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: left arm tingling, diplopia, headaches, polyuria, polydypsia major surgical or invasive procedure: craniotomy with resection of pituitary macroadenoma, procedure: 1. left-sided subfrontal and extended pterional approach for resection. 2. microscopic dissection and resection of tumor at anteriod skull base. 3. exenteration of frontal sinus. 4. pericranial pedicle flap for isolation of frontal sinus. 5. duraplasty using pericranial autograft. right picc placed history of present illness: mr. is a 28 year old man who initially presented to on in , ma with 3-4 weeks of arm numbness, associated with headaches, polyuria/polydipsia, and double vision. he reports that he had been having intermittant headaches for several years, but his symptoms had acutely worsened recently and were associated with periods of double vision. he and his family had also noted increased fluid intake/urinary frequency of several weeks durations. mr. has a whithered right arm with significant contractions; he has limited sensation/movement of this arm. the duration of this malformation is unclear at present, but it is of many years duration. he has not noted any numbness/tingling in his right arm. mr. any changes in shoes size, hand size, or facial features. he does not wear rings. he had noted increased sweating particularly at night. he had not had any changes in bowel habits. his libido had recently decreased, but continued to have morning erections. his weight had increased by lbs. he had not noticed easy bruising, or changes in cold/heat tolerance. . ed course here was notable for brief desaturation to the 70's while sleeping that resolved on stimulation and 2l of nasal o2. patient was admitted to the floor and continued to by hyperglycemia to 300's-500's. endocrine was consulted yesterday and recommended broad endocrine work-up given concern for secretory adenoma and possible acromegaly. mri revealed mass as well as old left sided encephalomalacia concerning for old stroke but family cannot recall event. also recommended insulin as patient was persistently hyperglycemic. this has so far revealed low lh and fsh, normal tsh, very marginally elevated am cortisol, low testosterone and hgba1c 17.0. patient never really got full trial of insulin sliding scale as persistent elevated blood sugars made surgery concerned and they put him on an insulin drip. as of this morning the patient has a blood glucose of 100-200 on 18 units of iv insulin though he was also on a d5 drip. nsg requested transfer for persistent hyperglycemia and as they do not plan to proceed w/ surgery as an inpatient. patient has been transitioned to sliding scale once again today w/ persistently elevated bg's in 300's but stable and no gap. . aside from glucoses other major issue has been impressive apnea and desats while sleeping. he is reportedly doing better on cpap but yesterday was noted to desat once on room air and, despite finger mid80s, abg revealed o2 sat 91% 7.34/49/63. his paresthesias and weakness have never been supported by exam and have improved on their own. patient will come to medicine for titration of insulin regimen and awaiting final diagnosis and management of likely secreting tumor. endocrine and nsg are following. past medical history: none documented; family reports illness when very young at which time he received treatment via right arm injections which resulted in right arm deformity. social history: illegal immigrant from , immigrated approximately . speaks some english. currently lives with father and stepmother in , ma. did not originally have health insurance; got health safety net insurance prior to discharge. smokes 1 pack per day, drinks socially, denies drug use. family history: patient is unaware of any history of diabetes or other endocrinopathies. physical exam: on admission: vs; bp 136/106 rr 16 100% ra, wt 160 lbs gen; young male, lying in bed, nad, he has underdevelopment of the left side of body.mild coarse facial features, no frontal bossing, heent; perla, eomi, no field defects on confrontation, no diplopia, poor dentition. mucous membranes moist, moderate sized tongue neck -no goiter, no nodules, no acanthosis nigracans cv; rrr, no murmurs pulm; cta b/l, no gynaecomastia abd; soft, nt, nd, no striae extr; no edema, looks doughy and squared skin -no bruising, no paucity of facial, axillary and pubic hair genital -normal sized testes neuro: cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3-->2mm. fields are full to confrontation however is not fully cooperative with exam. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: decreased bulk in right arm. right arm is held flexed at elbow and wrist. normal bulk and tone otherwise. no abnormal movements or tremors. uncooperative with formal testing but proximally rue 4-/5 with 0/5 distally (chronic). lue and lower extremities and symmetric. sensation: decreased to light touch in left arm and leg and pinprick in left arm. however, patient is somewhat inconsistent with responses. toes downgoing bilaterally coordination: normal on finger-nose-finger on l at time of discharge: vitals - t: bp: hr: rr: 02sat: ra general: pleasant, well appearing young man in nad heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. macroglossia. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. left hand enlarged, right hand deformity. there is a tender, slightly palpable cord over the cephalic vein on the lue. skin: no rashes/lesions, ecchymoses. neuro: alert, oriented to person and place, not to date. upper ext , les 5/5 strength pertinent results: on admission: 06:20pm blood wbc-8.0 rbc-4.70 hgb-13.1* hct-39.0* mcv-83 mch-27.7 mchc-33.5 rdw-16.1* plt ct-357 06:20pm blood neuts-62.7 lymphs-29.9 monos-4.7 eos-1.6 baso-1.1 06:20pm blood pt-11.1 ptt-24.8 inr(pt)-0.9 06:20pm blood glucose-307* urean-9 creat-0.6 na-140 k-3.8 cl-103 hco3-26 angap-15 09:25am blood na-151* 12:34pm blood na-149* 03:22pm blood na-147* 05:13pm blood na-146* 07:36am blood alt-18 ast-22 alkphos-110 amylase-68 totbili-0.3 07:36am blood lipase-24 06:20pm blood calcium-8.3* phos-3.8 mg-1.6 04:47pm blood caltibc-410 vitb12-535 folate-11.5 ferritn-53 trf-315 08:35am blood %hba1c-17.0* 06:20pm blood osmolal-303 07:36am blood osmolal-305 06:20pm blood prolact-4.2 tsh-0.36 06:35am blood tsh-0.16* 08:35am blood t4-6.3 calctbg-1.06 tuptake-0.94 t4index-5.9 free t4-1.0 11:23am blood t4-4.9 t3-45* free t4-0.74* 11:43am blood free t4-0.65* 08:35am blood cortsol-20.8* testost-50* 08:35am blood freetes-0.8* imaging: ct head impression: 1. similar appearance to sellar mass with suprasellar extension with compression of the optic chiasm, worse on the left. 2. persistent left mca territory extensive encephalomalacia, unchanged. mr pituitary w&w/o contrast impression: 1. sellar mass with suprasellar extension arising from the pituitary, most consistent with an adenoma. there is compression of the optic chiasm, with relatively greater compression of the left optic nerve. 2. extensive encephalomalacia along the left mca territory, consistent with an old infarct. 3. no acute hemorrhage or infarct. post-operative ct head impression: expected post-surgical changes are seen, with pneumocephalus and left frontal craniotomy. the previously noted mass has been partially resected. no surrounding hemorrhage is identified. pathology : pituitary adenoma, growth hormone-positive. immunostain for , chromogranin, and synaptophysin are positive. immunostains for acth, fsh, lh, tsh, prolactin, and hmb-45 are negative. discharge labs: 08:30am blood wbc-9.9 rbc-3.77* hgb-10.6* hct-31.7* mcv-84 mch-28.2 mchc-33.4 rdw-16.4* plt ct-439 08:30am blood glucose-98 urean-14 creat-0.6 na-144 k-3.7 cl-105 hco3-28 angap-15 03:04am blood alt-25 ast-14 ld(ldh)-209 alkphos-103 totbili-0.3 08:30am blood calcium-9.0 phos-5.4* mg-2.0 08:30am blood osmolal-299 07:15am blood vanco-14.8 post-operative adh, igf-1, levels pending at time of discharge. brief hospital course: =========================================== presentation/surgery: is a 28 year old male admitted to neurosurgery at on with a sella mass. endocrine consulted regarding high glucose levels (patient was not diabetic previously); insulin drip was initiated. head imaging by mri and ct showed a large 1.9 cm pituitaty tumor. the patient was transferred to medicine on . while on medicine, the patient's insulin regimen was titrated and normoglycemia was attained. he underwent field testing by neuro-opthalmology with their full evaluation in omr. he also was seen by the sleep consult service due to episodes of witnessed sleep apnea and associated desaturations to the 70s. he was started on cpap at night and with naps. overnight from , the patient developed headache and complained of vision changes although bedside field testing was unchanged from prior. stat head ct was also unchanged from prior. on the am of , the patient was nauseous and vomiting, was hypertensive, and continued to complain of vision changes. stat head ct was again done and was concerning for increase in size of suprasellar mass as well as possible hemorrhage within the mass. he was therefore taken to the or by dr for emergent craniotomy and pituitary macroadenoma resection, after which he was taken to the sicu. only partial resection of mass was possible. surgery was uncomplicated, with clear border between normal, compressed pituitary tissue, and adenoma. adenoma was resected from the left optic nerve as well. post operative course complicated by hypertension >200 noted pod1, w/o imaging evidence of worsening interval swelling/hemorrhage from day of operation. pathology returned secreting pituitary macroadenoma. new onset diabetes mellitus was therefore from growth hormone stimulation of igf-1 causing insulin resistance. it is expected that his diabetes will improve over time with the lesion now removed. ============================================= sicu course: while in the sicu the patient was noted to have persistent polyuria with dilute urine and polydypsia; was found to have post-operative panhypopituitarism with multiple endocrine abnormalities: increased , igf-1, and cortisol, decreased free t3, fsh, testosterone. hyperglycemia with a1c = 17.0, c-peptide positive, gad antibody negative. he was also noted to have a septic superficial thrombophlebitis of the lue near the antecubital fossa. the pus in this lesion was drained by vascular surgery, and he was treated with intravenous vancomycin. he was transferred to the medicine floor for further management on . ============================================== medicine hospitalization course: outlined by problem below. . #1: panhypopituitarism: #1a polyuria: initially thought to be secondary to adh deficiency or hyperglycemia. persisted following insulin management of hyperglycemia, making adh deficiency (diabetes insipidus) or primary polydipsia mixed with di more likely. npo/no ivf trial ( midnight to afternoon) completed, overall put out 13l of dilute urine and took in 0.4l w/o substantial serum concentration; results suggest unmeasured intake of free water/salt during npo trial. was able to concentrate urine at end of trial (urine osm > 400) indicating some adh secretion/responsiveness. . at time of discharge, was eating/drinking freely, serum na and serum osm normalized, uosm concentrated more appropriately with administration of desmopressin. urine output and polydypsia also improved more towards normal. - 200 mcg ddavp is final dose at time of discharge. - adh levels pending (send out labs) at time of discharge. . #1b polyphagia: extremely large food intake, possibly secondary to hypothalamic damage. endocrine did not think likely secondary to metabolic effects of /igf-1 given severity of polyphagia. - continue to follow weights. - will need nutrition consult/education as outpatient (or prior to discharge from rehab facility) given newly diagnosed diabetes mellitus. need calorie restriction if polyphagia persists and blood glucose poorly controlled. . #1c adrenal insufficiency: one measured cortisol prior to surgery at 20.8 (normal/high). at maintenance hydrocortisone at time of discharge 20 mg qam/10 mg qpm. on , held pm cortisone dose and am cortisol measurement was 8.1. per endocrine recommendations, kept 20 mg qam/10 mg qpm dosing. in weeks, can be reevaluated again to see if this should be continued. goal is for am cortisol to be >10 with pm dose being held, at which point hydrocortisone could be discontinued. . #1d hyperglycemia: likely insulin resistance secondary to activation of igf-1 secretion/signaling. normal c-peptide and negative gad argued against t1dm. insulin dependence persisted following surgery, may not completely resolve due to incomplete resection of adenoma. - at time of discharge, 70 units glargine qhs and metformin 500 mg (metformin started on ). after two weeks, metformin dose could be increased to 1000 mg . - monitor blood glucose values closely as diabetes will likely resolve and less insulin will be needed as and igf-1 levels normalize and associated insulin resistance improves. . #1e thyroid deficiency: low tsh (.16) and low t4 (.74) on suggests pituitary cause of hypothyroidism, likely present prior to surgery given low free t3 on . however, partial resection of pituitary is also a possibility. be complicated by sick euthyroid. started 100 mcg levothyroxine on . patient should have repeat tfts in weeks to see if dose needs to be changed. . #1f testosterone deficiency: low fsh and low testosterone consistent with pituitary failure prior to surgery. testicles appear grossly normal. - testosterone will need to be rechecked as an outpatient. consider hormone replacement for this young gentleman. . #2. bacteremia: blood culture in the context of septic thrombophlebitis grew coagulase negative staphylococcus resistant to oxacillin. patient was started on vancomycin at that time (now day 10). id was consulted. a picc was placed on . - patient should be continued on vancomycin 1250 mg tid until - id recommends regular vancomycin troughs with a therapeutic goal = 15, and surveillance blood cultures . #3. status post craniotomy and partial resection of secreting pituitary macroadenoma on . operation was uncomplicated, however, full resection of the tumor was not achieved. some non adenomatous pituitary tissue remained following resection, however, tissue was significantly compressed. surgical site has remained clear, dry, and intact without evidence of infection. sutures and staples have been removed - the patient is on sinus precautions until (no straws, no incentive spriometer, no nose blowing, no cpap) - repeat /igf-1 levels from are pending . #4. social: primarily portugese speaking. illegal immigrant from . lives with stepmother and father in , father is also an illegal immigrants. family is having difficulty paying rent secondary to expenses related to the patient's hospitalization; the hospital has advocated on their behalf with housing authority. currently has health safety net insurance. . #5. sleep apnea: combination of obstructive and central sleep apnea, with periodic, self resolving desaturations to the low 80s. has recently completed a sleep study, results are pending. - patient cannot use cpap because of sinus rest . #6. anemia: normocytic with large rdw. hct fell from mid 40s to low 30s during hospitalization. studies done showed ferritin 53 (low normal), iron 48 (low normal), tibc 410 (high normal), transferrin 315, all. vitamin b12 and folate wnl. studies consistent with anemia secondary to repeat blood draws, bordering on fe deficiency. started fe sulfate on . hct has remained stable in mid-low 30s since initiation of fe supplementation. . #7. superficial thrombophlebitis in left cephalic vein. no indication of septic thrombophlebitis; asymptomatic. - we have been treating with warm compresses . #8. dry eyes and blurry vision: the patient has decreased acuity, l 20/70 -1, r 20/50 -1, which improved with pin hole testing. ophthalmology has seen the patient and did not find evidence of pathology, and suggested corrective lenses. he has a baseline l rapd, but has field defect has resolved. - patient has been on standing eye ointment with eye drops prn - outpatient follow-up with neuro-ophthalmology has been arranged. . code status was confirmed as full code during this admission. he was deemed medically stable and fit for discharge to acute care rehabilitation on for completion of his iv antibiotic course. he has close outpatient follow-up scheduled. medications on admission: tylenol prn headaches. discharge medications: 1. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain / fever. 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 7. white petrolatum-mineral oil 42.5-56.8 % ointment sig: one (1) appl ophthalmic qhs (once a day (at bedtime)) as needed for dry eyes. 8. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for eye dryness. 9. nicotine 21 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 10. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 11. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 12. hydrocortisone 5 mg tablet sig: four (4) tablet po qam (once a day (in the morning)). 13. diphenhydramine hcl 25 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for insomnia. 14. desmopressin 0.1 mg tablet sig: two (2) tablet po bid (2 times a day). 15. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily): started on . 16. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 17. lantus 100 unit/ml solution sig: seventy (70) units subcutaneous at bedtime. 18. metformin 500 mg tablet sig: one (1) tablet po twice a day. 19. hydrocortisone 10 mg tablet sig: one (1) tablet po qpm. discharge disposition: extended care facility: discharge diagnosis: diabetes mellitus type 2 (secondary to secreting pituitary macroadenoma) sleep apnea adrenal insufficiency hypothyroidism diabetes insipidus growth hormone secreting pituitary macroadenoma (s/p resection) superficial septic thrombophlebitis with bacteremia acromegaly discharge condition: stable, afebrile, blood pressure wnl, no diplopia, no headache, s/p pituitary adenoma resection. discharge instructions: dear , you were admitted to the hospital because of headache, changes in vision, and drinking and urinating large amounts. you were found to have a tumor in your head, called a pituitary adenoma. this was removed surgically. as a result of this tumor being removed, you were left with hormone changes that will now require multiple new medications as outlined below. you were deemed medically stable for discharge to a rehabilitation facility on . you will require close follow-up as an outpatient. . all of your medications at the time of discharge are new. it is extremely important for your health that you take all of these medications exactly as prescribed and that you follow up with all of your appointments. . please call your doctor or go to the nearest emergency room if you have increasing shortness of breath, chest pain, you lose consciousness, have a fever >100.4, you have diarrhea or vomiting for more than 24 hours, you have a large increase or decrease in your urination, you develop a headache or changes in vision, you have bleeding, or other concerning symptoms. . it was a pleasure caring for you during this hospital stay. followup instructions: the following appointments have been scheduled for you. it is extremely important that you keep all of these appointments: provider: field screening phone: date/time: 2:30 pm provider: , md (ophthalmology) phone: date/time: 3:15 pm provider: , m.d. (endocrinology) phone: date/time: 12:30 pm / (sleep study) on at 2pm in clinical center . you will also be contact by dr. office in neurosurgery () and dr. office in nephrology (kidney medicine) in order to have follow up appointments made with them. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified formation of cranial bone flap frontal sinusectomy other excision or avulsion of cranial and peripheral nerves partial excision of pituitary gland, transfrontal approach diagnoses: obstructive sleep apnea (adult)(pediatric) tobacco use disorder unspecified acquired hypothyroidism pneumonitis due to inhalation of food or vomitus bacteremia long-term (current) use of insulin iron deficiency anemia, unspecified phlebitis and thrombophlebitis of superficial veins of upper extremities glucocorticoid deficiency other and unspecified infection due to central venous catheter staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation other disorders of neurohypophysis diabetes insipidus other testicular hypofunction acromegaly and gigantism cerebral artery occlusion, unspecified without mention of cerebral infarction benign neoplasm of pituitary gland and craniopharyngeal duct elevated blood pressure reading without diagnosis of hypertension benign neoplasm of cranial nerves iatrogenic pituitary disorders central sleep apnea in conditions classified elsewhere other acquired deformity of other parts of limb other disorders of optic nerve polyphagia 

Answer: The patient is high likely exposed to