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: isordil / dilaudid attending: chief complaint: back pain, fever. major surgical or invasive procedure: elective endotracheal intubation for mri. history of present illness: 72m with mds, recently discharged from 12r for diffuse body pain without improvement or diagnosis, initially planned for direct admit back to 12r. however, given slowed mental status, refusing speaking per family, evaluated in ed. initially in ed vs 104.3 114 141/59 18 99. pt refusing conversation but followed commands. labs significant for new renal failure cr 2.7, with k 5.7, ap 377, na 131, wbc 3.5 with 61%n and 9% bands, hct 29.2, plt 128, lactate 1.6. ua pending. infectious workup showed cxr, ct head negative. covered empirically for meningitis vanc, ctx, ampicillin. . family reported severe lower back pain and numbness in lower extremities, fever - concern for epidural abscess. plan for mri without contrast given renal failure, which was initiated but pt unable to tolerate due to agitation. able to get c spine and part of t spine, ? epidimoma, intrathecal mass c1-2. anesthesia intubated with 7.5 on propofol gtt. cxr confirmed placement of ett and og tube. insufficient staffing to get mri in ed. . renal failure - baseline 1.5-1.6. no change in po intake. unclear cause. given kayexalate 30, no ekg changes. no stools. gotten 2l ivf. . vs on transfer: temp 99.6. hr 125 since intubation, previously 90s, bp 135/69, ac 100, tv 450, 5peep, 12 ps, rate 20s. mv 10l. . of note, during recent admission, pt presented with diffuse pain and source not identified. ddx included neutrogen related, mds bony pain, lytic bony lesions (spep pending at discharge, now neg). planned for outpt bone marrow biopsy . . review of systems: pt not answering questions. past medical history: 1. myelodysplastic syndrome 2. obesity 3. peripheral vascular disease s/p bilateral angioplasty 4. atrial flutter 5. angina 6. glaucoma 7. hyperlipidemia 8. coronary artery disease s/p cabg 9. bph 10. gout 11. s/p ccy 12. h/o pancreatitis social history: home: lives with supportive wife occupation: recently started a new job as a mechanical design engineer etoh: rare drugs: denies tobacco: quit approximately 20 years ago; ~20-30 ppy history family history: mother - alcoholism, diabetes maternal grandmother - diabetes paternal grandmother - diabetes physical exam: general: intubated/sedated heent: sclera anicteric, perrla neck: supple, no lad lungs: bilateral bs, transmitted upper airway sounds cv: tachycardic, no murmurs abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: sedated, unresponsive pertinent results: admission labs : cbc: wbc-3.5* rbc-2.96* hgb-9.5* hct-29.2* mcv-99* mch-32.2* mchc-32.6 rdw-20.0* diff: neuts-61 bands-9* lymphs-17* monos-13* eos-0 basos-0 atyps-0 metas-0 myelos-0 smear: hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-2+ microcyt-normal polychrom-normal other: 04:30pm albumin-3.8 04:30pm lipase-53 04:30pm alt(sgpt)-13 ast(sgot)-36 alk phos-377* tot bili-1.5 04:42pm lactate-1.6 tox screen: 11:15pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg u/a: color-yellow appear-clear sp -1.018 blood-neg nitrite-neg protein-75 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg rbc-1 wbc-1 bacteria-mod yeast-none epi-1 granular-* . micro: blood cultures 5/14, , , - negative urine culture , - negative sputum culture x 2 - negative . ct head: there is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. mild prominence of the ventricles and sulci is compatible with mild diffuse atrophy which is age-appropriate. there is no acute fracture. included views of the mastoid air cells and paranasal sinuses are clear. there is moderate calcification of the cavernous segments of both internal carotid arteries, left greater than right. impression: no acute intracranial process. . mri: 1. 22 x 7 mm intramedullary mass within the cervical spinal cord from c2 to c3 which is hyperintense on t2-weighted imaging, with areas of lower signal intensity within the mid superior aspect. there may be an associated syrinx. this finding could represent a neoplastic process such as an astrocytoma. 2. there are multiple nodules within the lungs. therefore, an intramedullary spinal metastasis is not excluded. chest ct is recommended. 3. 11 x 8 mm right parotid lesion, t2 hyperintense may represent a cystic mass or node, and less likely a pleomorphic adenoma. 4. multilevel degenerative changes throughout the cervical and thoracic spine, with partial ankylosis of c3 to c5 with bulky anterior osteophytes. 5. rounded t1 hyperintense, t2 hypointense lesion within t6 and t2 hypointense lesions within the right t7 (with posterior extension), may represent metastases. these areas can be re-evaluated at the time of ct. 6. elevated creatinine levels precluded the use of gadolinium. 7. no evidence of epidural abscess. 