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: abd pain major surgical or invasive procedure: temporary hemodialysis catheter placement (now removed) hemodialysis history of present illness: 69 yo f with a fib, hypertension and dm with renal failure s/p renal transplant presenting with abdominal pain. day prior to admission she had acute onset of abdominal pain while in bed. pain persisted overnight and worsened the next day so came to the ed. denies fever, chills, ns, dysuria, c/p, palpitations, back pain or other focal complaints. . in the ed, intial vs were t98.5, bp 164/78, hr 63, rr 18, o298%ra, pain , exam notable for absence of cva ttp. labs notable for absence of wbc's, or le by ua, inr 6.2 and cr 3.1 (recent baseline). ct scan of abdomen showed stranding around the r-kidney. patient was given morphine 4mg iv x1, and ciprofloxacin 400mg iv x1 for a possible uti/pyelonephritis. . on arrival to the floor, patient was comfortable. she reported pain only with movement, but was otherwise comfortable. . ros: + increased abdominal distension, otherwise no change to bowel habits. . ros: ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. . during her hospital course her abdominal pain was felt to be radicular pain due to lumbar spinal stenosis. in addition, on she also developed new bilateral lower extremity weakness concerning for cauda equina compression given evidence of this on mri. neurology was consulted to evaluate. . she also developed altered mental status starting sunday . possible causes considered include infection, seizure, intracranial hemorrahge. she was started on ceftriaxone to treat for uti although culture not positive. she had a head ct and head mri both of which were unrevealing. of note her ms did improved after starting ceftriaxone. . she also developed progressive hyponatremia and hyperkalemia as well as worsening renal failure. k was 6.5 on the day of transfer to the icu and she was given kayexalate, 10 units regular insulin and 1 amp d50. . on the day of transfer to the micu () she had a tunnelled line placed in ir due to lack of access as well as possible need for dialysis given worsening renal function. past medical history: 1. esrd due to diabetic nephropathy and hypertension s/p renal transplant . ckd since that time with cr 1.7 at baseline post-transplant but now with baseline cr closer to 3.0 2. hypertension for 40+ years 3. type dm ii for 30+ years 4. atrial fibrillation on coumadin 5. chf 6. copd 7. gout 8. secondary hyperparathyroidism 9. chronic edema 10. anemia ckd social history: does not smoke, drink alcohol or use drugs. lives with son, has for coumadin dosing/labs. family history: one sister with cad and diabetes. another sister with heart disease nos. one sister died of ovarian cancer at age of 77. no other history of heart disease, cancer or diabetes. both parents deceased of unknown cause. physical exam: on admission: vs: t99.9, bp 142/66, hr 61, rr 20, o2 91%ra gen: elderly woman in nad, awake, alert heent: eomi, perrl, sclera anicteric, conjunctivae clear, op moist and without lesions neck: supple, difficult to appreciate jvd habitus cv: reg rate, normal s1, s2. +systolic murmur chest: coarse rales bilaterally - no wheezes, no ronchi abd: obese, prominent panus, +bs, no appreciable hepatosplenomegaly, abdominal pain does not localize well but greatest in lower quadrants, no rebound no guarding ext: chronic skin changes burns and skin grafts, no skin breakdown, 1+ le edema, clubbing or cyanosis back: no cva tenderness . pertinent results: 12:15pm wbc-6.9# rbc-4.23 hgb-12.4 hct-39.2 mcv-93 mch-29.4 mchc-31.6 rdw-18.1* 12:15pm neuts-83.3* lymphs-11.3* monos-4.9 eos-0.3 basos-0.2 12:15pm plt count-241 . 12:15pm alt(sgpt)-11 ast(sgot)-17 alk phos-70 tot bili-0.7 12:15pm glucose-125* urea n-65* creat-3.1* sodium-139 potassium-4.1 chloride-104 total co2-23 anion gap-16 . 05:45pm urine blood-sm nitrite-neg protein-500 glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-5.0 leuk-neg 05:45pm urine rbc-* wbc-0-2 bacteria-many yeast-none epi- 05:45pm urine granular-0-2 hyaline-* . bun/cr trend: 12:15pm blood urean-65* creat-3.1* 06:15am blood urean-65* creat-3.2* 07:05am blood urean-73* creat-3.8* 06:15am blood urean-77* creat-4.2* 07:00am blood urean-85* creat-5.2* 05:30am blood urean-92* creat-5.7* 05:21pm blood urean-100* creat-5.9* 11:53pm blood urean-97* creat-5.8* 11:53pm blood urean-97* creat-5.8* 03:32am blood urean-100* creat-6.0* 04:34pm blood urean-77* creat-4.5*# 03:09am blood urean-83* creat-5.0* 03:20pm blood urean-60* creat-3.8*# 08:45am blood urean-71* creat-4.0* . cxr new opacity in the left lower lobe in the retrocardiac area suggests aspiration given the clinical concern. small-to-moderate bilateral pleural effusions are unchanged. marked cardiomegaly is stable. left supraclavicular catheter is in place. there is no pneumothorax. . echo the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 0-10mmhg. