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: ivp dye, iodine containing attending: chief complaint: diarrhea major surgical or invasive procedure: egd/sigmoidoscopy history of present illness: pt is a 63 m with dm, htn, esrd s/p dcd renal transplant in on and prednisone c/b chronic allograft nephropathy who presented on with diarrhea x 2 weeks. he was admitted from with gi hx, before which he had been on a course of moxiflox for a resp infection. infectious colitis was suspected, but no pathogens were isolated and c diff toxin was negative x3. he was placed on flagyl from . also admission was complicated by a gout flare that was tx with prednisone pulse. he was later started on another out pt course of flagyl for his gi sx. on admission his vs were stable except for a temp or 100.1, he was tx with cipro and flagyl in the er. at home he also had been having fevers to 101 with the gi sx and had a non-productive cough. on the floor, pt continued to have joint pains. he had a arthrocentesis of the left ankle with little fluid removed, but no growth to date on cx. he also continued to have diarrhea, which was watery and frequent. he had a sigmoidoscopy that showed pseudomembranous colitis. despite negative tests this was thought to be c. diff, and he was started on po vanco with improvment of his diarrhea. he continued to spike fevers. he was restarted on hd for his failed transplant during this admssion. last night he had several episodes of dark emesis with coffee grounds. his hct dropped from 24 to 21, but responded with 1.5 units of blood. today he had an egd that showed severe esophagitis with erosions and evidence of bleeding. after the procedure he started to desat to 89% on a nrb, but improved to 6l in high 90s after some coughing. he went to hd, and then had new onset afib to 140s with stable bp. pt was tx with lopressor 5mg x 3 and dilt 10mg x 2. he was still in the 110s, so was started on a dilt gtt. his temp climbed to 101.6. he was transfered to the micu for dilt gtt and concern for sepsis. of note last night he missed his nifedipine and lopressor due to his emesis. . review of systems: denies sob, cp, dysuria, rash, lightheadedness. reports sx in hpi and pain with swallowing in throat and chest past medical history: 1. htn 2. elevated psa (followed by urology) 3. esrd req via a left av fistula from until cadaveric renal transplant of (on and prednisone). had hypertensive nephropathy. 4. type ii dm 5. hyperlipidemia 6. squamous cell skin cancers 7. gout social history: lives in with wife and one child. he is a substitute teacher having retired from his regular teaching job. remote smoking history (quit over 30 years ago), not currently. drinks etoh rarely. no illegal drugs family history: +early cad, noncontributory both parents died of mi at early ages, mother (46) & father 51; he has no personal cardiac history. physical exam: vitals t 98.7 p 80 bp 140/79 rr 20 o2 97% on ra general pleasant, appears tired, no distress heent cushingoid face, sclera anicteric, conjunctiva pink, no oral lesions appreciated, no sinus tenderness neck supple, jvp ~7cm pulm lungs with few bilateral wheezes, no rales appreciated cv regular s1 s2 no m/r/g abd soft +bowel sounds no organomegaly or mass. renal transplant in rlq nontender. guiac negative in er. extrem warm with palpable distal pulses 1+ bilateral pedal edema, no significant erythema, no cords or leg asymmetry. lue with av fistula +thrill. neuro alert, answering appropriately, moving extremities no gross deficits. mild bilateral postural tremor. derm no rash or jaundice lines/tubes/drains none . on admission to micu: vitals: 99.7 109 144/55 78 20 96% general: alert, oriented, some discomfort heent: sclera anicteric, mmm, oropharynx with some white plaques neck: supple, no lad lungs: rhonchi bilaterally cv: rrr, no murmurs, 2+ radial pulses, thrill over fistula on left abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding ext: warm, well perfused, no edema; there are effusions in both ankles l>r, left toes, right mcps, and left knee; joints are warm, red and tender to palpation neuro: moves all extremities, follows commands, pleasant pertinent results: chem 10 140 107 76 90 agap=18 4.4 19 7.8 ca: 7.4 mg: 1.7 p: 6.0 . ck: 66 . alt: 17 ap: 52 tbili: 0.2 ast: 15 : 69 lip: 138 . urica:11.1 . cbc 7.6 > 9.7 < 230 30.9 n:85.8 l:5.6 m:6.5 e:1.9 bas:0.2 . on transfer to micu: mcv-81 wbc-9.1 plts-252 hct-27.2 freeca:0.94 ph:7.47 ck: 192 ph 7.42 pco2 32 po2 110 hco3 21 o2sat: 98 lactate:0.8 138 99 62 agap=25 -------------<171 4.1 18 6.5 &#8710; ck: 198 mb: 2 trop-t: 0.07 pt: 15.6 ptt: 24.9 inr: 1.4 . on discharge: 05:36am blood wbc-4.8 rbc-3.27* hgb-8.6* hct-27.3* mcv-83 mch-26.4* mchc-31.7 rdw-15.7* plt ct-205 05:36am blood pt-12.6 ptt-21.1* inr(pt)-1.1 05:36am blood glucose-143* urean-44* creat-5.1*# na-140 k-4.0 cl-101 hco3-32 angap-11 05:36am blood calcium-7.6* phos-4.7* mg-1.8 05:36am blood rapmycn-3.0* images: ppd negative blood culture - ngtd jnt fluid neg