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: ibuprofen / codeine attending: chief complaint: cc: nausea, vomiting, dka reason for micu transfer: acute kidney injury with recent kidney transplant major surgical or invasive procedure: intubation history of present illness: mr. is a 48 yo male with history of type i dm, hypertension, and esrd s/p living unrelated transplant who presented to hospital on with dka. he was initially found by his mother at his home nauseous, vomiting, and unable to maintain adequate po intake. on arrival to the osh his bs was 500's. he was admitted to the icu for treatment of dka on an insulin gtt as well as sepsis. he received a dose of vanc in the ed and was started on zosyn. . he was lethargic on presentation which worsened in the setting of receiving his home pain and antianxiety medications, so on he was intubated for airway protection. on his ph dropped to 6.9 and bicarb was 15 so he was started on a bicarb gtt with improvement in his ph. his hospital course was also complicated by acute kidney injury with his most recent bun/cr of 77/4.6 (baseline cr 1.7-2.0). prograf level was noted to be elevated. renal was consulted and he underwent a transplant ultrasound which was normal. he was briefly off the insulin gtt on , however his sugars climbed back up and he was placed back on the insulin gtt. he was also noted to have a trop bump to 0.28 with ekg showing no acute ischmic changes. tte was performed which showed ef of 60-65%, but did show a focal wall abnormality. cardiology was consulted who recommended treating him emprically for cad once dka resolved. he was tachycardic in the 100's so he was started on iv lopressor. additionally he has a leukocytosis to 19.6 and cxr showing a lll pna so he is being treated for hap with zosyn and vanc. he was on ps 5/5 prior to transfer and his main barrier to extubation was mental status (per report he gets agitated and does not follow commands so hasn't been able to be extubated). . on arrival to the micu he was intubated and sedated. he no longer had the insulin gtt running, but did have a bicarbonate gtt. . unable to obtain a ros as the patient is intubated. past medical history: 1. end-stage renal disease secondary to diabetes s/p living unrelated transplant in 2. type 1 diabetes since the age of 18. 3. hypercholesterolemia. 4. hypertension for at least ten years. 5. hepatitis c which he knew about in . it is most likely acquired by iv drug abuse in his early 20s. 6. anemia 7. retinopathy 8. s/p appendectomy 9. s/p nerve reconstruction of his right fifth finger. 10. arthroscopic surgery on his left knee after a major trauma. 11. osteoporosis 12. testosterone deficiency 13. anxiety social history: (per medical records) he lives with his mother. works as a mechanical engineer. he is a former smoker. no drug use, social alcohol use. family history: (per medical records) negative for kidney disease, kidney stones, and cad. his mother has copd and developed diabetes late in her life. physical exam: gen: intubated, doesn't follow commands. heent: perrl, anicteric, ett in place resp: coarse breath sounds present bilaterally anteriorly. cv: rrr, no mrg abd:+bs, soft, ntnd, well-healed scar present in the lower abdomen. ext: no c/c/e, 2+dp skin: no rashes/no jaundice/no splinters neuro: sedated. moves all extremities spontaneously. pertinent results: 11:12pm urine color-yellow appear-clear sp -1.012 11:12pm urine blood-lg nitrite-neg protein-25 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 11:12pm urine rbc-* wbc-0-2 bacteria-few yeast-none epi-0-2 09:27pm glucose-127* urea n-72* creat-4.3*# sodium-148* potassium-3.8 chloride-114* total co2-20* anion gap-18 09:27pm alt(sgpt)-70* ast(sgot)-58* ld(ldh)-221 ck(cpk)-99 alk phos-140* tot bili-0.7 09:27pm albumin-3.6 calcium-9.3 phosphate-4.7*# magnesium-2.0 09:27pm vanco-9.9* 09:27pm urine hours-random creat-62 sodium-61 potassium-31 chloride-59 09:27pm urine osmolal-400 09:27pm wbc-12.1*# rbc-3.96* hgb-11.9* hct-35.9* mcv-91 mch-30.0 mchc-33.2 rdw-14.1 09:27pm neuts-94.5* lymphs-2.7* monos-2.5 eos-0.1 basos-0.1 09:27pm plt count-101* 09:27pm pt-14.2* ptt-33.5 inr(pt)-1.2* 09:27pm urine eos-negative labs at osh: tacro level - 38.5 na 142 k 2.9 cl 110 bicarb 14 bun 73 cr 4.0 alb 3.8 tprot 6.6 tbili 0.5 ast 85 alt 84 alk phos 160 ck 333 trop 0.382 na 149 k 3.3 cl 115 bicarb 20 bun 71 cr 4.5 ca 9.4 mg 2.2 phos 4.0 cbc 19.6 hct 28.5 plt 166 ekg: normal sinus rhythm, nl axis, nl intervals, poor r wave progression. no ste or std. unchanged from previous ekg. . micro: osh ua 4 wbc, 20 rbc, 3 granular casts, neg nitrites, pos leuk esterase, 1+ ketones bcx - ngtd sputum cx - yeast . imaging: osh: tte : ef 60-65%, normal biventricular systolic function with inferobasilar wall motion abnormality. unremarkable cardiac valves. dilated ivc. . renal us : unremarkable transplant renal ultrasound with normal arterial waveforms. renal artery and vein are patent. . cxr : mild interstital pulmonary edema . head ct : no evidence of acute infarction, hemorrhage, or mass lesion. . cxr (): left basilar , ett needs to be advanced 2-3 cm. ng tube in place. . transplant ultrasound: 1. no hydronephrosis and no perinephric fluid collection seen at the site of the transplant kidney. small simple renal cyst. 2. patent renal transplant vasculature with appropriate waveforms. brief hospital course: mr is a 48 yom with pmh esrd s/p renal transplant , iddm, hcv, chronic