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: fever altered mental status major surgical or invasive procedure: arterial line placement red blood cell transfusion history of present illness: the patient is a 62 yo m with no significant past medical history per his wife. was admitted to science benevolent association facility approx 6 weeks ago for urinary retention. staff at this facility assisted him with eating and toileting. he has not had any medical care for this issue. per family, he went to this facility because of problems with hematuria and urinary retention. he has also had trouble ambulating for multiple weeks and was complaining of lower back pain. per his family, over course of last week, mental status slowly declined, pt would "drift off," became sleepy but arousable, still communicating. this worsened in the leading up to admission and on day of admission patient was unable to take anything by mouth and was sent to the emergency department. in the emergency department, patient was febrile, tachycardic, and demonstrated altered mental status and combative behavior. a foley catheter was placed and was clamped after 1 liter of urine was released. initial vitals: t 101.4, hr 136, bp 138/110, rr 18, sat 94. of note, lactate 4.4, na 167, wbc 28.1, hct 33 (no baselines for comparison). he was empirically treated with vancomycin, levaquin, flagyl, tylenol, haldol, and morphine (to facilitate ct). he received a total of 4 l normal saline, followed by initiation of normal saline at 250cc/hr per renal service recommendations. total urine output in ed was 3.8 liters. past medical history: none social history: married with two daughters. and his wife are scientists and live in upperstate ny. he does not consume tobacco/etoh/drugs family history: non-contributory physical exam: vs (on arrival to micu): t 97 hr 111 bp 113/69 rr 20 sat 94% 2 l nc gen: pale, cachectic; minimally responsive to verbal stimuli, withdraws to pain heent: perrl; mm extremely dry; neck: stiff lungs: ctab heart: tachycardic, s1s2 present abd: +bs, soft, non-tender, non-distended ext: radial & dorsalis pedis pulses 2+, + muscle wasting, moves lower extremities skin: no petechiae/purpura gu: foley in place, draining brown urine neuro: minimally responsive; difficult to obtain deep tendon reflexes pertinent results: admission labs: 05:05pm glucose-115* urea n-110* creat-2.3* sodium-162* potassium-3.5 chloride-125* total co2-30 anion gap-11 05:15pm freeca-2.03* 05:05pm tot prot-5.3* 02:21pm albumin-3.0* calcium-14.8* phosphate-4.2 magnesium-3.0* iron-47 02:21pm caltibc-228* ferritin-133 trf-175* 02:21pm pth-22 02:21pm psa-9.5* 02:21pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 02:21pm wbc-20.8* rbc-3.04* hgb-8.4* hct-26.8* mcv-88 mch-27.8 mchc-31.5 rdw-17.6* 02:21pm neuts-90.5* lymphs-6.6* monos-2.7 eos-0.2 basos-0 02:21pm pt-18.0* ptt-23.2 inr(pt)-1.6* 09:30am urine hours-random creat-39 tot prot-81 prot/crea-2.1* 09:30am urine u-pep-multiple p ife-negative f osmolal-262 09:14am alt(sgpt)-35 ast(sgot)-15 ck(cpk)-49 alk phos-106 tot bili-0.8 09:14am lipase-28 09:14am ctropnt-0.01 07:35am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-mod 07:35am urine rbc-* wbc-21-50* bacteria-many yeast-none epi-0-2 07:31am glucose-108* lactate-4.4* na+-167* k+-5.1 cl--116* tco2-35* discharge labs: wbc rbc hgb hct mcv plt ct 19.6* 2.93* 8.4* 25.4* 87 369 glucose urean creat na k cl hco3 angap 106* 19 1.1 146* 3.5 106 31 13 microbiology: blood cx : no growth 7:35 am urine site: catheter leg added @ 14:33. **final report ** urine culture (final ): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. escherichia coli. >100,000 organisms/ml.. work-up per dr. , pager . gram positive bacteria. 10,000-100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. gram positive bacteria. 10,000-100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. 2nd morphology. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ 8 i meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ 4 s trimethoprim/sulfa---- <=1 s legionella antigen : negative cytology: urine atypical keratinizing squamous cells. atypical urothelial cells. note: the squamous cells display hyperchromatic angulated nuclei. the differential diagnosis includes urothelial carcinoma with squamous differentiation, squamous cell carcinoma, squamous dysplasia and metaplasia. imaging studies: ct head : findings: there is no evidence of hemorrhage, edema, masses, mass effect, or infarction. the ventricles and sulci are normal in caliber and configuration. there are no fractures identified. the sinuses are clear. two destructive bony lesions are seen in the occipital bones which are concerning for metastatic disease. these are seen on series 2, images 15 and 24. impression: 1. no evidence for hemorrhage or masses. 