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: iodine-iodine containing / morphine attending: chief complaint: hyponatremia, acute renal failure, hyperkalemia major surgical or invasive procedure: intubation cvvh s/p pleurex placement for drainage tips procedure which stenosed s/p nephrostomy for obstructing left ureteral stone history of present illness: pt is a 49yo man with complicated past medical history including multiple myeloma and plasma cell leukemia progressing despite therapy c/b portal hypertension of unclear etiology s/p abdominal pleurex catheter placement on for symptomatic draininage last admitted with cellulitis in now presents with diarrhea and fatigue s/p pet scan foud to have hyponatremia, acute renal failure, hyperkalemia. . he has currently been on pulses of decadron 4 mg alternating with 12 mg pulse therapy x four days and re-started - 10mg po every other day. on tuesday given concerns about a possible infection due to declining blood pressures, penile irritation and leukopenia his decadron was decreased from 4 mg to 2 mg po qd 2 days prior to presentation. he then had increased fatigue one day prior to presentation. he does not tolerate fatty foods well and is usually on a low fat diet. in preparation for his pet scan he ate fatty foods and subsequently developed diarrhea loose bms. upon arrival to the floor this has ceased. the stool was descrbied as brown with flecks of blood. he did not have nausea, vomiting or abdominal pain. he usually drains 1-2l of fluid from his abdominal pleurex catheter daily but it has decreased to 1l per day. he does have a stage ii decubitis which has become more irritated in light of the diarrhea. he has not had any fevers, chills or cough. he is currently being evaluated by dr. for treatment of his portal hypertension. he is s/p liver bx with hepatic venous pressure gradient also performed. per his wife given the results of the liver bx and the hepatic venous pressure gradient study dr. thinks that he is a candidate for a tips procedure. past medical history: oncology history: *: presented with rib fx, fatigue, dyspnea, hypercalcemia, , and pancytopenia. rx'ed with decadron, velcade, cad, xrt to b/l hip and femers, it lipsomal cytarabine, hd mtx, pamidronate * disease progression despite therapy and therapy switched to cytoxan, doxorubicin, and dexamethasone * mr done for pain, shows confluent abnormal signal in the femoral necks bilaterally raising concern for fracture risk. completed radiation to bilateral hips on */ received 5 more cycles of velcade and dexamethasone * new symptom of diplopia, neuro evaluation concerning for disease involvement at cns 4 and 7. lp + for plasma cells. * it depocyt * iv mtx 3500 mg/m2 * developed upper extremity paresthesias and lue weakness and mr showed evidence of brachial plexus and conus medullaris involvement. * xrt to skull, brachial plexus and conus medullaris * cytoxan 500 mg/m2 x 2 cycles and it depocyt x 3 cycles * ablative sibling allogeneic stem cell transplant with cytoxan and tbi as conditioning regimen. * lp done for positional headache confirms cns relapse. it depocyt x 2 cycles. * 1st dli at 5 x 10^6 tcells/kg * started 5 mg * mr done for liver assessment shows adenopathy, pet scan confirms fdg avid retroperitoneal disease * core biopsy of perinephric and retroperitoneal masses shows atypical plasma cell infiltrate * 2nd dli at 1 x 10^7 t cells/kg * started cyclophosphamide/velcade/dex * admitted with urinary incontinence and cauda equina due to disease progression --> hydronephrosis. * c1d1 dtpace (doxorubicin, ctx, cddp, etoposide, dexamethasone). * depocyt dli #3 on . continuing on . current treatment plan: intervals of decadron 4 mg alternating with 12 mg pulse therapy x four days as np/md. - 10mg po every other day. other past medical history: nephrolithiasis asthma chronic low back pain obstructive sleep apnea social history: pt has phd in engineering and lives with wife and three young sons. worked as a professor prior to his illness and his wife is a plastic surgeon. no tobacco, alcohol, or illicit drugs. family history: no family history of premature ca. mother with cad in old age (80's). father had aaa in his 80s. physical exam: physical exam: vs: temp 96.7, bp 86/50, hr 112, rr 20, sao2 99% ra, general: chronically ill appearing thin male man in nad, comfortable, appropriate heent: nc/at, eomi, sclerae anicteric, mmm, op clear axilla: large r axillary lymph node neck: supple, no lad or thyromegaly lungs: cta bilat, no r/rh/wh heart: rrr, nl s1-s2, no mrg abdomen: +bs, soft/nt/nd, no hsm extrem: b/l 2+ le edema- stable and slightly improved per his wife. skin: stage ii decubitus which is not infected. frothy white d/c present at anus. