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: no known allergies / adverse drug reactions attending: chief complaint: hyperglycemia, leg swelling major surgical or invasive procedure: right heart catheterization history of present illness: mr. is a 62 year old male with type ii diabetes mellitus, coronary artery disease, hypertension, obstructive sleep apnea, chronic kidney disease stage iii, and a prior pulmonary embolism, presented to the hospital with hyperglycemia and leg swelling. the patient had several critically high finger sticks the morning of admission, and also endorsed impaired cognition, polyuria, and polydipsia. after calling clinic, he was advised to come to the ed. the patient denied fevers or chills, nausea, vomiting, or diarrhea. he had some abdominal discomfort and felt that his abdomen was swollen. his last bowel movement was 2 days prior. in the ed, initial vitals were t98.7, p70, bp124/68, r18, o2sat96% on room air labs were notable for a blood glucose of 376 chest xray was normal, abdominal xray did not show free air or obstruction mr. received 125 units of u500 insulin vitals on transfer were bp112/51, p70, t97.0, r16 o2sat96% on room air ros: (+) for increasing swelling in legs and abdomen over 3 months, 30 pound weight gain during same time, slowed mentation, memory loss (short and long term) (-) for orthopnea, pnd, worsened nocturia, head trauma, history of substance abuse, and chest pain past medical history: - hypertension - hyperlipidemia - type ii diabetes mellitus - atypical depression - coronary artery disease with pci and 2 stents in - anxiety - somatization disorder - osa on cpap 16 - s/p cervical laminoplasty - attention deficit disorder - pulmonary embolism in - atrial flutter s/p ablation ; on coumadin - fatty liver - fibromyalgia social history: mr. lives alone. he quit smoking in , but smoked one pack per day prior to . he denies alcohol and illicit drug use. he used to work in the family buisness marketing clothing accessories, and later ran a clothing store in , but he does not currently work and is on disability. family history: maternal grandfather: mi in his 40's, died at 57 paternal grandfather: mi in his 40's, died at 63 physical exam: on admission: vitals: 96.7 128/68 68 20 97% on ra general: well-appearing man in nad, comfortable, appropriate, generalized swelling and edema is notable in face, lower extremities, back and abdomen. heent: nc/at, perrla, eomi, sclerae anicteric, dry mucous membranes, op clear. neck: supple, hard to assess jvd, no carotid bruits heart: heart sounds are almost inaudible, hard to remark lungs: cta bilat, no r/rh/wh, good air movement, resp unlabored. abdomen: distended, protuberant, non-tender, no masses or hsm, no rebound/guarding. positive shifting dullness extremities: wwp, tight edema with minimal pitting in lower extremities and back, no scrotal edema, stasis dermatitis changes on shins, normal peripheral pulses. no signs of dvt. neuro: intact except mild bradyphrasis and bradyphrenia: awake, a&ox3, cns ii-xii grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, dtrs 2+ and symmetric, cerebellar exam intact, steady gait. on discharge: vitals: 97.8 119/73 53 18 99%ra wt: 124 i/o: 1250/4380 general: nad, anxious about going home, appropriate, a+0x3, sitting in chair taking medications heent: sclerae anicteric, mmm, op clear. neck: no masses, jvp 7 heart: rrr no m/r/g lungs: cta bilat, no wheezes/rhonchi abdomen: distended, non-tender, obese, no masses/ hsm, no rebound/guarding, extremities: wwp, 1+ edema, erythematous chronic skin changes, neuro: intact pertinent results: labs on admission: 05:15pm blood wbc-6.1 rbc-3.97* hgb-12.8* hct-37.6* mcv-95 mch-32.2* mchc-34.0 rdw-13.8 plt ct-155 05:15pm blood neuts-67.4 lymphs-19.7 monos-9.1 eos-2.4 baso-1.4 05:15pm blood plt ct-155 05:15pm blood glucose-376* urean-66* creat-1.8* na-132* k-5.1 cl-93* hco3-28 angap-16 05:15pm blood calcium-8.6 phos-2.7 mg-2.3 interval labs of interest: 07:45am blood alt-111* ast-97* ld(ldh)-213 alkphos-81 totbili-0.4 06:55am blood vitb12-1206* folate-18.8 06:55am blood tsh-1.4 07:30pm blood ferritn-494* 07:10am blood pep-no specific abnl 07:30pm blood c4-27 07:10am blood hiv ab-negative 07:05am blood cortsol-20.6* 11:56pm blood o2 sat-67 06:17pm blood hgb-11.9* calchct-36 o2 sat-68 06:12am blood o2 sat-66 labs on discharge: 07:25am blood wbc-4.7 rbc-4.11* hgb-13.1* hct-38.0* mcv-93 mch-31.8 mchc-34.4 rdw-14.0 plt ct-145* 07:25am blood plt ct-145* 07:25am blood pt-20.7* inr(pt)-1.9* 07:25am blood glucose-331* urean-39* creat-1.2 na-135 k-4.1 cl-93* hco3-32 angap-14 07:25am blood calcium-9.4 phos-4.0 mg-2.1 studies: ekg : sinus rhythm. occasional atrial premature beats. otherwise, no other significant diagnostic abnormality. compared to the previous tracing of there is no significant diagnostic change. rate pr qrs qt/qtc p qrs t 60 148 94 436/436 37 13 17 kub supine and left lateral