2. destructive bony lesions in the occipital bones, concerning for metastatic disease. ct abdomen/pelvis ct of abdomen without contrast: the visualized lungs are clear without nodule or masses. there are no pleural effusions. the heart is normal in appearance without pericardial effusion. there is a 3.9 x 3.5 cm soft tissue mass in the right posterior chest wall causing a convex bulge along the right posterior pleura. this lesion which is arising from the right 12th rib is compatible with metastasis (2:11). an enlarged lymph node is seen in the posterior mediastinal space on s2, i2, measuring 1.7 cm. additional prominent retrocrural nodes are noted measuring up to 13mm. the noncontrast appearance of the liver, spleen, adrenals, pancreas, and gallbladder is unremarkable. within the right kidney, two hypodense rounded lesions are seen, the larger of which measured 3.2 x 2.9 cm. these may represent simple cysts but are incompletely characterized on this noncontrast evaluation. there are punctate calcifications within the lower pole of the left kidney which could represent nonobstructing stones. there is no hydronephrosis seen within either kidney. the abdominal loops of small and large bowel are grossly unremarkable on this noncontrast study. there is no free air. there is no free fluid. there is extensive bulky retroperitoneal lymphadenopathy, most prominent along the left aortic chain extending into the left hemipelvis. the largest of these (2:26) measures 3.4 x 3.2 cm. ct of the pelvis without contrast: there is a large irreguylar mass arising from the anterior bladder wall measuring approximately 8.2 (tr) x 4.6 (ap) x 9.6 (cc) cm. there is peripheral calcification noted along the luminal (posterior) border of this mass. there is irregularity along the bladder wall with apparent infiltration of the prevesical fat, compatible with tumor extension. there is likely a second area of disease along the posterior wall of the urinary bladder where calcification (4.9 x 1.8 cm) is also noted though evaluation is quite limited without contrast. there is a foley catheter present within the bladder. there is no free air, there is no free fluid. there is significant bulky pelvic lymphadenopathy, measuring up to 6.3 x 2.7 cm (s301b, i50). the rectum, sigmoid colon and pelvic small and large bowel are grossly unremarkable. there are scattered diverticula within the sigmoid colon without evidence for diverticulitis. bone windows: there are multiple destructive bony lesions which are compatible with metastasis. these are seen throughout the vertebral column, pelvis and proximal femurs. in particular there is a large lesion eroding the right proximal femoral shaft measuring 4.7 x 4.1 cm. there is soft tissue density in the marrow cavity of the left proximal femur (2:88). there is a 2.4 x 2.5 cm soft tissue density causing lytic destruction of the anterior right- sided pubic ramus. there is a 3.3 x 2.9 cm soft tissue density with lytic destruction of the posterior inferior left sacral ala (2:60). there is a 3.8 x 2.6 cm left sided iliac crest lytic soft tissue density and a 3.2 x 2.3 cm soft tissue mass causing lytic destruction of the posterior left-sided ischium and a 2.4 x 2.1 cm soft tissue mass causing lytic destruction of the posterior right-sided ischium. within the left sided posterior aspect of the l5 vertebral body (2:44), there is a 1.4 x 1.3-cm lytic soft tissue mass with cortical disruption. this soft tissue density mass protrudes into the spinal canal and indents the thecal sac. there are no fractures identified; however, given the burden of lytic lesions, there is a high risk of possible future pathological fractures. impression: 1. large calcified bladder mass with bulky retroperitoneal and pelvic lymphadenopathy and extensive osseous metastasis. recommend biopsy for definitive diagnosis. 2. l5 vertebral body metastatic lesion indents the thecal sac. recommend mri for further evaluation as clinically warranted. 3. no evidence of pathologic fracture but the lesions in the femur, especially on the right, place this patient at high risk for future complications. mr lumbar spine findings: there are multiple metastatic masses throughout the imaged bones. a mass in the left posterior elements of l1 extends into the left l1/2 neural foramen, where it may contact the left l1 nerve root. a mass in the left posterior superior aspect of the l5 vertebral body extends into the left anterior epidural space, displacing the left l5 nerve root posteriorly. there is an at least 3.5 cm mass in the inferior sacrum, partially imaged on the sagittal images only, which extends into the presacral soft tissues, as seen on the concurrent abdominal/pelvic ct scan. its effect on the sacral plexus is not evaluated. there is no evidence of cauda equina compression in the lumbar spine. the conus terminates at l1, and it appears unremarkable. there is a partially visualized mass in the right lower ribs, which is better seen on the concurrent ct scan. at l4/5, there is a disc bulge and a central disc protrusion, which does not contact any nerve roots. facet joint arthropathy is also present at this level. at l5/s1, there is a disc bulge and facet joint arthropathy, resulting in mild narrowing of the neural foramina without evidence of nerve root impingement. there is a partially imaged mass in the bladder. retroperitoneal lymphadenopathy is present. cystic lesions are noted in the kidneys. these findings are better evaluated on the concurrent abdominal/pelvic ct scan. impression: 1. metastases throughout the imaged bones. 