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: lipitor / levofloxacin/dextrose 5%-water attending: chief complaint: arf and question of multiple myeloma major surgical or invasive procedure: : 1. anterior t3 corpectomy. 2. anterior spinal fusion t2-t4. 3. application of inner body cage t2-t4. 4. posterior spinal fusion t1-t5. 5. segmental posterior instrumentation t2-t5. 6. thoracic decompression laminectomy t1-t2,t2-t3, t3-4 and t4- t5 . : thoracentesis history of present illness: 59 y/o man with pmh significant for hypercholesterolemia, htn, and transferred from for further care for arf and question of multiple myeloma. pt was in his usual state of health until mid when he noted that he was feeling poorly with fatigue, low grade fevers of 99, and nausea. the pt was seen in his pcp's office where he reports numerous labs were drawn that did not show any abnormality. however, the pt continued to have the above symptoms. then, in late he "strained" his back lifting some heavy items while doing a home remodeling project. the discomfort improved slowly with ibuprofen until when he fell while fishing and struck his back. he has experienced increasing back pain since that time. two weeks after the accident, he presented to his pcp for further evaluation. at that time, films revealed compression fractures of l1 and l3. the pt was prescribed percocet and also continued on ibuprofen for the pain. however, it continued to worsen to the point where he was bed bound and needing a cane for ambulation. he also experienced severe nausea and constipation. on , the pt presented to for further care. at that time, he rated his back pain . the pt was found to have lumbar and rib fractures in addition to hypercalcemia, arf, and anemia. a body scan was then obtained on for further evaluation showing bilateral renal enlargement without evidence of excretion (nonspecific but compatible with infiltrative disease or acute glomerulonephritis), increased uptake in left ribs, increased uptake in multiple joints suggesting polyarthirits, and increased uptake in the epigastrium. the pt also had multiple other radiology studies--- please see below for the individual results. of note, at the time he entered the osh, the pt had been taking 1200 mg of ibuprofen daily for approximately six weeks. . tonight, the pt reports that he continues to have severe back pain with any movement. it does not radiate but is localized to his lumbar back. he reports that he has had several stools with resolution of his constipation. his nausea is also much better but his appetite remains poor. of note, the pt had noted decreased urine output at home but had attributed this to deydration secondary to his poor po intake. at this time, he reports that he is making large amounts of urine. past medical history: pmh: 1. hypercholesterolemia 2. htn 3. djd 4. episodic vertigo 5. sleep apnea on nasal cpap 6. occular migraines . psh: 1. s/p scopes of the knees bilaterally 2. s/p hernia repair at age 2 social history: the pt is married. he worked for inspiron corporation in but retired in 04/. no tobacco (quit smoking 30 years ago) or drugs. rare etoh. the pt's pcp is . in family history: the pt's mother has osteoporosis and lupus. his father has heart disease. several other family members have dm and hypercholesterolemia. physical exam: 98.7 164/96 83 18 95% 3l nc gen- tired, slightly anxious appearing gentleman resting in bed. alert and oriented. nad. pleasant. heent- nc at. eomi. anicteric sclera. mmm. no lesions in the oropharynx. cardiac- rrr. s1 s2. no m,r,g. pulm- cta anteriorly and laterally. no wheezes, rales, or rhonchi. abdomen- soft. diffuse, minimal tenderness. no rebound or gaurding. nd. positive bowel sounds. extremities- no c/c/e. 2+ dp pulses bilaterally. neuro- cn ii- intact. 5/5 strength in upper and lower extermities bilaterally. pertinent results: labs from : () c-anca- <1:20 p-anca- <1:20 c3 complement- 144 c4 complement- 39 () wbc- 9.4, hct- 25.7, platelets- 252, na- 142, k- 3.8, chloride- 117, bicarb- 14, bun- 75, creatinine- 6.6, glucose- 83 . cxr ()- heat size is within normal limits. no acute infiltrate seen. pleural thickening laterally on the left. question healing left fifth rib fracture. costophrenic angle is minimally blunted. . ap and lateral thoracic spine ()- bones are osteoporotic. there are significant blastic and lytic changes in the t3 vertebral body with loss of height suspicious for metastatic disease. on the ap film, the spinous processes are aligned. pedicles are intact. . lumbar spine ()- moderate loss of vertebral body height of l1 and l2. no destructive porcess seen. however, metastatic disease involving the bone cannot be excluded. bones overall are osteoporotic. on the ap film, spinous processes are aligned and pedicles