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact -motor: decreased normal bulk, normal strength and tone throughout. no abnormal movements noted. access: l piccl cdi foley: present none trach: present none peg:present none site c/d/i colostomy: :present none site c/d/i pertinent results: labs: on admission: 10:00pm creat-1.8* sodium-128* potassium-5.3* chloride-98 10:00pm calcium-8.1* phosphate-3.8 magnesium-1.6 10:00pm urine hours-random urea n-802 creat-80 sodium-less than potassium-75 chloride-13 10:00pm urine osmolal-462 10:00pm urine color-yellow appear-clear sp -1.011 10:00pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 10:00pm urine rbc-5* wbc-2 bacteria-none yeast-none epi-1 10:00pm urine hyaline-3* 06:10pm plt count-60*# 02:00pm urea n-67* creat-1.8* sodium-126* potassium-5.8* chloride-96 total co2-22 anion gap-14 02:00pm alt(sgpt)-49* ast(sgot)-25 ld(ldh)-315* alk phos-369* tot bili-0.8 02:00pm albumin-2.6* calcium-7.2* phosphate-3.6 magnesium-1.6 02:00pm osmolal-282 02:00pm wbc-4.0# rbc-2.80* hgb-10.1* hct-29.6* mcv-106*# mch-36.2* mchc-34.2 rdw-21.8* 02:00pm neuts-78* bands-3 lymphs-10* monos-9 eos-0 basos-0 atyps-0 metas-0 myelos-0 02:00pm hypochrom-normal anisocyt-2+ poikilocy-normal macrocyt-1+ microcyt-normal polychrom-occasional 02:00pm plt smr-very low plt count-26* micro: 12:36 am blood culture source: venipuncture. **final report ** blood culture, routine (final ): enterobacter cloacae. identification and sensitivities performed on culture # 337-5014c, . aerobic bottle gram stain (final ): gram negative rod(s). 7:33 pm urine source: catheter. **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. yeast. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- =>16 r vancomycin------------ =>32 r 6:41 pm urine source: catheter. **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. sensitivities performed on culture # 337-6184c . yeast. >100,000 organisms/ml.. 11:24 am urine source: catheter. **final report ** urine culture (final ): enterococcus sp.. >100,000 organisms/ml.. parapsilosis. >100,000 organisms/ml.. dr requested yeast id and fluconazole sensitivities. susceptible to fluconazole susceptibility testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- =>16 r vancomycin------------ =>32 r 11:24 am sputum site: endotracheal source: endotracheal. gram stain (final ): pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): yeast(s). smear reviewed; results confirmed. respiratory culture (final ): sparse growth commensal respiratory flora. yeast. sparse growth. legionella culture (final ): no legionella isolated. fungal culture (preliminary): yeast. 3:28 pm sputum site: endotracheal gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): budding yeast with pseudohyphae. respiratory culture (final ): commensal respiratory flora absent. yeast. moderate growth. legionella culture (final ): no legionella isolated. fungal culture (preliminary): yeast. 10:56 am urine source: catheter. **final report ** urine culture (final ): yeast. >100,000 organisms/ml.. 6:30 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): sparse growth commensal respiratory flora. yeast. sparse growth. imaging: pet scan: impression: 1. no new fdg-avid disease identified. previously seen right retroperitoneal soft tissue mass has resolved. 2. bilateral perinephric and left periureteral soft tissue lesions are not well assessed on the present study and were fully described on recent mr . 3. increased moderate ascites. 4. decreased small bilateral non-fdg-avid pleural effusions. 5. slightly increased small pericardial effusion. 6. unchanged mild left hydronephrosis. 7. relatively increased fdg-uptake in the t2-t11 vertebral bodies could be due to either recent radiation to this aspect of the spine, or prior radiation to the remainder of the spine. renal us: impression: 1. echogenic kidneys consistent with medical renal disease. 2. multiple stones in left kidney with hydronephrosis which has worsened since the prior mri in . proximal hydroureter. no definite obstructing stone seen. 3. cyst within the left kidney. 4. nonobstructing stone in the right kidney. 5. ascites. mri pelvis: impression: 1. this examination is limited somewhat by lack of administration of contrast; however, there is interval increase in size of the perinephric deposits surrounding the left kidney in particular suggestive of disease progression. the perinephric deposit surrounding the proximal left ureter is stable. the overall moderate hydronephrosis and proximal hydroureter in the left kidney is grossly unchanged when compared to prior imaging. 2. hemosiderosis. 