2. a mass in the left posterior elements of l1 extends into the left l1/2 neural foramen, where it may contact to the left l1 nerve root. 3. a mass in the posterior left vertebral body of l5 extend into the left anterior epidural space, displacing the left l5 nerve root posteriorly. 4. partially imaged mass in the inferior sacrum, which extends into the presacral soft tissues. given the patient's symptoms, sacral plexus protocol mri of the pelvis would be helpful for evaluation of the sacral plexus. 5. partially visualized bladder mass, retroperitoneal lymphadenopathy, cystic renal lesions, and right lower rib mass, which are better evaluated on the concurrent abdominal/pelvic ct scan. mr cervical and thoracic spine : cervical spine: multifocal cervical spine metastases are identified including involvement of the dens and left aspect of the c2 vertebral body with involvement of the right pedicle and facet of c2 also observed. there is also evidence of involvement of the spinous process and right facet at c4 as well as involvement of the left pedicle and facet at c6. vertebral body height and alignment is maintained and there is no evidence for spinal canal narrowing or cord compression. cervical spinal cord signal intensity is normal. thoracic spine: there is vertebral height loss secondary to diffuse metastasis at t2 with mild retropulsion of t2 into the spinal canal, which appears to contact the anterior aspect of the thoracic cord. there is also evidence for metastasis to t3, though tvertebral height appears maintained at this level. signal intensity changes and enhancement involving the inferior aspect of t12 is noted without significant height loss and metastasis here cannot be excluded. the same is noted along the superior aspect of the t7 vertebral body. the remainder of the vertebral body heights appears preserved. at t7/t8 a moderate-to-severe posterior disc protrusion appears to cause narrowing of the spinal canal and cord compression. smaller disc protrusions from t8/9 through t11/12 cause only mild spinal canal narrowing without compression. multiple rib metastases are identified including the right 7th and 12th and left 8th ribs. multiple prominent posterior mediastinal lymph nodes are partially imaged, though evaluation of the chest is incomplete on this study. impression: 1. multilevel cervicothoracic metastatic disease, with the most significant height loss and posterior retropulsion noted at t2 which produces moderate canal narrowing and contacts the anterior thoracic cord. rib metastases as described. 2. multilevel thoracic degenerative disc changes, most severe at t7/8 where disc protrusion compresses the anterior thoracic spinal cord. 3. prominent posterior mediastinal nodes incompletely evaluated. recommend chest ct for more complete evaluation. lung scan : interpretation: ventilation images obtained with tc-m aerosol in 8 views demonstrate central clumping of the tracer, consistent with diffuse airway disease. perfusion images in the same 8 views show heterogeneity in a sub-segmental distibution, also most likely due to airways disease. chest x-ray shows hyperinflation without evidence of pneumonia. there is no ventilation- perfusion mismatch to suggest a pulmonary embolus. impression: low probability of pulmonary embolus. diffuse airway disease. cxr : portable chest radiograph: compared to prior study, is increasing opacity in the medial aspect of right lower lung. pulmonary vascularity is unchanged. there are no focal consolidations in the left lung. there are no large pleural effusions. impression: increasing opacity in the right lower lung, concerning for possible infection. discussed with dr. on , . bilat femur (ap and lat) : findings: right femur: there is a lytic expansile lesion in the proximal right femur located immediately inferior to the greater trochanter. in addition, note is made of a lytic lesion in the right pubic symphysis. there is no evidence of fracture at this time, however, these lesions are consistent with metastates and the right proximal femur lesion in particular is concerning for an impending pathologic fracture. left femur: there are multiple lytic lesions in the proximal left femur, some of which are causing endosteal scalloping. there is no evidence of acute fracture at this time, but these lesions which are consistent with metastases place the patient at risk for pathologic fracture. there is a tiny lytic lesion along the distal left femoral cortex which may also represent metastasis. mr head : comparison is made with ct head from . there are multiple calvarial metastases including