are intact. . lateral film cervical spine ()- c1 through c6 is identified. c7 is not seen. vertebral bodies are aligned. no significant loss of height. minimal disc space narrowing at c5-c6. . lateral film skull ()- small lucencies seen throughout the skull questionable for metastatic disease. . ap pelvis ()- both hips are internally rotated. no obvious fracture on the single view. limited images of the iliac bones show no fracture. there is overlying stool and feces. . single view right femur ()- no blastic or lytic lesions seen. . single view left femur ()- no blastic of lytic lesions seen. . single view right humerous ()- no blastic or lytic lesions seen. . single view left humerous ()- no blastic or lytic lesions seen. . bone scan total body ()- bilateral renal enlargement without evidence of excretion. the appearance is nonspecific but compatible with infiltrative disease or acute glomerulonephritis. increased uptake in the left ribs is likely posttraumatic despite the recent nondiagonstic left rib x-rays. increased uptake in multiple joints suggest polyarthritis. increased uptake in the epigastrium is a nondiagnostic finding and is not explained on the basis of either this exam or the recent abdomen ct scan. . renal us ()- kidneys are normal without evidence of renal mass, stone, or obstruction. the right kidney measures 13.0 cm in length and the left measures 12.5 cm. small amount of urine in the bladder. . noncontrast ct scan of abdomen and pelvis ()- moderate compression of the l2 vertebral body and mild compression of the superior endplate of l1. no other definite abnormality is seen. sigmoid diverticulosis. . noncontrast ct of t spine ()- lytic destruction of the t4 verterbal body with extension into the perivertebral tissues bilaterally. posteriorly this extends into and slightly narrows the spinal canal. lytic soft tissue lesion within the left t3 transverse process. l1 insufficiency fracture of indeterminate age. diffuse bony demineralization. large bilateral pleural effusions. . noncontrast ct of l spine ()- moderate/severe l2 and mild l1 insufficiency compression fractures. diffuse bony demineralization. . mri l-t spine ()- pathologic compression fracture of t3, with a soft tissue lesion involving the vertebral body, pedicle and transverse process. epidural soft tissue is also present, displacing, but not compressing, the spinal cord. mild chronic l1 compression fracture. edema within the l2 vertebral body, suspicious for a multiple myeloma lesion. possible subtle compression fracture as there is mild loss of vertebral body height. . t-spine plain film ()- patient is status post posterior thoracic spinal fusion, spanning t2-t6 with rods and pedicle screws. the patient is also status post l4 corpectomy, new when compared to . the remaining thoracic vertebral bodies maintain normal height. multilevel degenerative endplate changes noted. no listhesis. cardiomediastinal contours are unremarkable. visualized lung is clear. surgical staples are seen to overlie the posterior midline of the thorax. . l-spine plain failm ()- again seen are compression fractures involving the l1 and l2 vertebral bodies. loss of height is similar in degree when compared to the ct exam of . no listhesis. intervertebral body disc spaces are maintained. surgical staples project over the right lower quadrant. there is mild degenerative change involving the bilateral sacroiliac joints. . bone marrow biopsy ()- diagnosis: cellular bone marrow, extensively infiltrated by a plasma cell myeloma. the bone marrow aspirate shows a predominance of plasma cells, enumerated at 76% of marrow cellularity. some plasma cells show atypical features. the concurrent bone marrow biopsy was sub-optimal for morphological evaluation and light chain immunoprofiling. however small marrow spicules are present and show at least 50% plasma cells. overall the findings are consistent with involvement by plasma cell myeloma. . bone marrow cytogenetics ()- fish was performed with a panel of abbot molecular inc./ vysis, inc. probes for mm and is interpreted as abnormal for the ccnd1-xt probe. fish evaluation for an igh-ccnd1 rearrangement was performed on nuclei with the vysis lsi igh/ccnd1 dual color, dual fusion translocation probe for igh at 14q32 and ccnd1 at 11q13 and is interpreted as abnormal, although an igh-ccnd1 rearrangement was not detected. an abnormal hybridization pattern was observed in 24/100 nuclei, indicative of tetrasomy for the corresponding region on chromosome 11. a single hybridization was detected with the lsi d13s319 probe at 13q14.3 in 5/100 nuclei, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 5% of cells in normal samples can show apparent 13q deletion using this probe set. no rearrangement was detected with the lsi igh/fgfr3 