3. moderate volume intra-abdominal ascites also noted. renal us: impression: 1. stable moderate-to-severe left hydroureteronephrosis with two stones in the lower pole calices. no calculi identified in the ureter. the left ureteral jet was seen. 2. non-obstructive stone in the lower pole of the right kidney. ct head: impression: no evidence of acute intracranial process to explain patient's altered mental status. echo: impression: hyperdynamic left ventricular systolic function. mildly dilated right ventricle with abnormal septal motion consistent with rv pressure/volume overload. mild pulmonary artery systolic hypertension. trivial to very small pericardial effusion. compared with the prior study (images reviewed) of , there is interventricular septal flattening consistent with right ventricular pressure/volume overload. the estimated pulmonary artery systolic pressure is greater, but may have been underestimated on the prior study. the pericardial effusion is slightly smaller. portable cxr: impression: right basal opacity could reflect aspiration or pneumonia. portable cxr: findings: endotracheal tube ends 3.6 cm above the carina and is appropriate in position, orogastric tube courses below the diaphragm into the stomach; however, the distal end is off radiograph view and left internal jugular line ends at lower svc. since right upper pneumonia has worsened and moderate to large right pleural effusion persists. left lung is clear, no effusion. heart size, mediastinal and hilar contours are normal. ruq ultrasound: impression: 1. sludge within an otherwise normal appearing gallbladder. 2. large volume ascites. 3. right pleural effusion. 4. patent tips. echo: no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is hyperdynamic (ef>75%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with normal free wall contractility. there is abnormal septal motion/position. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the estimated pasp has increased slightly. abdominal us w doppler: kidneys are extremely echogenic and there is reduced corticomedullary differentiation suggesting significant impairment. mild fullness of the proximal ureters are seen, but there is no good evidence of hydronephrosis. there is a 1.5 cm calculus in the left kidney. there is likely a left-sided nephrostomy. the right kidney measures 12 cm. the left kidney measures 11.2 cm. there is a lower pole 9 mm right-sided non obstructing calculus. conclusion: bilateral but likely nonobstructing calculi. extremely echogenic kidneys. ruq us: conclusion: findings suggestive mid tips stenosis and narrowing, although the tips remains patent. large volume ascites. small amount of sludge in the gallbladder. cxr: multifocal consolidations appear unchanged on the right and slightly worse on the left. the supporting tubes and lines are unremarkable. there is potentially slight interval decrease in right pleural effusion, although it might reflect semi-upright position of the patient as opposite to supine with layering of pleural effusions. brief hospital course: 49 yo m with h/o mm/plasma cell leukemia which was progressive despite therapy c/b portal htn of unknown etiology admitted originally with diarrhea and acute renal failure with prolonged hospital course complicated by significant rp plasmacytomas, tips procedure which subsequently stenosed, obstructing left ureteral stone s/p nephrostomy, respiratory failure requiring intubation/ventilation, enterobacter/enterococcus septic shock requiring levophed/vasopressin and renal failure requiring cvvh. ultimately, despite our best efforts, the patient's status continued to decline. he was continued on aggressive measures up until the end, including pressors, cvvh, and mechanical ventillation, but he finally succumbed to his illness on at 11:27pm. he passed away peacefully with family at his bedside. please see below for a short summaries of the main problems of his course. active issues by problem: # septic shock with multi-organ failure: he was intubated on in setting of likely aspiration event and respiratory decompensation and started on pressors for refractory hypotension. he was also on stress dose of steroids at this time. subsequent blood cultures grew enterobacter and urine grew vre. both sputum and urine grew yeast, later speciated as parapsilosis. he was treated broadly with meropenem, daptomycin, and micafungin, then changed to linezolid, tobramycin, meropenem, and micafungin. required vasopressin and levophed to maintain pressures, eventually at max-doses with continued refractory hypotension resulting in worsening renal failure, respiratory failure, and liver failure. # respiratory failure: intubated for acute respiratory failure following likely aspiration event. sputum had gnrs and yeast at the time of enterobacter bacteremia, however then consistently grew parapsilosis. in the final