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: iodine; iodine containing attending: chief complaint: fatigue major surgical or invasive procedure: bone marrow biopsy history of present illness: mr. is a 47 year old man with a history of obesity, asthma, chronic low back pain, and recent rib fracture who presented to the ed on for 2 weeks of severe fatigue & dyspnea on exertion. in of this year, the patient was diagnosed with a right lateral seventh rib fracture following incidental trauma (leaning over the arm of a chair). on , the patient was seen in pulmonology clinic for progressive dyspnea and bony pain, and his dyspne awas thought attributable to asthma. he was therefore restarted on pulmicort. , though a cxr was negative for fracture. his doe progressed and he developed profound fatigue, along with nightsweats and fevers. he therefore presented to the ed on . there, he endorsed mild subjective fevers at home, but denied any other b symptoms. initial vital signs were t98.4 p85 bp129/98 and 97% on ra. blood work demonstrated a hematocrit of 25.7 (baseline hct 45), a new thrombocytopenia to 101, and a wbc of 8.7 with abnormal myeloid cells. he also had a cr of 2.2 (baseline 0.8) and was noted to have a new murmur on exam. he was admitted to 3 for further management, but on the floor he was ill-appearing and further work-up demonstrated a ca of 17.7 and uric acid of 12.9. coags and fibrinogen were wnl, so he initiated ivf's, but then triggered on for increasing o2 requirement, somnolence and ams and he was transferred to the icu for further management. in the icu, heme-onc & renal were consulted. he was continued on aggressive ivf's, lasix 80mg , allopurinol, pamidronate (last dose on ), calcitonin, & dexamethasone 40mg iv (first dose on ). his cr rose to 3.6, but he continued to produce urine. a ct torso demonstrated diffuse lucencies in the bone without associated lymphadenopathy consistent with multiple myeloma, and his spep demonstrated a monocloncal igg kappa spike of 15% of total protein with normal viscosity. over the course of his icu stay, his serum ca trended down to 13.7, but his serum phosphate & uric acid continued to climb. his o2 requirement also continued to rise and a cxr on suggested a right middle lobe pneumonia so he was started on ceftriaxone & azithromycin for cap. oncology recommended initiation of chemotherapy and he was therefore transferred to bmt. at the time of transfer, his vital signs were: t 97.9 p84 bp 120/67 r 20's o2sat 95% on 5l, i 4,618cc o 7,090cc. on arrival to the floor, the patient immediately triggered for an o2sat of 88-89% on 6l nc, so he was switched to a nrb sat'ing 97%. he was quickly switched back to 6l, sat'ing 95-96% with a rr of 36. he appeared uncomfortable and was unable to speak in complete sentences. past medical history: asthma costrochondritis lower back pain w/ l3-l4 lateral disc protrusion obesity nephrolithiasis h/o atypical chest pain rectal bleeding hyperlipidemia sleep apnea, osa 11cm h20 s/p rib fractures x 1, depression social history: patient lives in with his wife & works on faculty at . they have three sons. his wife is a plastic surgeon who trained at the . tobacco: none etoh: none illicits: none family history: mother: cad and dm father: dm known family history of cancer physical exam: gen: ill appearing, diaphoretic, drenching the bed with sweat heent: mmm, no op lesions, no thyromegaly cv: rr, iii/vi holosystolic murmur pulm: ctab, poor effor, prolonged expiratory phase abd: bs+, soft, distended, ntnd, no masses or hsm but exam limited by habitus limbs: no le edema, no clubbing, no tremors lymphnodes: no epitrochlear, cervical, supraclavicular, axillary, inguinal, popliteal lad skin: no rashes or skin breakdown neuro: sleepy, slow to resond to questions but answers appropriately, reflexes are diffusely 1-, toes are down bilaterally pertinent results: transthoracic echo: the left atrium is elongated. the right atrium is moderately dilated. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thicknesses and cavity size are normal. left ventricular systolic function is hyperdynamic (ef>75%). a mid-cavitary and outflow tract gradient is identified without dynamic resting lvot obstruction (high output state). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. the aortic valve leaflets (3) are mildly thickened. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: high output stae. moderate pulmonary hypertension. . ct scan: findings: a limited examination of the porta hepatis and peripancreatic region was performed. no enlarged lymph nodes are seen. incidentally noted, but not fully evaluated, there is a round hypoechoic lesion within the left lobe of the liver. this lesion measures 1.3 x 1.5 x 1.3 cm. impression: 1. no lymphadenopathy identified. 