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild global left ventricular hypokinesis (lvef = 40 %) with more significant hypokinesis of the septum the right ventricular cavity is mildly dilated with borderline normal free wall function. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. the ascending aorta is moderately dilated. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (area 1.0-cm2). moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. moderate to severe tricuspid regurgitation is seen. the tricuspid regurgitation jet is eccentric and may be underestimated. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , left ventricular systolic function is now impaired. the severity of tricuspid regurgitation has increased. the severity of aortic regurgitation has increased. the other findings are similar. . eeg: impression: this is an abnormal routine eeg due to a slow and disorganized background indicative of a mild encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. there are no epileptiform features noted. . cxr: cvl tip at right atrium, no evidence of pneumothorax or apical hematoma, cardiomegaly still present, interval development of rll opacity most likely aspiration or aspiration/pleural effusion, mild volume overload in perihilar areas. . mri head: no evidence of acute ischemia. extensive periventricular white matter disease, consistent with small vessel ischemic change with more defined lacunar-type infarcts also noted. slight interval increase in fluid within the left sphenoid sinus, should be correlated for any signs of acute sinusitis clinically. . mri ctl spine: degenerative disc disease with evidence of spinal stenosis and spinal cord compression in the cervical spine. spinal stenosis and cauda equina compression in the lumbar spine. hyperintensity of lumbar intervertebral discs most marked at l2-3 and l4-5. although these likely reflect degenerative disc disease, the possibility of infection cannot be excluded. a preliminary report was issued that read "spinal stenosis at c4 through c7 with severe disc protrusion and ligamentum flavum calcification effacing thecal sac, worst at c6-7. no cord signal change. no priors to establish time intensity relationship. thoracic cord no compression. . ct head: corona radiata hypodensities bilaterally are age-indeterminate in the absence of prior scans. if clinical suspicion for acute/subacute stroke, consider mr for further characterization. the white matter changes appear well defined, markedly hypodense, and likely chronic. i agree that mr may be helpful if there is continued concern of possible acute infarction. . renal transplant: 1. interval increase in resistive indices, worrisome for rejection. 2. interval slight decrease in the pelvocaliectasis. . ct abdomen/pelvis: 1. effacement of the fat around the transplant kidney for which the differential includes pyelonephritis and renal vein thrombosis. right wall small seroma/ hematoma. 2. increased right pleural effusion. 3. prominent cisterna chyli. 4. atherosclerotic vascular changes. 5. persistent right renal cyst. 6. stable appearance to left lower lobe pulmonary nodule. . micro urine cx negative x 4 blood cx (including 1 mycolytic) negative x 6 (2 pending, no growth to date) cmv vl undetectable mrsa screen negative x 2 c.diff pending labs on discharge 05:17am blood glucose-96 urean-76* creat-2.1* na-130* k-3.8 cl-91* hco3-31 angap-12 . asymptomatic pyuria (urine cultures all negative) 12:10pm urine rbc-59* wbc-261* bacteri-none yeast-none epi-1 renalep-3 02:41pm urine rbc-21-50* wbc-* bacteri-mod yeast-none epi- transe- 05:45pm urine rbc-* wbc-0-2 bacteri-many yeast-none epi- brief hospital course: 70 yo f with pmh afib, hypertension, dm with esrd s/p renal transplant admitted with abdominal/back pain spinal stenosis with course c/b uti, acute on chronic renal failure, altered mental status and hyponatremia. . #. acute on chronic kidney disease s/p transplant: concerning for transplant rejection with worsening hyperkalemia and volume overload. other consideration is nsaid induced given that pt was taking nsaids for acute gout flare prior to admission. other possibilities are prerenal failure due to adrenal insfficiency vs poor cardiac output vs volume depletion. fena is consistent with prerenal etiology. no evidence of post renal obstruction. cmv not detected. patient was intiated on dialysis and had third round on and electrolytes improved. cr continued to trend down by day of discharge. pt was tapered off high dose steroids, and was continued on prednisone 5mg po daily. calcitriol and calcium carbonate were continued. sodium bicarbonate was discontinued. prograf was adjusted and continued at lower dose of 3mg po