days before he died, he had increasing requirements on the ventillator to maintain his sats, and chest xrays showed new infiltrates that were likely due to ongoing aspiration events. # renal failure: found to be in acute renal failure, with creatinine continuing to trend up. he has a known history of l hydronephrosis, and given his worsening liver failure, there was also concern for hepato-renal syndrome. the patient was being seen by hepatology and was s/p tips for reduction of portal pressures. the patient was maintained on midodrine and octreotide initially for hepatorenal syndrome while in the icu, with doses being titrated up because of no improvement in his renal funciton. he was also started on albumin, which was uptitrated to 100 grams daily. because of the evidence of l hydronephrosis, the patient also underwent ir procedure and perc nephrostomy tube was placed, which initialy drained bloody fluid. his bun/creat ultimately kept climbing, and because of his worsening mental status, he ultimately was started on hd. midodrine and octreotide were stopped at that time. pt then developed sepsis (see above) and was unable to tolerate hd, so he was transitioned to cvvh on . given his septic shock, at that point it was thought that there was really no chance of renal recovery, but cvvh was continued per request of the family after discussion of goals of care. it was continued until the day that he passed away. # portal hypertension, liver failure: known to have portal hypertension, thought to be secondary to nodular regenerative hyperplasia, unclear etiology. possibly due to his underlying hematologic malignancy. patient underwent a tips procedure, however this was found to be partially stenosed on admission the icu. the patient was s/p tips on admission to the micu, and on ultrasound to evaluate tips patency, there was some initial evidence of stenosis. he was initially maintained on midodrine/octreotide, however as his sepsis picture worsened, these medications were stopped. his liver enzymes began to rise slightly as septic shock set in, and his labs showed evidence of liver failure with decreased synthetic function (namely, an elevated inr). # mm and plasma cell lymphoma: pt with refractory disease despite bone marrow transplant and numerous aggressive therapies. had been treated with dexamethasone and on admission, however dexamethasone was held when he was placed on stress dose steroids. his was also held. bmt continued to follow the patient throughout hospitalization, but unfortunately treatment options for his myeloma were exhausted. medications on admission: confirmed with wife on admission atovaquone suspension 1500 mg po/ng daily after dinner multivitamins 1 tab vitamin d 1000 unit po/ng daily @ 2134 view testosterone 5mg patch 1 ptch td daily @ 2134 view folic acid 1 mg po/ng daily @ 2134 view acyclovir 400 mg po/ng q12h patient has been on this at home. dexamethasone 2 mg po qd 10 mg po qod oxycodone (immediate release) 5 mg po/ng q4h:prn pain change dc oxycodone sr (oxycontin) 10 mg po q12h discharge medications: expired discharge disposition: expired discharge diagnosis: multiple myeloma sepsis hypoxemic respiratory failure renal failure liver failure discharge condition: expired discharge instructions: expired followup instructions: expired procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis percutaneous nephrostomy without fragmentation venous catheterization for renal dialysis injection of anesthetic into spinal canal for analgesia intra-abdominal venous shunt phlebography of the portal venous system using contrast material diagnoses: hyperpotassemia thrombocytopenia, unspecified urinary tract infection, site not specified acute and subacute necrosis of liver acute kidney failure, unspecified hepatorenal syndrome acquired coagulation factor deficiency unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia severe sepsis portal hypertension candidiasis of other urogenital sites atrial fibrillation peripheral stem cells replaced by transplant acute respiratory failure pneumonitis due to inhalation of food or vomitus septic shock infection with microorganisms without mention of resistance to multiple drugs other complications due to other vascular device, implant, and graft antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use paralytic ileus pressure ulcer, buttock other septicemia due to gram-negative organisms other ascites do not resuscitate status hepatic encephalopathy hypovolemia glucocorticoid deficiency hydronephrosis calculus of kidney mixed acid-base balance disorder pressure ulcer, stage ii pressure ulcer, stage iii multiple myeloma, in relapse plasma cell leukemia, in relapse 

Answer: The patient is high likely exposed to