8. trace secretions within the trachea. findings: i concur with dr. very comprehensive analysis. additionally, there are multiple sternotomy sutures. there is no paravertebral soft tissue swelling to suggest an ongoing inflammatory process. conclusion: intramedullary mass within the upper cervical cord. see above report for differential diagnosis. degenerative changes of the cervical spine. please see above report for numerous additional observations. comment: please note that the present study contained imaging only as far distally as t9, as the patient was unable to continue the procedure at this time. . mri head: non-enhanced study with: 1. no evidence of intracranial mass or cerebral edema. 2. moderate global atrophy. 3. diffusely and uniformly t1-hypointense regional bone marrow signal, as on the recent mr examinations of the spine; this likely relates to the apparently known underlying myelodysplastic syndrome . mri lumbar: findings of concern for metastatic neoplastic disease involving the visualized lower thoracic and lumbar spine, with additional findings as noted above. bone scan : impression: widespread foci of abnormal tracer activity throughout the axial and appendicular skeleton as described above. pattern most compatible with widespread osseous metastasis from an unknown primary. cxr : all these support lines and tubes have now been removed. cardiac size is at the upper limits of normal. no failure is present. there is some loss of the right heart border suggesting infiltrate in right middle lobe. impression: probable right middle lobe pneumonia. cxr : findings: as compared to the previous radiograph, the mid lobe opacity is unchanged. in addition, a small left suprabasal opacity has occurred that could correspond to local atelectasis. otherwise, there is no relevant change. unchanged size of the cardiac silhouette. unchanged absence of pulmonary edema. unchanged absence of pleural effusions. old right-sided clavicular fracture. the study and the report were reviewed by the staff radiologist. pathology pending at time of discharge brief hospital course: 72 yo m with mds, chronic back pain of unknown source with recent neg eval, returns with back pain, fever, ams. . # fever: patient admitted with fever and concurrent rise in wbc from 2s to 3.6 and diff changed from 3 30-40% neutrophils and no bands, to 61%n and 9%bands. given the back pain there was concern for epidural abcess. patient was started on vanc/ctx 2g/ampi for meningitis. mri r/o abcess (no contrast given creatinine of 2.7), but showed metastatic disease to the spine. patient initially did not spike on antibiotics, so thought was that it was covering whatever infectious process was going on. ampicillin was stopped on and ctx was decreased to 1g. then, patient spiked again. so far cultures have been negative including blood and urine. cxr has been unchanged. vs have been stable not suggesting sirs. posibility includes malignancy-related fevers. antibiotics were discontinued on as no obvious source of fever was present. patient again spiked a fever to 101 after his bronchosopy, and was noted to be confused an mildly hypoxic to 91 on ra. a cxr showed evidence of rll infiltrate, so he was treated with 7 days of po levofloxacin. . # lung nodules: multiple very small lung nodules. ct scan images from osh were obtained and reviewed and nodules only seem to be amenable to open lung biopsy or ct-guided biopsy. repeat ct torso showed interval increase in the size of his lung nodules as well as interval increase in the size of a mediastinal lymph node. interventional pulmonary was consulted and performed bronchosopy on with biopsy of an endoluminal lesion, pathology was pending on discharge. . #. spinal masses: mri with multiple masses throughout his spine suggestive of metastatic disease. mri of the head without any metastasis. oncology was consulted and suggested biopsy of the lowest risk spinal lesions. interventional neuro radiology felt that the spinal lesions were not necessarily metastasis and may be related to his mds. a ct torso was performed, which was less suggestive of spinal metastasis. a bone scan was performed which suggested widespread bony metastatic disease. . # acute on chronic renal failure: cr baseline 1.5, stage 3 admitted with cr of 2.7 ua with sg 1.018, pos for protein and bacteria, no wbcs/leuks/epis. he received ivf and had good uop. creatinine trended down to his baseline. . # hyperkalemia: 5.7 on admission. he received kayexalate but no bm. no ekg changes. he was normal throughout the rest of the admission. . # intubation: pt electively intubated for mri given concern for epidural abcess. he was kept intubated given concern for metastatic disease and further work up needed (mri of head). he was succesfuly extuabted on . . # myelodysplastic syndrome: on aranesp and neupogen. some concern that this pain is related to his neupogen, although his pain has not improved despite decreased dose of neupogen. given his worsening anemia and bony pain, there has been consideration of repeating a bone marrow biopsy. alk phos at baseline (300s-400s last week). spep last week with polyclonal igm increase. upep showed was within normal limits. he received neupogen twice with subsequent increases in his wbc count from 1.5 to 7.8. patient received