q12 at discharge. pt did not require any additional sessions of hemodialysis, and temporary hd line was removed on day of discharge by ir. . # acute mental status change: this was thought to be secondary to hyponatremia and uremia in setting of worsening acute on chronic renal failure. mri head was negative for acute etiology. confusion resolved after several sessions of hemodialysis and resolution of hyponatremia and uremia. pt was aox3 on day of discharge, and back to baseline per family. . #. depressed ef - can't exclude chf as cause of renal failure, however stroke volume 5.5l per minute. unlikley that there has been an acute demise in her cardiac function, by exam not hypoperfusing, bounding pulses, limited treamtnet options. cards was consulted, and did not think her cardiac function was the cause for her worsening renal failure. by day of discharge, pt's metoprolol was titrated up to 25mg po tid, lasix 60mg po bid. lisinopril and isodil continued to be held while renal function recovered. lisinopril should be resumed in the near future. . #. hyponatremia: thought hypovolemic hyponatremia by the floor team, with urine lytes consistent with prerenal syndrome. sodium worsened to 122 from 139 on admission. due to altered mental status she was transferred to the icu for hypertonic saline. patient was given stress dose steroids, tsh was normal, echo with depressed ef to 40%. resolved with dialysis and ms improved. was likely secondary to acute on chronic renal failure and fluid overload. pt was placed on a fluid restriction of 1200ml. na was stable at 129-130 at discharge. . # back/abdominal pain: on admission, was initially thought to be secondary to pyelonephritis given dirty u/a and localized to lower abdomen, but given negative urine cultures and imaging, now thought to be most likely related to lumbar spinal stenosis and radiculopathy seen on ct abdomen/pelvis. pt experienced mental status change and developing weakness toward beginning of admission, and neurology and neurosurgery were consulted. mri head was negative for acute etiology. pt was given a dose of decadron 10mg per neuro. neurosurgery recommended conservative management during acute mental status change and uremia. following management of electrolyte abnormalities in the micu, pt was transferred back to the floor with improvement in pain, but persistent weakness in hand grip and lower extremities. neurosurgery re-evaluated pt, and felt that though symptoms persisted, pt did show improvement, and thus would be able to consider elective surgery in outpt setting. pt will be following up with dr. in neurosurgery to discuss possible surgical management of the cervical/lumbar stenosis as outpatient. . # hand and lower extremity weakness: see above. . #paroxysmal atrial fibrillation - currently in normal sinus rhythm. pt was continued on amiodarone. coumadin was temporarily held on admission while supratherapeutic, then again when temporary hd line was placed. pt is now back on coumadin, with loading dose of 10mg po daily to be given on day of discharge at rehab, followed by 5mg po qday with goal inr . pt is on heparin sc, which should be discontinued when inr becomes therapeutic. . #diabetes - pt experienced hypoglycemia with bs in the 60s following her micu stay, likely secondary to decreased po intake. home nph dosing was decreased from nph 22units qam, 3units qpm to 13units qam and none in pm. humalog insulin sliding scale was also continued. . # htn - pt's lisinopril and lasix were initially held on admission given acute on chronic renal failure. then in the micu, above meds as well as hydralazine were held given hypotension. as blood pressure is now back to baseline, pt will be discharged on metoprolol and lasix, with hydralazine prn, and lisinopril held as renal failure continues to resolve. lisinopril will need to be resumed in near future. isodil should also be considered. . # fen- renal diet with sugar-free shake supplements, fluid restrict 1200ml . # ppx- heparin sq while coumadin is becoming therapeutic, ppi . # code- full medications on admission: amiodarone 200 qd calcitriol - 0.25 mcg 5 days a week colchicine - 0.6 mg tablet qod darbepoetin alfa in polysorbat - 100 mg tablet qd mycophenolate mofetil - 500 mg tablet prednisone - 5 mg tablet qd protonix - 40mg tablet, qd tacrolimus 4 mg q12 warfarin - 2.5 mg tablet - tablet(s) by mouth at bedtime or as directed by coumadin clinic calcium carbonate - 500 mg tablet,qid prn calcium carbonate-vit d3-min qd ferrous sulfate qd insulin nph human recomb - (prescribed by other provider) - 100 unit/ml suspension - 22 units in the am, sliding scale in pm insulin regular human - (prescribed by other provider) - 100 unit/ml solution - sliding scale 4 times daily . discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 2. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. furosemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). 5. prednisone 5 mg tablet sig: one (1) tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 8. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 9. simethicone 80 mg tablet, chewable sig: tablet, chewables po qid (4 times a day) as needed. 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po hs (at bedtime) as needed for constipation. 13. tramadol 50 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain. 14. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 15. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 16. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 17. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units sc injection tid (3 times a day). 18. tacrolimus 1 mg capsule sig: three (3) capsule po q12h (every 12 hours). 19. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for fever . 20. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for yeast infection. 21. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: start . 22. warfarin 5 mg tablet sig: two (2) tablet po once daily at 4 pm for 1 days: administer . 23. insulin glargine 100 unit/ml solution sig: thirteen (13) units subcutaneous at bedtime. 24. hydralazine 10 mg iv q6h:prn for sbp >170 25. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 26. darbepoetin alfa in polysorbat 100 mcg/0.5 ml pen injector sig: one (1) injection subcutaneous once a week. 27. insulin lispro 100 unit/ml solution sig: as directed units subcutaneous qachs: please use as directed by sliding scale. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: acute on chronic renal failure hyponatremia uremia cervical and lumbar spinal stenosis insulin dependent diabetes mellitus hypertension . secondary: paroxysmal atrial fibrillation discharge condition: good, afebrile, hemodynamically stable, aox3, urinating (incontinent) discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction:1200ml . you were admitted for evaluation of abdominal/back pain. you were found to have spinal stenosis, which is likely contributing to your pain as well as your hand and leg weakness. you will be following up with dr. , neurosurgery, as outpatient to discuss surgical options. . your hospital stay was also complicated by acute mental status change, caused by your worsening kidney function. this as well as your kidney function improved with temporary hemodialysis. as your kidney function has continued to improve and you are urinating on your own, you will not need additional dialysis. you were resumed on your home lasix. . your blood sugars have been low during your stay, likely caused by decreased eating. your insulin was adjusted. . your coumadin dose was adjusted, as you were supratherapeutic when you were first arrived. now you are subtherapeutic, so your dose will need to be adjusted for inr . the following changes were made to your medications: stop colchicine stop hydralazine stop lisinopril stop cellcept change metoprolol to 25mg po twice daily change coumadin to 10mg po x 1 today (), then decrease to 5mg po daily . if you experience any fever, chills, nausea, vomiting, worsening abdominal pain, new weakness/numbness, decreased urine output, confusion, or have any other concerns, please notify the md. followup instructions: please have your cbc, complete metabolic panel, and coags checked on friday with results faxed to the renal transplant center. fax: . please follow-up with dr. , neurosurgery,on at 1:30pm to discuss elective surgical options for your cervical/lumbar stenosis. w/lmob-3b ( . please follow-up with kidney clinic. you will be contact by the clinic within the next week for an appointment. . please follow-up with your pcp, . within 2 weeks. . . you also have the following appointments: provider: , rn phone: date/time: 8:00 provider: imaging phone: date/time: 9:00 provider: , m.d. phone: date/time: 9:30 md procedure: hemodialysis venous catheterization for renal dialysis diagnoses: hyperpotassemia anemia in chronic kidney disease abnormal coagulation profile congestive heart failure, unspecified acute kidney failure, unspecified hyposmolality and/or hyponatremia chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation chronic kidney disease, unspecified diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin chronic systolic heart failure long-term (current) use of anticoagulants secondary hyperparathyroidism (of renal origin) anticoagulants causing adverse effects in therapeutic use encephalopathy, unspecified complications of transplanted kidney diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled cervical spondylosis without myelopathy cauda equina syndrome without mention of neurogenic bladder spondylosis with myelopathy, lumbar region 

Answer: The patient is high likely exposed to