc-3.23* hgb-8.4* hct-25.3* mcv-78* mch-26.1* mchc-33.3 rdw-22.5* plt ct-491* 06:30am blood wbc-9.2 rbc-3.00* hgb-7.7* hct-23.5* mcv-78* mch-25.8* mchc-32.9 rdw-22.2* plt ct-493* 06:25am blood wbc-9.2 rbc-3.16* hgb-7.8* hct-25.2* mcv-80* mch-24.7* mchc-31.0 rdw-22.5* plt ct-568* 06:50am blood wbc-10.7 rbc-3.71* hgb-9.5* hct-30.3* mcv-82 mch-25.6* mchc-31.4 rdw-21.8* plt ct-560* 06:35am blood wbc-9.8 rbc-3.35* hgb-8.7* hct-27.3* mcv-82 mch-25.9* mchc-31.7 rdw-22.1* plt ct-579* 06:50am blood wbc-7.2 rbc-3.39* hgb-8.5* hct-27.1* mcv-80* mch-25.1* mchc-31.4 rdw-21.8* plt ct-576* 06:45am blood wbc-6.4 rbc-3.60* hgb-9.0* hct-28.8* mcv-80* mch-25.0* mchc-31.3 rdw-21.7* plt ct-639* 06:10am blood wbc-7.0 rbc-3.84* hgb-9.5* hct-30.5* mcv-80* mch-24.8* mchc-31.2 rdw-21.9* plt ct-619* 07:30am blood wbc-5.0 rbc-3.65* hgb-9.3* hct-28.6* mcv-78* mch-25.6* mchc-32.6 rdw-21.3* plt ct-504* . abg: 02:11pm blood type-art temp-37.6 po2-90 pco2-43 ph-7.42 caltco2-29 base xs-2 intubat-not intuba 05:18pm blood type-art po2-64* pco2-41 ph-7.46* caltco2-30 base xs-4 . all blood cx, pleural fluid cx, bal cx no growth pleural analysis wbc rbc polys lymphs monos meso macro other 03:54pm 155* 420* 45* 4* 0 16* 21* 14*1 . 1. atypical cells,refer to cytology reviewed by on . pleural chemistry totprot glucose ld(ldh) 03:54pm 2.7 133 124 . other body fluid other body fluid ph 05:53pm 7.521 . pleural fluid aspergillus galactomannan antigen neg . ct spine: impression: 1. status post posterior fusion spanning from t5 to t12 with appropriate anatomical alignment, no evidence for hardware failure. intervertebral cage device between t8/t9. 2. moderate-to-large left pleural effusions, small right pleural effusion with bibasilar dependent consolidations, left greater than right, concerning for pneumonia and pleural effusions. 3. status post left nephrectomy. . ct torso: impression: 1. bilateral airspace opacities, predominantly at the left lung, concerning for pneumonia. airspace opacity at the right apex, could be due to early lymphangitic spread of tumor with metastatic burden here increased from prior. 2. large dependent pleural effusion on the left and small pleural effusion on the right. 3. status post posterior fusion spanning from t5 to t12 with appropriate anatomic alignment, and no evidence of hardware failure. intervertebral cage device between t8 and t9. the measurements for the target lesions were updated in the oncology table. . ct neck: impression: 1. no definite evidence of upper airway obstruction. 2. no significant lymphadenopathy in the neck according to ct size criteria. 3. bilateral peribronchial opacities at the lung apices, described in more details on the ct torso from the same day. final attending note: if there is concern for tracheomalacia, tracheal fluoroscopy may be useful. . tte : the left atrium is elongated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 60%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. the pulmonary artery systolic pressure could not be determined. no masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. compared with the findings of the prior study (images reviewed) of , no major change is evident. impression: suboptimal image quality. no definite vegetations seen . cxr pa/lat: findings: there is persistence of airspace disease in the left middle lung and the right lung base. extensive retrocardiac changes likely indicate coarse bronchiectasis. diffuse bilateral reticulonodular interstitial markings (right greater than left) likely represent lymphangitic carcinomatosis given clinical history, and is consistent with findings on chest ct from . there is interval removal of thoracic surgical clips. rods for fixation of the thoracic spine appears intact. upper abdominal surgical clips are in place. impression: 1) persistent bilateral pleural effusions and pulmonary infiltrates. 