2. left hepatic lesion measuring 1.3 cm, which cannot be further characterized with ultrasound. a multiphase ct could be performed for better characterization when the patient is better able to tolerate contrast. . ct chest/abdomen: ct chest without contrast: no pathologically enlarged axillary, mediastinal, or hilar lymph nodes are observed. small precarinal and subcarinal lymph nodes measure up to 8 mm in short axis which does not meet ct criteria for pathologic enlargement. the heart and great vessels are unremarkable and there is no evidence of pericardial or pleural effusion. there is diffuse ground-glass opacity throughout the lungs bilaterally, sparing the subpleural lung, with a more nodular pattern predominating in the upper lobes. the airways are patent to the subsegmental level bilaterally. ct abdomen without contrast: the liver, spleen, and adrenal glands appear unremarkable. wall thickening along the body and fundus of the gallbladder spares the gallbladder neck. non-contrast evaluation of the kidneys reveals a 7-mm nonobstructing right interpolar stone. intra-abdominal loops of large and small bowel are of normal caliber and there is no pneumoperitoneum or free fluid. atherosclerotic calcifications involve the abdominal aorta, otherwise of normal caliber. ct pelvis without contrast: the rectum and sigmoid colon are unremarkable. a foley is present within the bladder. bone windows reveal innumerable small lucent lesions throughout all visualized osseous structures. a healing right seventh rib fracture is noted anterolaterally. no vertebral compression deformities are observed. impression: 1. findings most consistent with multiple myeloma with innumerable lucent lesions seen throughout all visualized osseous structures. 2. diffuse ground glass and partially nodular opacities throughout both lungs is a nonspecific finding, though raises concern for an atypical infection; pulmonary edema alone is felt less likely. 3. no lymphadenopathy. . skeletal survey: 1. no obvious lucent lesions identified radiographically. however, the torso ct obtained the same day shows innumerable small lytic foci which are consistent with myeloma. please see report of that exam. subtle scalloping along left femoral diaphysis lateral cortex is of equivocal clinical significance. 2. diffuse pulmonary parenchymal opacities which require further evaluation. again, please see contemporaneous ct report. 3. degenerative changes in the spine. 4. aortic calcification, unusual in someone of this age. . mri lumbar spine : 1. heterogeneous signal intensity in the bone marrow, likely consistent with neoplastic infiltration from multiple myeloma. 2. multilevel disc degenerative changes throughout the lumbar spine as described in detail above, more significant at l3/l4 and l4/l5 level, causing left side neural foraminal narrowing at l3/l4 and right-sided neural foraminal narrowing at l4/l5. 3. disc desiccation and posterior diffuse disc bulge is also noted at l5/s1, apparently contacting the s1 nerve root on the right. these findings were communicated to dr. on , at 17:20 hours. mri thigh : diffuse, marrow infiltration in the pelvis and femurs, consistent with known multiple myeloma. while no definite fracture is evident, there is confluent abnormal signal in the femoral necks bilaterally, which would be susceptible to a pathologic fracture. the study and the report were reviewed by the staff radiologist. ct pelvis ortho w/out contrast : 1) innumerable lytic areas throughout the bones of the pelvic girdle and, to a lesser extent, in the proximal femurs. 2) two specific areas where the lesion thins and interrupts the overlying cortex -- one in the right iliac bone and one in the right proximal femoral neck posteriorly. although no conventional fracture is identified, both areas are associated with areas of complete cortical interruption. given the degree of osteoporosis and absence of overlying cortex, these areas are likely at increased risk for pathologic fracture, particularly in the right femoral neck lesion. labs on admission: 09:05am psa-0.3 09:05am pth-8* 09:05am tsh-0.84 10:08pm sed rate-80* 10:08pm hypochrom-normal anisocyt-1+ poikilocy-2+ macrocyt-normal microcyt-1+ polychrom-occasional ovalocyt-occasional stippled-occasional teardrop-occasional envelop-1+ bite-occasional 10:08pm neuts-30* bands-9* lymphs-34 monos-15* eos-3 basos-0 atyps-3* metas-4* myelos-2* 10:08pm wbc-8.7 rbc-3.05* hgb-9.0* hct-25.7* mcv-84 mch-29.4 mchc-34.9 rdw-16.5* 10:08pm b2micro-6.8* 10:08pm caltibc-360 vit b12-339 haptoglob-299* ferritin-675* trf-277 10:08pm tot prot-7.2 albumin-4.4 globulin-2.8 calcium-17.7* phosphate-4.4 magnesium-1.8 uric acid-12.9* iron-82 04:29am freeca-2.13* 09:05am pep-abnormal b igg-1578 iga-21* igm-21* ife-monoclonal 02:29pm calcium-16.4* phosphate-6.3* magnesium-1.5* uric acid-12.1* brief hospital course: 47m with asthma, obstructive sleep apnea, chronic low back pain, recent rib fracure, who presented with subacute history of malaise and exertional dyspnea found to have hyperglycemia, and constellation of findings consistent with multiple myeloma. . # hypercalcemia: the calcium of 17.7 (ionized 2.13) on admission was thought to be due to an underlying malignant process. he was vigourously hydrated with intravenous fluids and given lasix to maintain