decubitus views of the abdomen: no free intraperitoneal air or pneumatosis is definitively noted. there is stool noted throughout the colon and nonspecific gaseous distention of the small bowel. no air-fluid levels were noted on the decubitus view. there are mild degenerative changes in the imaged spine. calcified phleboliths are noted within the pelvis. impression: moderate amount of fecal loading throughout the colon with nonspecific gaseous distention of the small bowel. no free intraperitoneal air. cxr upright ap and lateral views of the chest: the cardiac, mediastinal and hilar contours are unchanged, with the heart size within normal limits. the lungs are clear. the pulmonary vascularity is normal. no pleural effusion or pneumothorax is seen. there are multilevel degenerative changes in the spine with anterior osteophyte formation. impression: no acute cardiopulmonary abnormality. echocardiography: the left atrium is mildly dilated. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). 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 root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. pericardial constriction cannot be excluded. cardiac mri impression: 1. normal left ventricular cavity size with normal regional left ventricular systolic function. the lvef was normal at 69%. the effective forward lvef was normal at 62%. small area of possible late gadolinium enhancement in the distal lateral wall. 2. mild flattening of the septum with inspiration, consistent with possible interventricular dependence in the absence of other signs of pericardial constriction. 3. no evidence of myocardial restriction. 4. normal right ventricular cavity size and systolic function. the rvef was normal at 68%. 5. mild mitral regurgitation. mild pulmonic regurgitation. 6. mild biatrial enlargement. cardiac catheterization comments: 1. resting hemodynamics revealed elevated right and left sided filling pressures with rvedp of 25 mm hg and mean pcwp of 26 mm hg. the cardiac index was preserved at 2.4 l/min/m2. there was moderate pulmonary artery hypertension with pasp of 44 mm hg. the pvr was normal at 150 dynes-sec/cm5. final diagnosis: 1. elevated and equalized right and left sided filling pressures. 2. moderate pulmonary artery hypertension. 3. consider restrictive physiology. ekg: sinus bradycardia. otherwise, findings are within normal limits. compared to the previous tracing of no significant diagnostic change. rate pr qrs qt/qtc p qrs t 50 150 98 13 brief hospital course: this is a 62 year old male with a past medical history of type ii diabetes mellitus, coronary artery disease, hypertension, obstructive sleep apnea, chronic kidney disease stage iii, past pulmonary embolism (on coumadin), and repeated admissions for uncontrolled hyperglycemia who presented with mild confusion, hyperglycemia, and mild transient pre-renal failure and was found to have significant anasarca. mr. was initially on the medicine service for 4 days with blood sugars better controlled on an insulin regimen and his renal status improved with fluids. he was subsequently transferred to the cardiology service for iv diuresis and further evaluation of the etiology of his chf. on the cardiology service, he had a right heart catherization suggestive of a restrictive physiology and was monitored in the cardiac critical care unit with a swan-ganz catheter. his volume overload was thought to be secondary to diastolic congestive heart failure and he returned to the cardiology floor for further diuresis with a lasix drip. 1. acute diastolic congestive heart failure: patient was found to have significant anasarca on admission with a reported weight gain of 30 pounds in recent weeks to months. patient was a poor historian and per medical records, his weight was 272 lbs on , 271 on , and 269 on 9/. admission weight was 288 lbs. after broad workup below, etiology of volume overload was determined to be likely congestive heart failure. on the medicine service, the patient was treated with iv furosamide 80mg initially then with iv furosamide 100mg with balance of -1l per day. on he received one dose of metolazone 2.5 mg and iv furosamide 100mg with balance of -3800cc for 24h. he was transferred to the cardiology service where he was started on a lasix drip. he was fluid restricted to 1.5l/day. spironolactone was changed to epleronone given concern for gynecomastia. torsemide was held. he had a cardiac mri to assess for constrictive pericarditis which was negative per wet read. he underwent right heart cath to assess for restrictive cardiomyopathy, which showed that he had elevated right-sided pressures and equalization of left and right heart pressures concerning for restrictive physiology. he was briefly transferred to the ccu for pulmonary artery pressure (pap) monitoring - paps ranged between 30-40s/17-20s concerning for volume overload. he was diuresed 4l in the ccu on a lasix gtt at 10 mg/hr. the