pain, who was admitted to the icu at after transfer from saints hospital for managment of diabetic ketoacidosis. # diabetic ketoacidosis/insulin dependent diabetes: patient initially presented to hospital with dka after 1-2 days of nausea and vomiting and inability to tolerate po intake. at saints hospital, he was treated with an insulin drip, and the anion gap closed and he had been transitioned to basal and parandial insulin at the time of transfer. following transfer, he re-developed hyperglycemia with anion gap and the insulin drip was resumed until the anion gap closed. was consulted who assisted in management of insulin regimen while in hospital. after transfer to the medical floor, patient reported food and fluid restriction prior to admission with a targed finger stick glucose of 70 (which had been set by the patient). he was seen by nutrition and counseled on diabetic diet and appropirate glucose targets. he was normalized on a basal/prandial insulin regimen and discharged with close follow up with his pcp. was reluctant to return to the as an outpatient but agreed to take their phone number and make an appointment if he changed his mind. . # acute kidney injury/esrd s/p living related transplant: baseline cr is 1.7-2.0. cr elevated at hospital with creatinine here initially 4.3. patient was reportedly oliguric at hospital, but making urine at the time of transfer. fena was calculated at 2% suggesting prerenal etiology, he was treated with intervenous fluids and creatinine returned to baseline. us of renal transplant was unremarkable. the renal transplant team consulted and felt his arf may be due to a combination of atn from the dka and pna as well as tacrolimus toxicity. tacrolimus level was high on admission and this was held. according to renal recommendations tacrolimus was changed to sirolimus which was started in the morning of . he was continued on his home cellcept and bactrim and discharged with a plan for close follow up with dr. , his renal transplant physician. . # respiratory status: prior to transfer, patient was intubated for airway protection in the setting of lethargy which is believed to be related to impaired clearance of outpatient pain and anti-anxiety medications in the setting of renal failure (see below). chest films from hospital showed lll infiltrate and he was covered with with vanc/zosyn for healthcare associated pneumonia, and completed an 8 day course. his ventilator settings were gradually weaned and he was extubated on . sputum cultures grew yeast which is believed to be a contaminant. . # lethargy/decreased mental status: the patient was reported to be lethargic upon presentation to hospital was intubated for airway protection. given high dose outpatient narcotic regiment and presentation with acute on chronic renal insufficiency, lethargy is believed to be related to impaired clearance of outpatient narcotics and benzodiazepines. head ct in the hospital was negative. narcotics and benzodiazepines were minimized. his sedation was weaned and after extubation his mental status slowly improved. he was re-started on benzodiazepines (which he takes at home). in house, his narcotic requirement was lower than outpatient and he was discharged with a lower dose of ms contin and oxycodone, both in limited prescription. he was discharged with a plan for close followup with his pcp to titrate pain regimen. . # elevated ck/trop at hospital: patient with a mildly elevated trop in setting of renal failure at hospital without ekg changes, tte showed a focal wall motion abnormality of undetermined age cardiology consulted at hospital who did not believe that presentation was consistent with acs and recommended medical treatment for cad since patient has dmi for many years and is at risk for early cad. ecgs remained unchanged and cardiac enzymes remained flat. he was started on metoprolol and asprin as well as high dose statin, however, his lfts trended up and statin was discontinued. the addition of ace inhibitors was avoided in the setting of renal insufficiency. on discharge, it is recommended that he follow up with his pcp : repeating his tte versus a stress test to risk stratify him and guide the medical management of his cad. he was started on metoprolol and aspirin which were continued at the time of discharge. . # widened mediastinum: initially cxr read as widened mediastinum, however, patient had had prior scans with lymphadenopathy and had no clinical evidence of aortic dissection. serial chest xrays revealed stable mediastinal width. it is recommended that he have a chest ct in followup. . # hypernatremia: was initially hypernatremic on admission which resolved with intervenousfluids. . # mild transaminitis: patient had a mild transamnitis at the hospital and has known hepatitis c. no evidence of synthetic dysfunction. lfts were slightly higher on repeat check and his atorvastatin was discontinued. at the time of discharge, his ast/alt remained mildly elevated at 44/30 respectively. atorvastatin was held at discharge, he should have his lfts checked again before resuming this medication. . # thrombocytopenia: plt of 100 on admission here with a baseline aroudn 170's and trended down to nadir of 74 although he had been on sqh there was low suspicion for hit. renal consultants felt he may have tacrolimus induced thrombotic microangiopathy, as haptoglobin was low and ldh was elevated. however, smear was reviewed