a urine output of over 200cc/hr. he was given pamidronate, steroids, and calcitonin in the icu. his calcium level dropped with this regimen and at time of discharge from the icu was low-normal. vitamin d levels were low, pth low, tsh wnl. he was transferred to the bmt floor and his serum ca remained in a low to low-normal range. . # multiple myeloma/ plasma cell leukemia: patient with m-protein in both urine & serum identified as igg kappa as well as end-organ damage manifested as arf and anemia, diffuse lytic lesions on ct and hypercalcemia suggested a diagnosis multiple myeloma. bone marrow biopsy results were positive for myeloma. he was started on dexamethasone therapy in the icu on . patient had a normal serum viscosity and was without signs or symptoms of hyperviscosity syndrome, but a beta-2 microglobulin was 6.8. ebv/cmv/toxo negative. patient was treated with dexamethasone 40 mg iv qd x 4d and then started on velcade. skeletal survey was not significant for lucencies, although these were appreciated on his ct chest. he ultimately completed 8 days of velcade, but peripheral blood demonstrated an increasing number of plasma cells (peak 38% plasma cells). subsequently, his therapy was switched to a modified hyper-cvad regimen with cytoxan/doxorubicin and dexamethasone. the patient tolerated cycle 1 of this therapy well and responded appropriately with complete clearing of plasma cells from peripheral blood. tumor lysis labs were monitored during treatment, and whiel ldh and uric acid where transiently elevated, the patient never required rasburicase treatment. neupogen was initiated 24 hours after completion of chemotherapy at a lower dose of 300 mcg due to profound splenomegaly in this patient. the patient remained afebrile while neutropenic. oxycontin with oxycodone prn for breakthrough pain was initiated prior to discharge. the patient was started on acyclover, atovaquone for prophylaxis. at the time of discharge, neutropenia has resolved and neupogen was discontinued. the patient will follow up with dr. for subsequent treatment of his pcl. . # lower extremity pain: prior to discharge, the patient developed lower extremity / hip pain. mri of thorasic and lumbar spine as well as left hip was performed and revealed significant disk disease and hyperdensity at femoral neck region which could represent an area more suscpetible to pathological fracture. however, there was no clear evidence of cortical interruption or pathologic fractures. in order to evealuate further for pathologic fracture, ortho ct of the pevis without contrast was performed and did not reveal any pathologic fractures, however revealed areas of possible cortical interruption in right iliac region and femoral neck, which may be susceptible to pathologic fracture. the patient was informed to abstain from signficant physical activity at this time. . # dyspnea/respiratory distress: early in the course of his hospitalization, the patient developed an increasing o2 requirement in the setting of known asthma, aggressive fluid therapy, and a new right middle lobe pneumonia with pulmonary edema on cxr and ct chest. for the pneumonia he was initially treated with ceftriaxone and azithromycin, but upon worsening of his respiratory status was empirically switched to cefepime and levofloxacin, ultimately completing a total of 14 days of antibiotics. in the setting of an elevated bnp, aggressive fluid hydration, and signs of overload on cxr, he underwent a repeated echocardiograms that demonstrated acute worsening of the patient's pulmonary artery hypertension with a peak pressure of 60mm hg. pulmonology and cardiology were consulted and felt that his distress was owed to his right-sided heart failure. he received aggressive diuresis with lasix balanced with his need for ivf's during chemotherapy and his respiratory status improved on this regimen. he was also continued on supplemental o2 with nc/face tent until his oxygen was weaned entirely and he was able to maintain his oxygen saturation on room air. the patient was no longer able to tolerate outpatient cpap at home settings, so autoset cpap was employed which resulted in significant improvement in patient's ability to tolerate cpap therapy. the patient's outpatient cpap machine was adjusted appropriately at the time of discharge. the patient will follow up with cardiology or pulmonology upon discharge. . # hyperuricemia: likely due to rate of cellular proliferation in conjunction with arf. he was started on allopurinol. he received rasburicase on . his uric acid levels downtrended following administration of rasburicase and aggressive hydration to wnl, at which time allopurinol was d/ced. his uric acid level normalized, but allopurinol was restarted during his cytoxan/doxorubicin therapy. as there was no evidence of tls and ldh / uric acid trended down, allopurinol was discontinued prior to discharge. . # arf: elevated cr on admission (baseline cr 0.6-0.8) that continued to rise initially during hospitalization. this was thought consistent with a tumor lysis/myeloma