lasix gtt was briefly held for sbps in the 80s. 250cc boluses x 4 were administered with improvement in bp. lasix gtt was restarted at 10 mg/hr prior to the patient being transferred back to the general cardiology floor on . on the cardiology floor, he was further diuresed with lasix gtt with output of 1.5-2 l daily. he was transitioned to po torsemide and po metolazone and continued to be 1-2l negative daily. his weight on discharge was 124kg. he was discharged on eplerenone 25 mg po daily, torsemide 80 mg po daily, and metolazone 2.5 mg po daily. a variety of etiologies for restrictive physiology were considered and ruled out as follows: -pulmonary hypertension secondary to obstructive sleep apnea (echo showed only mild pulmonary hypertension) -liver disease (+ fatty liver with stable transaminitis, but not significantly hypoalbuminemic) -prior studies of ct angio torso did not show vascular problems in the inferior vena cava, intrahepatic vessels, or any other sources for lower extremity edema -liver ultrasound on showed hepatic steatosis without clot -nephrosis (ua without proteinuria) -local vascular/lymph process (not consistent with distribution) -endocrine disorder (cortisol wnl, electrolytes wnl) -hereditary angioedema (c4 wnl) -constrictive pericarditis (unlikely w/ cardiac mri and right sided cath findings) -restrictive cardiomyopathy (cath suggests restrictive physiology, but spep/upep negative, ferritin wnl, ceruloplasmin negative in past). on discharge, it was felt that the severe fluid overload that the patient had at the time of right heart catherization may have contributed to the restrictive physiology that was observed. we would recommend considering an outpatient echo and right and left cardiac catherization when he is completely at dry weight to reassess for concomittant constrictive pathology or restrictive cardiomyopathy as no discernible etiology was identified on this admission. he has outpatient follow-up in diuresis clinic and with his cardiologist scheduled. enrolling in cardiac rehabilitation was encouraged. # obstructive sleep apnea - as pulmonary hypertension may be a contributing factor to heart failure, treating osa successfuly is an important part of his management. patient was not adherent to cpap at home. respiratory therapy was consulted and provided a mask that fit the patient more comfortably, and he tolerated cpap without difficulty while in the hospital. he was instructed on the importance of wearing cpap at home. # type 2 diabetes mellitus, uncontroleld - patient has a long standing history of very difficult to control diabetes, followed by as an outpatient. last hba1c = 9.0. he takes very high doses of insulin with good compliance at home but seems to be less compliant with diet. he presented with hyperglycemia and mild confusion without signs of dka. was consulted and helped manage his blood sugars with u500 and humalog sliding scale. his blood sugars were well controlled in 100-200s. recommendations, he was started on low dose metformin. the risk of lactic acidosis in setting of heart failure and steatohepatitis was thought to be low with low dose metformin, but it was decided not to titrate him to maximum dose of this medication. he will follow-up with as an outpatient. of note, he administers his insulin differently at home compared to in the hospital and this was discussed with him and taken into account in writing his discharge prescriptions. additionally, he sometimes eats meals in the middle of the night which also made managing his blood sugars challenging. # abdominal distention/discomfort: likely secondary to ascites from heart failure and constipation with no evidence of sbo or ileus on kub. a bed side us demonstrated moderate fluid + stool/air filled bowl. he was put on a aggresive bowel regimen with regular bowel movements on cardiology service. # acute on chronic kidney injury - he had an elevated creatinine on admission which was thought to be secondary to osmotic diuresis due to hyperglycemia and resolved with initial fluids. his creatinine again was elevated when diuresis was initiated so quinapril was held. his creatinine improved and was at 1.0-1.2 at discharge. quinapril was restarted prior to discharge. recommend close pcp and recheck of electrolytes and kidney function within a week of discharge. # history of pes - patient is on coumadin at home with goal inr . his inr was therapeutic on admission but coumadin was held for right heart cath. coumadin was restarted on . he was transiently treated with heparin gtt bridge but this was discontinued due to oozing from swan-ganz catheter site. he was placed on sc heparin and scds while inr was subtherapeutic. his inr was 1.9 on discharge. he will follow-up in . # cad s/p pci w/stent x 2 in : stable without chronic angina. patient is on aspirin, statin, beta blocker, and ace inhibitor. # htn: bps were low-normal in setting of diuresis. quinapril