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: atorvastatin attending: chief complaint: transferred by medvac from hospital, , , for acute renal failure, small bowel obstruction, and new brain mets. major surgical or invasive procedure: egd - (twice) duodenal stent placement - history of present illness: 55m with hiv on haart as well as widely metastatic pancreatic cancer (diagnosed early ), previously on gemcitabine last chemotherapy , transferred directly from by air ambulance after a complicated course in . the patient received 3 weeks of chemotherapy and then opted to travel to and for a final vacation. his disease progressed extraordinarily rapidly in , and patient presented to hospital w/ intractable vomiting, lethargy and arf, found to have sbo from new duodenal lesion and new liver and brain mets. was sepsis culture negative during that course. in was going to attempt to stent duodenal obstruction, but patient's symptoms reportedly improved slightly. pt had a prolonged flight from . main complaints are currently dry mouth/throat, mild back pain. pt states has had a bm today, and has been passing gas. . in the ed inital vitals were, pulse: 93, rr: 19, bp: 118/77, o2sat: 95. denies f/cp/sob/ab. the patient comes accompanied with no cds of images from , thus was sent for ct abd/pelvis in ed. ekg: sinus 89 na/ni twi i, iii, v3-4 (new from prior) pt started on vanc, unasyn (has been on pip-taz and cipro at osh). renal c/s: no need for emergent dialysis but will see in icu tmrw pivx1, with ngtube in place. vitals on transfer: 126/75 p89 rr18 97%3l . on arrival to the icu, afebrile 99 115/70 92% 3l. patient cachectic appearing, w/ ngt in nare. . review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - hiv infection: dx , manifested by periodontal disease and minor dermatologic problems; nadir cd4~ 160s, on arvs - chronic hepatitis b: dx asymptomatic, mildly increased transaminases; viral hepatitis serologies show positive hbsag/hbcab and undetectable vl on truvada - cad s/p inferolateral mi ': inferior/inferolateral hypokinesis, ef 45-50%, mild rv free wall hypokinesis, normal valves. cath , 99% mid right coronary artery thrombus status post drug-eluting stent x1. - pad, s/p l sfa stent ' with residual moderate right sfa/significant left infrapopliteal disease. - periodontal disease: s/p tooth extractions - lipodystrophy syndrome - hyperlipidemia - cigarette smoking: one pack per day for many years; patient quit with use of hypnosis in 2/95 but relapsed; : nicotine nasal spray unsuccessful; : chantix unsuccessful - alcohol use: "one case of beer" per week, now not drinking - h/o skin cancers: recurrent; followed in dermatology clinic - h/o warts: - h/o lateral epicondylitis - h/o facial cysts - h/o bronchitis - h/o scabies - h/o cellulitis - h/o low back pain: ls spine shows l4-5 and l5-s1 disc herniations - h/o dermatitis: eczema and tinea pedis - h/o gonorrhea - h/o hepatitis a - s/p cholecystectomy past oncological history (per summary by dr. : the patient initially presented with jaundice and abdominal pain at the end of . cta of the abdomen and pelvis revealed a 3.3 cm pancreatic head mass, highly worrisome for pancreatic adenocarcinoma invading the adjacent duodenal wall and obstructing the common bile duct without adjacent major vascular involvement and multiple rim enhancing round hypodensities in both lobes of the liver, the largest 15 mm across, suggesting metastatic involvement, intra and extrahepatic biliary ductal dilation, multiple nearby retroperitoneal lymph nodes noted, 19 mm left adrenal nodule, likely adenoma, likely bone islands, no concerning lytic or sclerotic osseous lesions identified. he underwent ercp on , which revealed a narrowing consistent with external compression seen at the junction of the duodenal bulb and d2 with severe post-obstructive dilation of the common bile duct measuring 20 mm secondary to a singular, irregular stricture of malignant appearance that was 3 cm long seen at the distal common bile duct. a metal biliary stent was placed and cytology samples were obtained from the common bile duct using a brush. the brushings were positive for malignant cells consistent with an adenocarcinoma. he received gemcitabine 1740 mg