kidney from multiple myeloma, as evidenced by his hypercalcemia / hyperuricemia. renal was consulted. he was given rasburicase and aggressive hydration. his urine output remained excellent throughout hospitalization and his cr following hydration began to downtrend. given his quantification of bence- proteins on upep and successful improvement, the renal service did not feel that plasmapheresis was indicated. his cr eventually gradually decreased to a baseline of ~1.0. . # anemia/thrombocytopenia: patient with a low reticulocyte count, elevated haptoglobin & ferritin. as his bone marrow biopsy demonstrated significant marrow infiltration, it was felt likely that this was due to ineffective production rather than destruction. no evidence of ttp or intravascular hemolysis. the patient's hematocrit and platelet counts were monitored and he was transfused as needed throughout admission. the patient had multiple episode of epistaxis during his icu stay with negligible blood loss that was corrected with afrin, platelet transfusion, and switching his nasal cannula to humidified o2 via face tent. these values remained stable prior to discharge and the patient had no further episodes of epistaxis. . # asthma: we continued albuterol, fluticasone, & ipratropium nebs q6h prn . medications on admission: albuterol inhaler 1-2 puffs q4-6h prn:dyspnea budesonide 180 mcg, 2 puffs, buproprion 150mg sr daily (patient not taking) aleve 220 mg prn:chest pain discharge medications: 1. cpap please adjust setting on cpap machine to autoset 5-20 cm h2o, room air. 2. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for wheezing/sob. 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 5. atovaquone 750 mg/5 ml suspension sig: two (2) po daily (daily). disp:*1 month supply* refills:*2* 6. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 7. oxycontin 10 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po twice a day. disp:*60 tablet sustained release 12 hr(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: plasma cell leukemia / multiple myeloma, pulmonary artery hypertension, acute right-sided heart failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital because you weren't feeling well. you were noted to have very high calcium levels, difficulty breathing and decreased kidney function. you were treated for these problems initially in the intensive care unit and they have resolved. you were diagnosed with multiple myeloma / plasma cell leukemia as the cause of these problems. received chemotherapy treatment initially with velcade and dexamethasone follwed by cytoxan, doxorubicin and dexamethasone. you were also seen by lung and heart doctors for -sided heart failure. you were given a water pill called lasix to remove extra fluid from your body. at the time of discharge, your counts have improved and you are ready to go home. we made the following changes to your medications: we started you on furosemide 20mg daily we strated you on atovaquone 750mg twice a day we started you on acyclovir 400mg every 8 hours we started you on oxycontin 10mg twice a day we started you on oxycodone 5mg every 4 hours as needed for pain not adequately treated with oxycontin please continue to take your other medications as prescribed. do not drive or operate heavy machinery while taking oxycontin or oxycodone as they can cause drowsiness. you have a number of follow-up appointments (please see below). please continue to use cpap machine at night. followup instructions: you will need to return for a follow-up appointment with your primary oncologist dr. on monday . as the clinic is closed, we are unable to schedule this appointment for you, so please call his offices at on monday morning to schedule a same day appointment. at that time, you can request to see both dr. and dr. . their offices are located on the of the building, of the . you will also need to return for a pamidronate infusion on tuesday, and can inquire about the time when you call for your appointment. you have the following follow-up appointment with your primary care doctor dr. . provider: , md phone: date/time: 10:30 am you need to follow-up with cardiologist dr. as follows: date and time: at 10:00 am. location: building, phone: you will also need to follow up with your pulmonologist dr. . you will be called by dr. office with an appointment date and time. if you do not hear from them in days, please call (. procedure: venous catheterization, not elsewhere classified biopsy of bone marrow closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified obstructive sleep apnea (adult)(pediatric) acute kidney failure, unspecified asthma, unspecified type, unspecified other chronic pulmonary heart diseases alkalosis antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use multiple myeloma, without mention of having achieved remission hypoxemia obesity, unspecified drug induced neutropenia diseases of tricuspid valve other abnormal blood chemistry hypercalcemia anemia in neoplastic disease 

Answer: The patient is high likely exposed to