lesions in the left temporal bones, left occipital bone and the right parietal bone. the lesion in the left occipital bone just to the left of midline has a dural component to it. there is no extension into the venous sinuses at this timw. no evidence for parenchymal metastases is seen. there is no mass, mass effect or midline shift. impression: multiple calvarial metastases, no evidence for intraparenchymal metastasis in the brain. cxr : pa and lateral upright chest radiograph was compared to , . the heart size is normal. mediastinal position, contour and width are unremarkable. bilateral lower lung opacities projecting at the level of inferior hila, and might represent worsening foci of infection. there is an area of rib destruction surrounding by soft tissue component, seventh and fifth on the right that most likely represent metastasis, unchanged. there is small amount of bilateral pleural effusion most likely unchanged since the prior study. multiple nodular opacities are seen in the lungs that might represent pulmonary nodules. impression: bibasilar focal opacities, progressing over the period of last couple of days, dating back to and may represent worsening pneumonia. rib metastasis. multiple pulmonary nodules that might represent metastatic spread as well. brief hospital course: this is a sixty two year old male presenting with confusion, urinary retention, hypernatremia and hypercalcemia found to have a large calcified bladder mass and likely metastatic squamous cell carcinoma of the bladder. 1)metastatic cancer: patient has evidence of significant metastatic disease. ct and mri demonstrate diffuse lytic lesions of the calvarium, all levels of the spine, bilateral femurs and ribs. there is also evidence of pulmonary nodules, significant mediastinal lymphadenopathy and bulky pelvic lymphadenopathy (details in reports section). ct of the pelvis demonstrates a 8.2 x 4.6x 9.6 cm bladder mass, as well as, bulky pelvic lymphadenopathy highly suggestive for a bladder cancer. this is further supported by urine cytology demonstrating atypical keratinizing squamous cells. patient was seen by the hematology/oncology consult team who felt that patient likely has terminal metastatic bladder cancer. they felt that tissue diagnosis should be obtained in order to proceed with palliative radiation therapy and possibly chemotherapy. the urology consult team felt that bladder biopsy should be obtained by interventional radiology rather than via cystoscopy due to the risk of bleeding with cystoscopy. patient was also seen by both the orthopedic spine team regarding metastic spinal lesions. the spine team was concerned about the patient's t2 compression fx with epidural extension and t7/8 disc protrusion w/ effacement of anterior cord. the team suggested vertebroplasty for the t2 fracture rather than surgery given the widespread nature of disease. radiation oncology was also consulted and felt it was reasonable to treat both the patient's spine and femur lesions palliatively with xrt. however, if the patient and his family wanted more aggressive treatment they recommended surgical resection of the t2 lesion with adjuvant xrt. the orthopedic trauma team saw the patient in regards to his femur lesions and recommended im rod for the right femur given the large size of the bony metastasis and the risk of fracture. none of these interventions were pursued given the family's request to have the patient transferred to st. hospital in ny for further medical management. 2)mental status changes: patient has been oriented to person, year, month, day. he has been consistently confused about his location. we feel that this confusion is due to a combination of his hypercalcemuia, hypernatremia, multiple infections and his metastatic cancer. patient continues to be treated for pneumonia and urinary tract infection. hypernatremia has resolved with intravenous fluids. hypercalcemia has been treated with pamidronate and calcitonin and intravenous fluids, though free calcium continues to be high. at time of transfer free calcium is 1.35 and total calcium is 11.1. the patient's continued disorientation is likely secondary to his calcium which has been difficult to control. 3)pneumonia:a cxr on showed possible right sided infiltrate concerning for pneumonia. in addition, the patient had an elevated white count that was trending up at the time these symptoms developed. that patient was initially treated for community acquired pneumonia with levaquin,however, white count continued to increase and patient's oxygen requirment became greater so his antibiotic coverage was switched to vancomycin and zosyn on . at time of discharge patient is afebrile and oxygen saturation is stable on room air -mid 90's. his wbc count remains elevated though it is unclear whether this represents persistent infection or presence of his malignancy. patient has a picc line in place. he should continue vancomycin and zosyn for 7 more days to complete a 14 day course (now on day 7). 