iv days 1, 8 and 13. (, and )(1000 mg/m2). social history: patient has a supportive partner. previously worked as a concierge at a hotel. he has recently continued to smoke. he has had no interest in alcohol in the last few months and reports no illicit drug use. family history: iddm in mother, dad died from lung cancer. physical exam: admission physical examination: afebrile 99 115/70 92% 3l general: alert, oriented, cachectic heent: sclera anicteric, mm extremely dry, temporal wasting neck: supple, jvp flat lungs: crackles scattered b/l cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, moderately distended, bowel sounds present, no rebound tenderness or guarding, hepatomegaly gu: foely in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . discharge physical exam: vitals: 98.4 120/60 86 22 94% 2l general: alert, oriented, cachectic heent: nc, at, mmm, op clear, temporal wasting, mild epistaxis related to nasal cannula neck: supple, no lad cv: rrr, nl s1 s2, no mrg resp: bilateral basilar rales, no wheezes or ronchi abd: soft, non-tender, non-distended, no rebound or guarding ext: warm, well-perfused, no cyanosis clubbing or edema. rle strength limited, right footdrop pertinent results: admission labs: 04:30pm blood wbc-29.8*# rbc-2.96*# hgb-9.2*# hct-27.2*# mcv-92 mch-31.1 mchc-33.9 rdw-13.6 plt ct-319 02:45am blood wbc-32.3* rbc-2.76* hgb-8.5* hct-25.0* mcv-90 mch-30.9 mchc-34.2 rdw-13.9 plt ct-275 04:30pm blood neuts-94.7* lymphs-3.6* monos-1.5* eos-0.1 baso-0.2 04:30pm blood pt-15.6* ptt-25.8 inr(pt)-1.5* 04:30pm blood glucose-245* urean-158* creat-9.0*# na-148* k-4.5 cl-103 hco3-23 angap-27* 02:45am blood glucose-244* urean-156* creat-9.1* na-146* k-3.8 cl-102 hco3-26 angap-22* 04:30pm blood alt-46* ast-33 ck(cpk)-43* alkphos-60 totbili-0.4 04:30pm blood lipase-1098* 04:30pm blood ctropnt-0.65* 04:30pm blood albumin-3.0* calcium-8.9 phos-10.2*# mg-3.1* 02:45am blood calcium-8.5 phos-9.9* mg-3.2* 02:46am blood vanco-15.3 10:11pm urine color-straw appear-clear sp -1.009 10:11pm urine blood-mod nitrite-neg protein-30 glucose-1000 ketone-10 bilirub-neg urobiln-neg ph-6.5 leuks-neg 10:11pm urine rbc-8* wbc-7* bacteri-none yeast-none epi-0 transe-<1 10:11pm urine hours-random urean-612 creat-43 na-55 k-25 cl-17 10:11pm urine osmolal-417 : 04:30pm blood alt-46* ast-33 ck(cpk)-43* alkphos-60 totbili-0.4 08:20am blood alt-35 ast-33 ld(ldh)-604* ck(cpk)-71 alkphos-55 totbili-0.4 04:30pm blood lipase-1098* 04:30pm blood ck-mb-3 ctropnt-0.68* 04:30pm blood ctropnt-0.65* 08:20am blood ck-mb-3 ctropnt-0.51* 02:46am blood vanco-15.3 08:20am blood vanco-31.7* 07:15am blood vanco-24.6* 06:15am blood vanco-19.5 06:15am blood vanco-16.2 08:17am blood type- po2-67* pco2-52* ph-7.37 caltco2-31* base xs-2 08:17am blood lactate-1.6 10:11pm urine color-straw appear-clear sp -1.009 10:11pm urine blood-mod nitrite-neg protein-30 glucose-1000 ketone-10 bilirub-neg urobiln-neg ph-6.5 leuks-neg 10:11pm urine rbc-8* wbc-7* bacteri-none yeast-none epi-0 transe-<1 10:11pm urine hours-random urean-612 creat-43 na-55 k-25 cl-17 10:11pm urine osmolal-417 discharge labs: 06:40am blood wbc-19.6* rbc-2.89* hgb-9.1* hct-25.3* mcv-88 mch-31.4 mchc-35.8* rdw-15.2 plt ct-162 06:40am blood neuts-90.4* lymphs-5.0* monos-3.4 eos-1.1 baso-0.1 06:40am blood wbc-19.6* lymph-5* abs -980 cd3%-80 abs cd3-780 cd4%-19 abs cd4-182* cd8%-63 abs cd8-613 cd4/cd8-0.3* 06:40am blood glucose-130* urean-143* creat-8.8* na-139 k-2.8* cl-95* hco3-24 angap-23* 06:40am blood calcium-6.8* phos-9.4* mg-2.4 microbiology: 4:30 pm blood culture blood culture, routine (preliminary): staphylococcus, coagulase negative. of two colonial morphologies. aerobic bottle gram stain (final ): gram positive cocci in clusters. urine culture - negative blood culture - negative blood culture - negative blood culture - negative stool clostridium difficile toxin a & b test - negative blood culture - pending blood culture - pending blood culture - pending imaging: ct abdomen and pelvis (): 1. no signs of small-bowel obstruction are seen. 2. known pancreatic carcinoma with interval increase in the size of liver metastasis. 3. new ascites. 4. new omental stranding is seen. this might be secondary to third spacing; still, omental involvement (peritoneal diseaes) cannot be excluded. 