dual color, dual fusion translocation probe for igh at 14q32 and fgfr3 at 4p16 in 100/100 nuclei, which is within the normal range established for these probes in the cytogenetics laboratory at . up to 1% of cells in normal samples can show apparent igh-fgfr3 rearrangement using this probe set. one hybridization signal with the lsi p53 probe at 17p13.1 was observed in 3/100 nuclei, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 3% of cells in the normal samples can show apparent 17p deletion using this probe set. . surgical pathology ()- t3 lesion: fibrous tissue with plasma cell infiltrate, consistent with plasmacytoma. t3 bone: plasmacytoma. fragments of bone, cartilage and fibroadipose tissue with focal areas of necrosis, consistent with fracture. . ecg ()- sinus rhythm. probable left ventricular hypertrophy. prominent u waves could be due to left ventricular hypertrophy or possible drug/electrolyte/metabolic effect. since the previous tracing of st-t wave changes have decreased. . tte ()- the left atrium is moderately dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. the aortic valve leaflets (3) are mildly thickened. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. . bilateral lower extremity ultrasound ()- no evidence of bilateral lower extremity dvt. . ap and lateral cxr ()- moderate-sized left-sided pleural effusion with associated atelectasis versus consolidation. unchanged appearance of cervical/thoracic hardware. . portable cxr ()- no pneumothorax. near complete interval resolution left- sided pleural effusion. . microbiology: -stool cultures negative for c. difficile & -t3 wound swab negative for microorganisms -urine cultures no growth -blood cultures no growth x2 -pleural fluid no growth, cytology pending -blood cultures x2 pending brief hospital course: 59 y/o man with pmh significant for hypercholesterolemia, htn, and transferred from for further care for arf and question of multiple myeloma. . 1. multiple myeloma- was the initial concern compression fractures, arf, anemia, hypercalcemia, and blastic and lytic lesions seen on plain imaging (not on bone scan). however, review of the osh records do not reveal a u-pep or s-pep. the pt had also not had a bone marrow biopsy. spep and upep done at was consistant with myeloma. here, imaging showed mass at t3, spep had + monoclonal spike and bone marrow bx. confirmed myeloma (m spike in plasma and urine, 76% plasma cells in marrow, renal failure). his calcium was slightly elevated on admission (10), but has normalized. baseline crt 0.9. he has been anemic, with low retic and elevated ferritin, and was transfused 2uprbc's , 2 uprbc's , 2 uprbc's , with 2 uffp . he was given vitamin k 10mg x3 for anticoagulation. as treatment he received dexamethasone for 40mg po for 4 days (day 1 ). he is scheduled for outpatient follow-up with dr. . . 2. pt with severe arf on presentation to the osh, creatinine initially 12.6 () ---> 11.4 () ---> 6.6 () with a bun of 145 () ---> 133 () ---> 75 (). urine protein was in the nephrotic range by a spot protein/creatinine ratio. renal us did not show obstruction, stones, or any other clear abnormality. arf thought to be multifactorial - hypercalcemia, nsaid use - 1200mg motrin daily for 6 weeks for back pain) and myeloma kidney. this improved here and by discharge creatinine was 0.8. he was advised to discontinue nsaid use. . 3. t3 vertebral lesion - seen by ortho spine - dr - he was taken to surgery for t3 corpectomy and t1-t5 fusion which was uncomplicated. after which he was placed in tlso brace whenever head >45 degrees and worked with pt prior to discharge. post operative pain control with dilaudid po. he additionally experienced chest wall muscle spasm controlled with flexeril 10mg po tid. he has follow-up for staple removal w/ortho . additionally he had a dexa to look for osteoporosis - has a t score -3.5, likely from his lactose intolerance. . 4 post-operative fevers - started post op day 1 and continued for the remainder of his hospitalization, max 102. he had no specific localizing signs or symptoms except a left sided pleural effusion which was tapped by thoracentesis and found to be transudative and sterile. it did not recur after throcentesis. blood cultures pending ng x4, urine neg , pleural fluid cx ngtd, blood cx ngtd x4 . given immunocompromised state from mm (hypogammaglobulinemia) pneumonia possible (at risk for infection with incapsulated organsims), no apparent response to abx (vanco x5d, flagyl/ciprox4d, azithro/ctx x1 day). tuberculosis potential was considered, but ppd negative, and with regard to pulmonary tuberculosis, no intrapulmonary findings on imaging and no cough. mm induced or drug fevers were also entertained. antibiotics were stopped 48 hours prior to discharge per recomendation of id and he continued to have low-grade fevers (<100.5) but continued to have no localizing signs or symptoms and was decided stable for discharge. . 