mrsa - neg rrv - neg stool (ngtd) throat - ngtd urine - ngtd hsv/cmv - ngtd cmv: neg cx neg iga = 45 low ttg = 2 b-glucan = 68 pg/ml intermidiate. aspergillus antigen 0.1 hsv= neg /ebv = neg /fungal markers pending. . pathology: gi bx: colonic mucosa with focal crypt regeneration, mild cryptitis, active inflammation, and foci of prominent edema (see comment). . comment. the features are suggestive of pauci-inflammatory acute colitis, with the prominent edema raising the possibility of an ischemic-type injury, such as can be seen due to a vascular insult, drug effect (eg. nsaid's) or certain infections, particularly c. difficile. the surface epithelium is nearly completely denuded, precluding further evaluation. . unilat up ext veins us right study date of impression: no evidence of right upper extremity dvt. . portable tte (complete) done : the left atrium is moderately dilated. the right atrium is moderately dilated. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the rhythm is now atrial fibrillation and the right ventricular cavity is slightly dilated. the estimated pa systolic pressure is similar (was overestimated on the prior study). . ct chest impression: 1. mild worsening of small airways disease since . the differential diagnosis includes bacterial, viral, and less likely fungal etiology. 2. near resolution in atypical configuration of the stomach since . . ct abd impression: 1. wall thickening of the sigmoid and rectum with increased thickening of the sigmoid colon and increased surrounding fat stranding since prior study from . etiologies could be infectious, inflammatory or less likely ischemic. no pneumatosis or portal venous gas seen. 2. new small right pleural effusion. 3. pancreatic ductal dilatation in the pancreatic head, up to 5mm. if not previously recently evaluated, mrcp or us recommened for further evaluation. 4. multiple renal transplant hypodensities, likely cysts. these were evaluated on prior renal ultrasound from . hypodensities of the native kidneys can be further evaluated with renal ultrasound as clinically warranted. . egd severe erythema with exudate involved the entire mucosa. this was consistent with severe esophagitis. brushings were taken and sent to micro for viral culture (cmv, hsv) and fungal culture. otherwise normal egd to third part of the duodenum . sigmoidoscopy diffuse exudate versus pseudomembranes in the sigmoid colon. the exudate did not wash away with flushes. no ulcers noted. cold forceps biopsies were performed for histology at the sigmoid colon. . brief hospital course: mr. is a 63m with dm and htn s/p dcd renal transplant in c/b chronic allograft nephropathy who is being tx for colitis, and now has esophagitis, new oxygen requirments, and new afib with transfered to micu for a dilt gtt briefly. . # afib with rvr: hr up to 140 which improved on dilt gtt to 90s. likely afib is secondary to infectious process in setting of fever. patient was also having pain from his gout which may have worsened his rate. also, on last echo, patient had enlarged atria, increasing his risk for afib. patient's diltiazem gtt was discontinued the morning after transfer to the micu and although he remained in atrial fibrillation, his heart rate was significant better controlled. patient also received a 500 cc bolus of intravenous fluids, had thyroid function tests checked (which were normal) and a repeat echo that was negative for ischemic etiology for his acute onset of afib with rvr. patient was monitored on telemetry without issues. anticoagulation was not initiated in the setting of patient's recent gi bleed. patient's gout pain was controlled. after arrival back to the floor, patient was noted to be in sinus rhythm and remained so at the time of discharge. # fevers: pt has mulitple possible causes including his esophagitis, his colitis, and his gout. also confirmed with radiology that patient aspirated. infectious disease is following the patient and recommended following up on cultures and starting fluconazole in this immunosuppressed patient given risk for fungal infections. he was maintained on po vancomycin for his colitis and prednisone for his gout. he became afebrile on the floor and was without fever for over 24 hours at the time of discharge. . # upper gi bleed/esphagitis: egd showed extensive esophagitis with evidence of bleeding. unclear cause. patient is at risk for infection due to immunosupressive meds including viral - hsv, cmv, or fungal. patient was continued on intravenous ppi twice daily, fluconazole x3 days per infectious disease (although per renal, fluconazole can interact with , levels will need to be followed while patient is on fluconazole). patient beta-glucan and galactomannan were checked and a oral sore was swabbed and negative for fungus. patient was continued on lidocaine for symptomatic relief of throat discomfort. per gi, his diet was advanced to clears which he tolerated well. subsequently, he tolerated a regular diet and was discharged with po ppi . he will follow up with gi for a repeat egd in 6weeks. . # colitis: diarrhea with radiographic evidence of proctocolitis. fevers (could be due to gout flare) and recent history is suggestive of an infectious process - eg c difficile colitis given prior antibiotics. given prior transplant, cmv, ebv, bk are suspects; vs. diverticulosis, medication related, or simple antibiotic-associated diarrhea. gi eval notable for pseudomembrane on flexsig, although c. diff is neg x3. after his sigmoidoscopy, patient's diet was advanced to clears. patient was empirically treated for cdiff with iv flagyl and po vancomycin. stool cdiff, ova and parasite, stool cultures were negative. he was continued on vancomycin at the time of discharge. he will follow up with gi for a repeat scope as an outpatient. . # gout: pt has hx of gout and now had multiple joints inflammed. recent tap of ankle was a small sample but did not show crystals or infection. however, due to presentation gout is most likely the cause. pt is at risk with his renal failure. patient was given standing tylenol and iv morphine prn for pain and given one time dose of methylprednisolone 40mg iv with significant improvement of discomfort. rheumatology recommended to continue on prednisone then a taper over the few weeks. he continued to improve at the time of discharge. he was told to follow up with his outpatient rheumatologist. . # hypoxia: likely aspiration event after egd. pt may also have aspirated with his recent emesis. chest xrays, per radiolgoy, confirmed this. patient was continued on supplemental oxygen as needed, sputum cultures, nebulizers as needed. he was also continued on vancomycin iv, cefepime and flagyl to cover for aspiration pneumonia and health care associated pneumonia, given his immunosuppression. he completed his course of antibiotics was discharged in afebrile and stable condition. # gap acidosis: improved after hemodialysis and likely due to his uremia/end-stage liver disease. lactate was normal. patient was supplemented with bicarbonate per renal. . # pancreatic ductal dilatation: ct showed duct at 6mm, stable from ct earlier in the month. lipase was initially elevated at 138 from normal level last month. pt has had no abdominal pain on exam, but this may be masked by his immunosuppresive meds. his lfts and lipase were trended and the former was within normal limits, the latter decreased to the 60s. he was told to follow up as an outpatient for eus in the next couple of weeks. . # esrd s/p renal transplant: patient was recently restarted on hemodialysis given transplant graft failure. patient was continued on home prednisone, sirolimus, cinacalcet, sevelemer. renal continued to follow this patient in house. he will continue hd as an outpatient on a mwf schedule. . # dmii: stable on insulin sliding scale while in the hospital . # anemia: hematocrit remained stable after transfusions and egd. his hematocrit was monitored twice daily in the micu, with active type and screen maintained. . # hypertension: patient's blood pressures were stable. his diltiazem drip was discontinued. patient's nifedipine was held and he was continued on home metoprolol 50mg with good control . #code: full code confirmed medications on admission: 1. prednisone 10 mg tablet sig: as directed tablet po once a day for 5 days: : 4 tablets (40 mg); : 2 tablets (20 mg); : 2 tablets (20 mg); : 1 tablet (10 mg); : 1 tablet (10 mg); : resume 5 mg daily dosing. disp:*10 tablet(s)* refills:*0* 2. calcitriol 0.5 mcg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 3. cinacalcet 30 mg tablet sig: one (1) tablet po bid (2 times a day). 4. glimepiride 1 mg tablet sig: one (1) tablet po once a day. 5. metoprolol tartrate 100 mg tablet sig: one (1) tablet po twice a day. 6. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 7. pioglitazone 30 mg tablet sig: one (1) tablet po once a day. 8. sirolimus 1 mg tablet sig: three (3) tablet po daily (daily). 9. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). disp:*90 tablet(s)* refills:*2* 10. metronidazole, dose unknown to patient (prescribed by pcp) discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. prednisone 10 mg tablet sig: see other instructions tablet po daily (daily): please take 3 tablets a day for ; ; please take 2 tablets a day from ; please take 1 tablet a day from . . disp:*27 tablet(s)* refills:*0* 3. prednisone 5 mg tablet sig: one (1) tablet po once a day: please take this dose once the taper has been completed. . 4. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 2 days. disp:*8 capsule(s)* refills:*0* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 6. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). disp:*180 tablet(s)* refills:*2* 7. cinacalcet 30 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 9. sirolimus 1 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. calcitriol 0.5 mcg capsule sig: one (1) capsule po once a day. 11. glimepiride 1 mg tablet sig: one (1) tablet po once a day. 12. pioglitazone 30 mg tablet sig: one (1) tablet po once a day. 13. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po twice a day. disp:*60 tablet sustained release(s)* refills:*2* discharge disposition: home with service facility: health vna and hospice discharge diagnosis: diagnoses: c. difficile colitis gout flare upper gastrointestinal bleeding atrial fibrillation pancreatic duct dilation esrd s/p renal transplant now requiring hemodialysis diabetes mellitus anemia hypertension hyperlipidemia . discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - requires assistance or aid (walker or cane) discharge instructions: it was a pleasure taking care of you here at . you came to the hospital with an inflamed knee and unresolved diarrhea. you were diagnosed with a condition called c.difficile colitis which was the cause of your diarrhea. we provided you with antibiotics and your diarrhea nearly completely resolved by time of discharge. we also determined that you had a gout flare in your knee. we treated the gout flare with steroids, and you have been discharged on a steroid taper schedule as below. . we also determined that your transplanted kidney was failing which required us to put you back on hemodialysis. your outpatient hemodialysis sessions have all been arranged for you and you have a follow-up renal appointment with dr. in about a month ( see below). . while in the hospital, you had an episode of gi bleeding which required us to transfuse you. during this event, your heart transiently went into an abnormal rhythm which required us to transport you to the micu for treatment. you tolerated the treatment well and recovered uneventfully and your heart has a normal rate and rhythm now. . you had some elevated blood glucose levels in the hospital while your prednisone was increased. you were contolled with insulin and your usual oral diabetic medication was briefly held but it is now being restarted at discharge and you do not need to continue insulin. . please follow with you doctors below. please note we made the following changes to your medications. . this is the list of medications you are discharged on: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po twice a day. 3. prednisone 10 mg tablet sig: see other instructions tablet po daily (daily): please take 3 tablets a day for ; ; please take 2 tablets a day from ; please take 1 tablet a day from . 4. prednisone 5 mg tablet sig: one (1) tablet po once a day. 5. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 2 days. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 7. sevelamer carbonate 800 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 8. cinacalcet 30 mg tablet sig: one (1) tablet po once a day. 9. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 10. sirolimus 1 mg tablet sig: two (2) tablet po daily (daily). 11. calcitriol 0.5 mcg capsule sig: one (1) capsule po once a day. 12. glimepiride 1 mg tablet sig: one (1) tablet po once a day. 13. pioglitazone 30 mg tablet sig: one (1) tablet po once a day. . here is a summary of medication changes on this admission: 1.prednisone taper 2.added pm nifedipine for better blood pressure control and nifedipine increased to 60mg twice daily 3.oral vancomycin was given for your diarrhea 4.pantoprazole given for your gi bleed and acid protection 5.sirolimus changed to 2-mg daily 6. your beta blocker (metoprolol) was increased to 100mg three times daily 7. you can continue cinacalcet 30mg daily . . followup instructions: appointment #1 md: specialty: internal medicine/ cardiology date/ time: location: , phone number: special instructions for patient: dr. will contact you on to book your follow up appointment. if you do not hear by tuesday, , please call the number above to schedule your appointment. appointment #2 md: specialty: rheumatology date/ time: , , 10am location: , . , phone number: special instructions for patient: gout flair follow up appointment #3 md: specialty: gastroenterology date/ time: wednesday, , 4pm location: , . , phone number: special instructions for patient: gastroenterology to obtain outpatient eus regarding dilated pancreatic duct and a repeat egd in 6 weeks. . appointment #4: follow up with dr. on friday at 9am - at , 7 fl (). if you need to reschedule call . . session info: provider: ,schedule hemodialysis unit date/time: 7:30 md procedure: hemodialysis esophagogastroduodenoscopy [egd] with closed biopsy arthrocentesis closed [endoscopic] biopsy of large intestine diagnoses: acidosis anemia in chronic kidney disease end stage renal disease diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled gout, unspecified atrial fibrillation hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia pneumonitis due to inhalation of food or vomitus intestinal infection due to clostridium difficile hematemesis esophagitis, unspecified complications of transplanted kidney other specified diseases of pancreas swelling of limb 

Answer: The patient is high likely exposed to