5. multifocal ground-glass opacities are seen in the visualized lung fields might represent infectious or inflammatory process. 6. bilateral enlargement of the kidneys that appear swollen with no obvious cause (though the exam is limited). no hydronephrosis. 7. bilateral small-moderate pleural effusions with associated compressive atelectasis. renal ultrasound (): 1. no evidence of renal artery stenosis, hydronephrosis or perinephric fluid collections. 2. nonspecific, slightly elevated resistive indices may relate to medical renal disease. 3. small amount of free fluid in the pelvis. mr head (): 1. no evidence of metastatic disease, although exam was somewhat limited due to the lack of contrast. 2. small right centrum semiovale cavernoma. 3. mild chronic small vessel ischemic disease. cxr (): stable cardiac and mediastinal contours. there is a bilateral air space process with layering pleural effusions. these findings together favor moderate pulmonary edema with bibasilar compressive atelectasis rather than diffuse pneumonia. no pneumothorax. calcific density contiguous to the greater tuberosity of the right humerus may be related to remote trauma or the presence of calcific tendinitis. clinical correlation is advised. le ultrasound (): findings: -scale and color doppler son imaging was performed of bilateral common femoral, right superficial femoral, right popliteal, right peroneal, and right posterior tibial veins. normal compressibility, flow, and augmentation was demonstrated. impression: no evidence of dvt in the right lower extremity. kub (): single supine frontal abdominal radiograph: the left lateral abdomen is excluded from the study. there is no evidence of nasogastric tube in either the visualized distal esophagus or the stomach. the stomach is mildly gas-distended. there is overall paucity of bowel gas in the visualized abdomen. impression: no nasogastric tube in the stomach or the distal esophagus. egd : impression: - feeding tube was located in the upper esophagus. given location, the tube was removed. - esophagitis - retained fluids in stomach - friability, erythema and congestion in the first part of the duodenum and second part of the duodenum compatible with obstruction - otherwise normal egd to third part of the duodenum recommendations: - protonix 40mg iv bid. - ng tube to suction. - consider attempted placement of a duodenal stent by advanced endoscopy team. egd with advanced endoscopy (): impression: - limited exam of esophagus and stomach were unremarkable - erythema and congestion of the mucosa with contact bleeding were noted in the first and second part of the duodenum with near complete obstruction of the duodenal lumen. - fluoroscopy also revealed a previously placed metal biliary stent. - a 450 cm jag wire was passed through the narrowed duodenal segment into the third part of the duodenum under fluoroscopic vision. - a wallflex tm duodenal 22mmx120mm (lot: , ref: 6503) metal stent was placed successfully over the guide wire under endoscopic and fluoroscopic guidance. - otherwise normal egd to third part of the duodenum recommendations: - return to floor - start clear liquids and then advance slowly to liquid diet tomorrow. brief hospital course: ========================== brief clinical summary ========================== 55m with hiv on haart as well as widely metastatic pancreatic cancer (diagnosed early ), previously on gemcitabine last chemotherapy , transferred directly from by air ambulance after a complicated course in . patient to have multi-disciplinary approach to palliative care and eventual return to home. ========================== active issues ========================== # arf / anion gap alkalosis: bun 158, cr 9.0, from baseline 1.0. differential is broad. unlikely to be post-renal secondary at this point since draining urine with foley, although patient stated that foley was difficult and required urology prostate enlargement. likely combination of intrinsic renal disease secondary to atn and hypotension at osh with pre-renal etiology in setting of prolonged course of nausea and vomiting, profound volume depletion. patient presented with an anion gap metabolic acidosis secondary to gi acid losses