5. anemia - normocytic, likely infiltration of marrow by myeloma cells, inappropriately low retic on admission, with elevated feritin, could be a component of chronic disease, vitamin b12 and folate wnl, iron studies c/w anemia of chronic dx. last tx , hct relatively stable since. tranfussion goal hct>21 unless brisk bleeding present or active end-organ damage/angina, active type and cross. . 6. diarrhea - had some diarrhea - for 2 days initially. c diff was neg, but he was given empiric metronidazole with resolution of diarrhea. . 7. osa- on home cpap, had his machine in house and was able to initiate use prior to discharge, which worked well for him. . 8. htn- he was continued on his home dose of norvasc. metoprolol was added peri-operatively and he was discharged on this medication. . 9. h/o hyperlipidemia: on fenofibrate as outpatient, held on admission renal failure, now that renal failure improved consider restarting (though potentially nephrotoxic so held on discharge, recommend discussing with pcp for alternative medication with consideration for mm treatment. . 10. osteoporosis - should be considered for bisphosphinates after this acute phase, after discussion with heme onc re calcium levels etc. . 11. fen- lactose free diet. agressive iv hydration. . 12. proph- bowel regimen; pneumoboots, lovenox. . 13. advanced pt's wife is his healthcare proxy, full code. medications on admission: medications at home: 1. tricor 145 mg daily 2. asa 81 mg daily 3. norvasc 10 mg daily 4. ibuprofen prn 5. glucosamine daily . medications at : 1. epoetin alfa units sc mon-wed-fri 2. calcitonin nasal spray 1 spray daily 3. odensetron 4 mg iv q8h prn 4. amlodipine 10 mg daily 5. tylenol 650 mg q6h prn 6. morphine 2 mg sc q4h prn discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4-6h (every 4 to 6 hours) as needed. 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). disp:*90 tablet, chewable(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*60 capsule(s)* refills:*3* 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tabs* refills:*3* 7. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*3* 8. hydromorphone 2 mg tablet sig: 1-2 tablets po q3-4h (every 3 to 4 hours) as needed. disp:*30 tablet(s)* refills:*0* 9. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical daily (daily) as needed. disp:*qs bottle* refills:*0* 10. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day) for 14 days: apply to affected groin area. disp:*qs tube* refills:*0* 11. flexeril 10 mg tablet sig: one (1) tablet po every eight (8) hours. disp:*90 tablet(s)* refills:*0* discharge disposition: home with service facility: vital care of discharge diagnosis: multiple myeloma acute renal failure l1/l2 compression fracture l3 vertebral body tumor discharge condition: stable discharge instructions: please refer to instruction sheet. please keep incision clean and dry. if you notice any increased redness, swelling, drainage, temperature >101.4, or shortness of please take all medications as prescribed. you may resume any normal home medications. please follow up as below. call with any questions. followup instructions: you have an appointment with dr. (orthopedics) on wednesday, at 10:30am, located in the clinical center . you will have your staples removed at this visit. please call ( if questions. . you have an appointment with dr. on thursday, at 1:30pm. this is located in the clinical center . please call if questions. . you have an appointment with a new primary care doctor (dr. ) on thursday at 11:10am. if you need to change this appointment, or make a sooner appointment please call . your appointment will be on the of the building at . please go to the central suite on the . md procedure: thoracentesis non-invasive mechanical ventilation biopsy of bone marrow dorsal and dorsolumbar fusion of the anterior column, anterior technique other excision of joint, other specified sites transfusion of packed cells dorsal and dorsolumbar fusion of the posterior column, posterior technique insertion of interbody spinal fusion device fusion or refusion of 4-8 vertebrae diagnoses: pure hypercholesterolemia congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified hyposmolality and/or hyponatremia unspecified sleep apnea osteoporosis, unspecified multiple myeloma, without mention of having achieved remission diarrhea other specified complications of procedures not elsewhere classified other and unspecified coagulation defects diastolic heart failure, unspecified anemia in neoplastic disease pathologic fracture of vertebrae spasm of muscle 

Answer: The patient is high likely exposed to