4)urinary tract infection: urine positive for pansensitive e.coli. patient was initially treated with levaquin which was switched to zosyn for empiric treatment of hospital acquired pneumonia as noted above. as noted above, he should continue vancomycin and zosyn for another 7 days to complete a 14 day course of antibiotics. 5)hypercalcemia: ionized calcium was 2.03 on admission. patient was treated with pamidronate 30 mg iv x 1 on and calcitonin 100 units x 6 days. calcium has trended down following this treatment though free calcium remains elevated at 1.35 and total calcium of 11.1. we have continued the patient on intravenous fluids. 6)hypernatremia: sodium was 164 on admission. patient felt to be profoundly dehydrated and with large free water deficit. patient seen by the renal consult team who recommended fluid resucitation with d5w. as patient's mental status cleared his po intake also improved and he was more conscious of his thirst. serum sodium resolved and remains stable at time of transfer. 7)acute renal failure: cr was 2.4 upon admission. this was likely secondary to both urinary obstruction and hypovolemia. cr normalized with fluid resuscitation. 8)anemia: this is likely an anemia of chronic disease secondary to the patient's malignancy. iron studies demonstrated normal iron level and ferritin with low tibc and transferrin. hct has remained stable. he was transfused 1 unit prbc on 10/0 for hct of 21.7. hct remained stable >21 for rest of admission. would suggest continuing to monitor hct. 9)malnourishment:patient appears chronically ill and malnourished. albumin 2.4 and inr elevated (1.4-1.6)at time of transfer. patient seen by nutrition who felt that peg placement for tube feeds would be necessary given poor caloric intake. peg was not pursued given plans for transfer and family wishing for all procedures to occur at st. . patient was a full code during this admission. medications on admission: none discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day) as needed for ppx. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 5. ibuprofen 600 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, headache. 6. potassium chloride 20 meq packet sig: two (2) packet po daily (daily). 7. sodium chloride 0.9% flush 3 ml iv prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 8. piperacillin-tazobactam na 4.5 g iv q8h 9. vancomycin 1000 mg iv q 12h 10. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care discharge diagnosis: primary: metastatic malignancy, pneumonia, urinary tract infection secondary:hypercalcemia, acute renal failure discharge condition: stable discharge instructions: you were admitted becuase you had a significant change in your mental status and were not urinating. on admission you were found to have many abnormalities in your electrolytes. further testing and imaging revealed that you have a metastatic cancer, which we believe to be bladder cancer. you have a large mass in your bladder and evidence of metastatic disease throughout your spine, leg bones, and possibly your lungs. you were seen by our oncology team who agreed that you likely have a terminal bladder cancer. they felt that it was important for you to have a biopsy of the mass in your bladder so as it appropriately guide palliative treatment. you were also seen by our orthopedic surgeons who suggested that you have surgery to your spine and right leg to stabilize these bones. the radiation oncology team also saw you and felt that radiation treatment could be an appropriate therapy for your spine and leg bones, as well. we presented you and your family with the perspectives and suggestions of the aforementioned specialists. you and your family decided that you would prefer to have your treatment at st. hospital since this facility is closer to your home in , . we have also been treating you for pneumonia and a urinary tract infection. you have been recieving intravenous antibiotics. we suggest that you continue taking these antibiotics for another 7 days. you have also recieived treatment for elevated calcium. your calcium remains high and will require further treatment. we feel that this is likely contributing to your confusion and disorientation. you are being transferred to st. hospital to continue your medical care, including your work-up and management of your cancer. followup instructions: you are being transferred to st. hospital in , per the request of you and your family. the accepting physician is . . procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances arterial catheterization diagnoses: pneumonia, organism unspecified anemia, unspecified urinary tract infection, site not specified acute kidney failure, unspecified unspecified protein-calorie malnutrition retention of urine, unspecified dehydration hyperosmolality and/or hypernatremia secondary malignant neoplasm of bone and bone marrow malignant neoplasm of other specified sites of bladder 

Answer: The patient is high likely exposed to