and contraction alkalosis. potassium was not elevated. na 149 on admission. he was both free water and total body water depleted on presentation. although the patient had elevated calcium and phosphorus, and was at risk for precipiation, binders were initially of little use as the patient was npo. renal consultation sought, they found no indication for emergent dialysis. as volume status normalized, urine lytes and consistent hypokalemia despite renal failure raised concern for type 1 rta. uop increased to roughly 1 l/day. foley removed prior to discharge, patient voided normally. started aluminum hydroxide for phosphate binding with good effect. the renal team recommended using potassium supplementation to avoid hypokalemia given persistent renal wasting. . # metastatic pancreatic adenocarcinoma: discussed patient with dr. on evening of admission. patient with very rapidly progressing pancreatic adenocarcinoma, worsening liver mets, although no brain mets despite prior report from osh. further treatment unlikely to be helpful at this time. previously treated with dexamethasone for concern of brain mets, however after mr imaging this was discontinued. inter-disciplinary meeting with oncologist and palliative care on , and patient and partner brought up to speed on prognosis. he remained full code, wished to pursue treatment for all conditions noted. although discharged home with hospice, if his renal function normalized he would be interested in palliative chemotherapy to reduce tumor burden. . # sbo/goo: patient presented with intractable nausea and vomiting, which was thought related to small bowel obstruction and also potentially from cerebral edema. ct scan in ed showed no clear e/o obstruction. seemed as if prior obstruction had resolved given bm and flatus, however there continued to be concern for functional ileus or obstruction due to peritoneal carcinomatosis. egd performed for possible gi bleeding revealed 95% obstruction of duodenum, the likely cause of these symptoms. this was stented successfully, and the patient was able to tolerate liquid diet prior to discharge. ngt removed . . # gib: the patient presented with coffee grounds in ngt output on . he received 2 units prbcs with good response, and ng lavage was negative. iv ppi was started. he had multiple guaiac positive and melanotic stools over the next several days with persistently negative ng lavage. egd revealed no source of bleeding and his hct remained stable following transition. however, the location of his tumor adjacent to the duodenum put him at high risk for future bleeding due to erosion into the vasculature of the small bowel. no intervention could lower this risk. his asa and plavix were held for several days due to concern for bleeding, but following consultation with his cardiologist, his asa was restarted the day following discharge. oral ppi continued. . # gpc bacteremia / ? pna: patient treated for sepsis at osh for cxr suggestive of l lung base consolidation. urine and blood cultures negative from osh. received iv vanc and unasyn at osh. per culture growing gpc in clusters. started vanco/zosyn . cxr showed no consolidation. antibiotics were discontinued given multiple negative cultures. . # cad: tropinemia most likely secondary to cardiac demand (ischemia, as evidenced by twi on ekg) in background of arf. patient had no lad disease on prior cardiac cath. unlikely to be acs as having no typical anginal symptoms. continued asa and plavix through , then discontinued for several days given concern for gi bleeding. restarted asa the day following discharge per cardiology recommendations. . # anemia: hct 27.2 from most recent of 36. most likely from marrow suppression in setting of malignant disease, anemia of chronic disease. despite concern for gi bleeding, the patient had good response to transfusion without further hct drop. . # hyperglycemia: pt w/ blood sugars > 250 on admission. likely secondary to use of steroids used for possible brain met. patient maintained on insulin sliding scale. blood glucose normalized and this was discontinued. . # hiv: patient previously with very well-controlled hiv. truvada on hold given renal failure, kaletra on hold given risk of resistance. contact outpatient