2) reticulonodular interstitial disease likely lymphangitic carcinomatosis. . pleural fluid cytology: negative for malignant cells . pathology of lung, left lower lobe, transbronchial biopsy: carcinoma morphologically consistent with metastatic renal cell carcinoma (history of renal cell carcinoma) brief hospital course: the patient is a 58 year old female with a history of metastatic renal carcinoma to the brain, spine and lungs who was admitted for an elective vertebrectomy and reconstruction of t8 and t9 for spinal stabilization. she tolerated this procedure well on , but developed postoperative respiratory distress and likely hospital acquired pna. she was briefly transferred to the micu for respiratory disress, and then to the oncology service. . 1) hospital acquired pneumonia/respiratory distress: patient transferred to the micu on for acute respiratory distress with tachycardia, tachypnea and fevers. pt with poor pulmonary reserve s/p multiple lung resections with mild restrictive defect on recent pfts at baseline. ct torso showed pneumonia and dependent effusion in l lung. ct neck without obstruction of upper airways. she completed an antibiotics course as follows: meropenem (), vancomycin and cipro (), and cefipime (). patient was persistently febrile on antibiotics, and underwent thoracentesis and bronchoscopy/bal, but all blood cultures, pleural fluid cultures and bal cultures were negative. in addition, a tte was performed showing no evidence of any vegetations. during this period, the patient was treated with supplemental oxygen, ipratropium, atrovent and lidocaine nebulizers, as well as guaifenesin and benzonatate for cough. on , the patient restarted everolimus and on all antibiotics were stopped. . 2)t8 + t9 vertebrectomy and reconstruction: pt was admitted and brought to inr suite where she underwent embolization to the thoracic spine in prepartion for or. she tolerated this procedure well. there was concern about possible extension into t9 vertebral body as well as t8 and she therefore also underwent bone scan on . this showed uptake at t8 adjacent to a larger photopenic area, likely related to osteoblastic activity in a known mixed lytic and sclerotic metastasis and minimally increased activity at multiple thoracic levels not as avid and extensive as would be expected from the appearance on ct suggesting the tumor is primarily osteoclastic, decreasing the sensitivity of the bone scan for visualization of metastatic disease. she was readied for the or and on under general anesthesia she underwent t8 and 9 vertebrectomies with fusion including cage, hooks, pedicle screws and rods. she tolerated this procedure well with intraop transfusions and was transferred to ticu. due to long time in prone position of surgery she remained intubated overnight. post op she had full strength. ct t-spine with appropriate anatomical alignment, no evidence for hardware failure. patient treated initially with dilauded and morphine for pain control, which was gradually stopped. the patient underwent a trial of toradol with good relief. at discharge, pain well-controlled on standing tylenol and naproxen, with fentanyl lozenges prn. plan to followup with neurosurgery six weeks postoperative. . 3) metastatic renal cell carcinoma: patient taking everolimus as part of the rad001 protocol prior to surgery, restarted on with significant improvement in breathing. no obstructing mass see on bronchoscopy, but biopsies positive for renal cell carcinoma. . 4) persistent tachycardia: likely multifactorial in setting of acute illness, fever, anxiety, anemia and medications such as xopenex. ekg showed sinus tachycardia with no acute ischemic changes. . 5) chronic normocytic anemia, likely related to renal cell carcinoma and chronic inflammatory state. on aranesp at home. patient transfused with 3 units prbcs over the course of her hospitalization. also treated with b12 and folate supplementation. . 6) vaginal candidal infection on examination . patient asymptomatic, treated with vaginal nystatin while inpatient. . 7) peptic ulcer disease, continued protonix 40 mg . . 8) diabetes, on glyburide at home. treated with humalog sliding scale while inpatient. . #access: peripherals . #code: dnr/dni . communication: patient and partner medications on admission: glyburide 5 mg daily naprosyn d/c'd omeprazole 20 mg daily tylenol (as needed) zofran aranesp injector, everolimus 20 mg daily ativan 0.5 to 1 mg (as needed) discharge medications: 1. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 2. furosemide 20 mg tablet sig: one (1) tablet po every other day as needed for shortness of breath or wheezing. 3. fentanyl citrate 400 mcg lozenge on a handle sig: one (1) lozenge on a handle buccal q12h () as needed for pain. 4. senna 8.6 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for constipation. 5. everolimus 10 mg tablet sig: one (1) tablet po daily (). 6. zolpidem 5 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for insomnia. 7. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po tid (3 times a day) as needed for nausea. 8. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 9. docusate sodium 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for constipation. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*30 units* refills:*1* 12. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 13. vitamin b-12 1,000 mcg tablet, sublingual sig: one (1) sublingual once a day for 1 months. disp:*30 tabs* refills:*0* 14. naproxen 250 mg tablet sig: two (2) tablet po q8h (every 8 hours). 15. nebulizer kit sig: one (1) miscellaneous every four (4) hours. disp:*1 kit* refills:*0* 16. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 17. ondansetron 4 mg tablet, rapid dissolve sig: tablet, rapid dissolves po q8h (every 8 hours) as needed for nausea. 18. glyburide 5 mg tablet sig: one (1) tablet po once a day. 19. home oxygen sig: one (1) continuous as needed for shortness of breath or wheezing: 2l continuous pulse dose for portability. disp:*1 tank* refills:*0* 20. 3-in-1 commode sig: one (1) as needed. disp:*1 commode* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: renal cell carcinoma metastatic to thoracic spine anemia pneumonia/bilateral pleural effusions discharge condition: good: afebrile, ambulatory off of o2, neurologically stable, taking po discharge instructions: you have a diagnosis of metastatic renal cell carcinoma and were admitted to the hospital for an elective spinal surgery. postop, you had respiratory distress and pneumonia, treated with antibiotics. in addition, your respiratory distress was treated with oxygen, nebulized bronchodilators and cough suppressants. after a course of antibiotics, you were restarted on your prior treatment drug, everolimus, with significant improvement in your breathing. discharge instructions for spine cases ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/ take daily showers ?????? no pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? limit your use of stairs to 2-3 times per day ?????? have a family member check your incision daily for signs of infection ?????? take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit call your surgeon immediately if you experience any of the following: ?????? pain that is continually increasing or not relieved by pain medicine ?????? any weakness, numbness, tingling in your extremities ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f ?????? any change in your bowel or bladder habits . if you experience any of the above symptoms, chest pain, dizziness, persistent high fevers, or significant worsening of your shortness of breath, please return to the hospital or call your primary oncologist dr. . followup instructions: please call to make an appointment with dr. for tuesday clinic in 2 weeks. . please call to schedule an appointment with dr. to be seen 6 weeks from the date of your surgery. you will need xrays prior to appointment procedure: thoracentesis closed [endoscopic] biopsy of bronchus excision of bone for graft, other bones dorsal and dorsolumbar fusion of the posterior column, posterior technique injection or infusion of cancer chemotherapeutic substance insertion of interbody spinal fusion device fusion or refusion of 4-8 vertebrae other therapeutic apheresis other operations on joint structures diagnoses: pneumonia, organism unspecified unspecified pleural effusion acute posthemorrhagic anemia candidiasis of mouth secondary malignant neoplasm of brain and spinal cord secondary malignant neoplasm of lung personal history of malignant neoplasm of kidney secondary malignant neoplasm of bone and bone marrow candidiasis of vulva and vagina anemia in neoplastic disease 

Answer: The patient is high likely exposed to