prbc to maintain a hct of over 25. he was treated with neupogen twice during his hospitalization. . # angina/cad s/p cabg - aspirin was held given possible procedure. lisinopril and metoprolol were initially held. . # aflutter: currently sinus. holding metoprolol . # hyperlipidemia - continued zetia . # enlarged prostate - patient was continued on tamsulosin. on exam, prostate was enlarged, asymmetric, firm with irregular surface. psa on admission was 14. per records, psa was 3 in , and 9 in . # gout: patient noted r metatarsal-phalangeal joint pain and swelling, consistent with prior joint flare. he was treated with colchicine with modest improvement of his symptoms. . # type 2 diabetes - held glipizide and metformin given npo and renal failure. pt was put on iss. glipizide and metformin were restarted on discharge. . medications on admission: 1. acetaminophen 1000mg 2. omeprazole 20mg 3. aspirin 325 mg daily 4. ranolazine 500 mg daily 5. lisinopril 20mg daily 6. finasteride 5mg daily 7. metoprolol succinate 100 mg daily 8. ezetimibe 10mg daily 9. tamsulosin 0.4 mg qhs 10. nitropatch 0.2mg/hour daily 11. glipizide-metformin 5-500 mg daily 12. oxycodone 5-10mg q4 13. neupogen injection twice weekly 14. aranesp (polysorbate) 100 mcg/ml solution injection weekly discharge medications: 1. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 2. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 3. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 5. ranolazine 500 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po daily (). 6. nitroglycerin 0.2 mg/hr patch 24 hr sig: one (1) patch 24 hr transdermal q24h (every 24 hours): on for 12 hours, then off for 12 hours. 7. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 8. acetaminophen 500 mg tablet sig: two (2) tablet po q 12h (every 12 hours). 9. aspirin 325 mg tablet sig: one (1) tablet po once a day. 10. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 11. ezetimibe 10 mg tablet sig: one (1) tablet po once a day. 12. levofloxacin 750 mg tablet sig: one (1) tablet po daily (daily) for 2 days. disp:*2 tablet(s)* refills:*0* 13. colchicine 0.6 mg tablet sig: one (1) tablet po once (once) for 1 days: start on . disp:*1 tablet(s)* refills:*0* 14. oxycodone 30 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po every twelve (12) hours: do not drive or operate heavy machinery as this can cause sedation. disp:*60 tablet sustained release 12 hr(s)* refills:*0* 15. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain: do not operate heavy machinery or drive with this medication as it can cause sleepiness. disp:*60 tablet(s)* refills:*0* 16. glipizide-metformin 5-500 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: discharge diagnosis: malignancy with metastases, unknown primary fever back pain pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for back pain and fever. an mri of your back did not show any signs of infection. further imaging with ct and bone scan showed lung nodules, and lesions in your bones suspicious for cancer. a bronchoscopy was performed to take a biopsy of a lymph noed in your mediastinum (chest). after the procedure you developed fevers, confusion and shortness of breath. a cxr was suspicious for pneumonia, so you were treated with antibiotics. also, your pain was controlled with long acting and short acting narcotics. please note the following changes in your medications: 1. please start oxycontin 30 mg by mouth every 12 hours for your pain. this is your basal, long acting pain medication. 2. please start oxycodone 5-10 mg by mouth every 4-6 hours for breakthrough pain. this is your short acting pain medication. *** you should not drive or operate heavy machinery with this medication as it can cause sleepiness *** 3. please continue levofloxacin 750 mg by mouth for 2 more days (last day ). this is the antibiotic for your pneumonia. take this in the morning after you have eaten. 4. please continue to take colchicine 0.6 mg by mouth for 1 more day. take this in the morning of for your gout. please keep all your medical appointments. your lung lymph node biopsy is pending and your oncologist (cancer doctor) should follow up the results of this with you. followup instructions: please follow up with your oncologist dr. . appointment: wednesday, , 9:30am you have an appointment on at - at 2:30 pm. primary care doctor appointment with: , a location: - address: , , phone: procedure: closed [endoscopic] biopsy of bronchus closed endoscopic biopsy of lung diagnoses: pneumonia, organism unspecified hyperpotassemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status peripheral vascular disease, unspecified unspecified glaucoma atrial flutter hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) myelodysplastic syndrome, unspecified other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) fever, unspecified secondary malignant neoplasm of lung other malignant neoplasm without specification of site secondary malignant neoplasm of bone and bone marrow gouty arthropathy, unspecified 

Answer: The patient is high likely exposed to