was restarted at half of his prior home dose. # mental status changes: per medicine team, patient noted to have slow speech, often in the am. this appears to be a chronic issue. tsh, vitamin b12, and folate were normal; rpr and hiv were negative. his apriprazole was discontinued as it was felt that this medication may be contributing to his slowed mentation and mildly prolonged qt interval. he was seen by social work while in the hospital and advised to follow-up with his psychiatrist and to consider cardiac rehabilitation, both for his heart health and also to provide some structure to his day. consideration to outpatient cognitive neurology evaluation may also be given. --- transition of care: - needs electrolytes and renal function checked a week following discharge. - renin level pending at time of discharge. - consider repeat right heart cath when patient at dry weight. - encourage patient to enroll in cardiac rehabilitation. medications on admission: 1. aripiprazole 15 mg tablet sig: one (1) tablet po daily (daily). 2. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 3. pregabalin 75 mg capsule sig: four (4) capsule po bid (2 times a day). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 8. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 9. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 10. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 11. warfarin 1 mg tablet sig: four (4) tablet po once daily at 4 pm. 12. tizanidine 2 mg tablet sig: three (3) tablet po tid (3 times a day). 13. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 14. torsemide 20 mg tablet sig: four (4) tablet po bid (2 times a day). 15. quinapril 20 mg tablet sig: two (2) tablet po bid (2 times a day). 16. insulin regular hum u-500 conc 500 unit/ml solution sig: one y (150) units injection at breakfast. 17. insulin regular hum u-500 conc 500 unit/ml solution sig: one y five (125) units injection at lunch. 18. insulin regular hum u-500 conc 500 unit/ml solution sig: one y five (125) units injection at dinner. 19. humalog 100 unit/ml solution sig: per sliding scale units subcutaneous before meals and at bedtime: please see attached sliding scale; if any questions, contact your doctor. 20. fexofenadine 60 mg tablet sig: one (1) tablet po once a day. 21. provigil 200 mg tablet sig: 1.5 tablets po once a day: in the morning. 22. provigil 200 mg tablet sig: one (1) tablet po once a day: at noon. discharge medications: 1. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 2. pregabalin 75 mg capsule sig: four (4) capsule po bid (2 times a day). 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 4. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 7. trazodone 100 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 8. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 9. warfarin 2 mg tablet sig: two (2) tablet po once daily at 4 pm: check your inr weekly to adjust dose appropriately. 10. tizanidine 2 mg tablet sig: three (3) tablet po tid (3 times a day). 11. eplerenone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. fexofenadine 60 mg tablet sig: one (1) tablet po daily (daily). 13. modafinil 100 mg tablet sig: as directed tablet po twice a day: 3 tablets in the morning and 2 tablets at noon. 14. insulin regular hum u-500 conc 500 unit/ml solution sig: as directed injection three times a day: if hyperglycemic on u-100 switch to u-500 and take 30 units at breakfast 22 units at lunch 22 units at dinner. 15. humalog 100 unit/ml solution sig: as directed subcutaneous four times a day: -per sliding scale -before meals and at bedtime -for questions, contact your doctor. 16. quinapril 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 17. modafinil 100 mg tablet sig: three (3) tablet po qam (once a day (in the morning)). 18. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 19. torsemide 20 mg tablet sig: four (4) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 20. metolazone 2.5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 21. vicodin 5-500 mg tablet sig: one (1) tablet po at bedtime as needed for pain. disp:*30 tablet(s)* refills:*0* 22. multivitamin tablet sig: one (1) tablet po daily (daily). 23. warfarin 4 mg tablet sig: four (4) tablet po once a day: patient is to resume previous dose by taking 4 of the 1mg warfarin pills at 4pm each night. 24. senna 8.6 mg tablet sig: two (2) tablet po at bedtime as needed for constipation. 25. colace 100 mg capsule sig: one (1) capsule po twice a day. 26. bisacodyl 5 mg tablet sig: two (2) tablet po once a day as needed for constipation. disp:*30 tablet(s)* refills:*0* 27. milk of magnesia 400 mg/5 ml suspension sig: five (5) ml po twice a day as needed for upset stomach or constipation. disp:*1 each* refills:*2* 28. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 29. vitamin d 50,000 unit capsule sig: one (1) capsule po once a week. 30. fish oil 1,000 mg capsule sig: one (1) capsule po once a day. 31. tizanidine 2 mg tablet sig: three (3) tablet po three times a day. disp:*270 tablet(s)* refills:*1* 32. insulin regular human 100 unit/ml solution sig: as directed injection three times a day: take 60 units with breakfast, 45 units with lunch, and 45 units with dinner. if blood sugars are elevated, switch to half dose of u-500. disp:*3 vials* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: primary -anasarca -heart failure with restrictive physiology -mild transaminitis -diabetes meillitus, type ii secondary -obstructive sleep apnea -chronic kidney disease, stage 3 -coronary artery disease -hypertension -history of pulmonary embolism on coumadin discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to for hyperglycemia and leg swelling. the diabetes center was consulted and tried to help control your blood glucose levels. they made recommendations regarding your insulin dosing. you are being discharged on a regimen of u-100 (regular insulin: 60 units, 45 units, and 45 units) and humalog insulin sliding scale. if you notice that your blood sugars are elevated, then please switch to u-500 insulin at half dose (30 units, 22 units, 22 units for actual doses of 150, 110, and 110 units). if you have any difficulties with your diabetes, please call your physician at the diabetes center. you were diuresed to remove fluid from your body. you had a cardiac mri and a right heart catherization with swan-ganz catheter monitoring in the coronary care unit - these studies suggest that you were retaining fluid due to heart failure. we used intravenous diuretics to remove excess fluid from your body and then transitioned you to diuretic pills with good results. it will take time to remove all of the excess fluid but you are making good progress on your current regimen. it is important to weigh yourself daily and notify your doctor if you weight increases by more than 3 pounds. your weight on discharge is 124 kg. you should drink no more than 1.5 liters of fluid daily. do not forget that popsicles, juice, coffee, and soda all count as fluid. you should follow a heart healthy, diabetic, low salt diet at home. it is important for you to wear a cpap machine at night because you have obstructive sleep apnea. this will help prevent further stress on your heart. we highly recommend that you go to the - institute for cardiac rehabilitation. the following changes were made to your medications: stop spironolactone and start epelerone 25 mg daily instead. decrease torsemide to 80 mg daily and start metolazone 2.5 mg daily these medications will help with diuresis. for control of diabetes: start metformin 500 mg twice a day change u-500 insulin to: 60 units with breakfast, 45 units with lunch, and 45 units with dinner. we have given you a copy of your new insulin sliding scale. please follow-up with your diabetes physician at the as below. stop aripiprazole. we think this medication made your thinking slower and may also affect the conduction of your heart. talk to your doctors about whether this medication should be restarted. decrease quinapril to 20 mg twice a day. this medication may be increased again in the future depending upon your blood pressure. followup instructions: the following appointments have been made for you: department: when: tuesday at 10:20 am with: , md building: (, ma) campus: off campus best parking: on street parking department: radiology when: wednesday at 3:00 pm with: xmr building: cc campus: west best parking: garage department: radiology when: wednesday at 3:40 pm with: xmr building: cc campus: west best parking: garage department: cardiac services when: thursday at 2:00 pm with: , np with the clinic phone: building: sc clinical ctr campus: east best parking: garage department: cardiac services when: friday at 2:40 pm with: , m.d. building: sc clinical ctr campus: east best parking: garage department: diabetes management when: 3:30pm with: dr. where: diabetes center, department: cardiac services when: friday at 9:40 am with: , md building: campus: east best parking: garage md procedure: pulmonary artery wedge monitoring right heart cardiac catheterization diagnoses: obstructive sleep apnea (adult)(pediatric) congestive heart failure, unspecified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified other chronic pulmonary heart diseases atrial flutter percutaneous transluminal coronary angioplasty status constipation, unspecified chronic kidney disease, stage iii (moderate) long-term (current) use of anticoagulants family history of ischemic heart disease personal history of venous thrombosis and embolism other ascites personal history of noncompliance with medical treatment, presenting hazards to health diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled acute diastolic heart failure unspecified persistent mental disorders due to conditions classified elsewhere 

Answer: The patient is high likely exposed to