by heme service who did not see evidence of hemolytic anemia. tacrolimus was changed to sirolimus and platelets increased to low 200's at the time of discharge. . # chronic anemia: hct at baseline. no clinical evidence of bleeding, may be related to renal disease however colonoscopy is recommended to evalate for occult malignancy in this middle aged male. . # chronic pain: he received fetanyl gtt while intubated. once extubated and mental status stabilized his pain reqirement was relatively low and he was discharged with a limited prescription for ms contin 30mg and oxycodone 5mg q4 prn. he will follow up with his pcp regarding titration of his pain medication. . # anxiety: his citalopram was continued and ambien, trazodone, and xanax were held while intubated. once extubated he was kept on iv ativan while unable to take pos and then transitioned back to his home regimen. . # testosterone deficiency: continued androderm patch 5mg/24h q24h . # osteoporosis: patient is on alendronate 70 mg po qweekly. he was continued ca/vit and alendronate was resumed at the time of discharge. . comm: brother, , mother, code: full code . medications on admission: alendronate 70 mg po every week alprazolam 0.5 mg po tid prn citalopram 30 mg po daily lantus 10 units qam and 4 units qpm humalog sliding scale morphine sr 100 mg po bid morphine ir 30mg po bid mycophenolate mofetil 1000 mg po bid omeprazole 40 mg po bid oxycodone 15-25 mg po q4h prn polyethylene glycol 17g daily bactrim 400-80 mg po daily tacrolimus 5 mg po bid androderm patch 5mg/24h q24h trazodone 200 mg po qhs ambien 10 mg po qhs prn calcium/vitd discharge medications: 1. outpatient lab work please draw sirolimus trough (morning level prior to dose) on friday and fax results to dr. at (. 2. androderm 5 mg/24 hr patch 24 hr sig: one (1) transdermal once a day. 3. alendronate 70 mg tablet sig: one (1) tablet po once a week. 4. duloxetine 60 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 5. insulin glargine 100 unit/ml cartridge sig: as directed subcutaneous twice a day: take 12 units every am and 6 units every pm. 6. insulin lispro 100 unit/ml cartridge sig: as directed subcutaneous four times a day: see attached sliding scale. 7. morphine 30 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). disp:*10 tablet sustained release(s)* refills:*0* 8. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 10. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*15 tablet(s)* refills:*0* 11. polyethylene glycol 3350 17 gram/dose powder sig: 17 grams po daily (daily). 12. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 13. sirolimus 1 mg tablet sig: five (5) tablet po daily (daily). disp:*120 tablet(s)* refills:*0* 14. calcium carbonate 400 mg (1,000 mg) tablet, chewable sig: one (1) tablet, chewable po three times a day. 15. cholecalciferol (vitamin d3) 1,000 unit capsule sig: one (1) capsule po once a day. disp:*30 capsule(s)* refills:*0* 16. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 17. alprazolam 0.5 mg tablet sig: one (1) tablet po three times a day as needed for anxiety. disp:*15 tablet(s)* refills:*0* 18. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: diabetic ketoacidosis secondary: acute on chronic renal failure, delirium, type 1 diabetes mellitus 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 with dka (diabetic ketoacidosis, a consequence of poorly controlled blood sugars). we adjusted your insulin with the help of the diabetes doctors. you kidney function initially worsened, but is now back to your baseline. please take all medications as prescribed and go to all follow up appointments. the following medication changes were made: - started metoprolol, a medication for your heart that helps reduce blood pressure - started aspirin to protect your heart - changed tacrolimus to sirolimus for your kidney transplant - stopped your trazodone and zolpidem (ambien) until you discuss with your primary care doctor next week - increased your glargine (lantus) insulin and provided a new humalog sliding scale - decreased your morphine and oxycodone doses as you were overly sedated when you came in followup instructions: please go to your local lab on friday () morning before taking your sirolimus dose to have the sirolimus level checked. this result will be faxed to dr. . name: , j. address: , , , phone: appt: , at 1pm department: transplant center when: tuesday at 2:40 pm with: , md building: lm campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified other chronic pain subendocardial infarction, initial episode of care anemia, unspecified coronary atherosclerosis of native coronary artery pure hypercholesterolemia acute kidney failure with lesion of tubular necrosis unspecified essential hypertension unspecified septicemia severe sepsis other opiates and related narcotics causing adverse effects in therapeutic use dysthymic disorder acute respiratory failure long-term (current) use of insulin osteoporosis, unspecified antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use thrombotic microangiopathy hyperosmolality and/or hypernatremia drug-induced delirium chronic viral hepatitis b without mention of hepatic coma without mention of hepatitis delta delirium due to conditions classified elsewhere diabetes with ketoacidosis, type i [juvenile type], uncontrolled kidney replaced by transplant other testicular hypofunction 

Answer: The patient is high likely exposed to