pcp/hiv provider for guidance. haart held on discharge, however given cd4 < 200 he will be started on pentamidine for pcp . . # sacral pressure ulcer: from long-term hospitalization. wound care team consulted, provided assistance for management on discharge. . # rle edema: b/l le edema, r>l, concerning for dvt given long hospitalization. patient could receive heparin due to concern for gib, venodynes used instead. rle ultrasound negative for dvt. edema likely due to atn and prolonged bedrest. . # persistent leukocytosis: wbc as high as 48 during admission. be partially due to use of dexamethasone, however this remained elevated throughout admission regardless of antibiotic use. patient remained afebrile. . # goals of care: continually addressed while in icu, patient remained full code. transitioned to hospice care on discharge. however, should renal function normalize he would be interested in pursuing further chemotherapy. . abx hx (per records from st james' ): pip/tazo started , continued through cipro started , d/c on transfer metronidazole started , d/c on transfer clarithromycin started , d/c on transfer vanco started , continued through =============================== transitional issues: =============================== - pentamidine should be started for pcp . this was not administered prior to discharge. medications on admission: clopidogrel - 75 mg tablet - 1 tablet(s) by mouth daily (daily) emtricitabine-tenofovir - 200 mg-300 mg tablet - one tablet(s) by mouth every day lisinopril - 20 mg tablet - take one tablet(s) by mouth once a day lopinavir-ritonavir - 200 mg-50 mg tablet - 2 tablet(s) by mouth twice a day lorazepam - 2 mg tablet - tablet(s) by mouth nightly as needed for insomnia omeprazole - 40 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth daily ondansetron hcl - 8 mg tablet - 1 tablet(s) by mouth every 8 hours as needed for nausea oxycodone - 5 mg tablet - take one tablet(s) by mouth every four hours as needed for pain polyethylene glycol 3350 - 17 gram/dose powder - 1 scoop by mouth daily as needed for nausea prochlorperazine maleate - 10 mg tablet - 1 tablet(s) by mouth every six (6) hours as needed for nausea to start following the first day of chemotherapy rosuvastatin - 10 mg tablet - take one tablet(s) by mouth once a day temazepam - 7.5 mg capsule - take one to two capsule(s) by mouth at bedtime as necessary medications - otc aspirin - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth daily docusate sodium - 100 mg capsule - 1 capsule(s) by mouth twice daily take this every day; add the senna and the miralax as needed loperamide - 2 mg tablet - 1.5 tablet(s) by mouth daily nicotine - 21 mg/24 hour patch 24 hr - apply topically as directed every 24 hours sennosides - 8.6 mg tablet - 1 tablet(s) by mouth twice daily take this as needed for constipation discharge medications: 1. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po tid (3 times a day) as needed for nausea. disp:*30 tablet, rapid dissolve(s)* refills:*0* 2. ipratropium bromide 0.02 % solution sig: one (1) vial inhalation q6h (every 6 hours). disp:*120 vial* refills:*0* 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) vial inhalation q6h (every 6 hours). disp:*120 vial* refills:*0* 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) vial inhalation q2h (every 2 hours) as needed for dyspnea. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 6. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. disp:*30 tablet, rapid dissolve(s)* refills:*0* 7. aluminum hydroxide gel 600 mg/5 ml suspension sig: five (5) ml po three times a day as needed for with meals: with meals. disp:*300 ml(s)* refills:*0* 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* 10. 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* 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for nausea, anxiety, insomnia. disp:*30 tablet(s)* refills:*0* 12. potassium chloride 20 meq packet sig: one (1) packet po tid (3 times a day). disp:*90 packet(s)* refills:*2* 13. pentamidine 300 mg recon soln sig: one (1) recon soln inhalation once a month. 14. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*20 tablet(s)* refills:*0* discharge disposition: home with service facility: hospice of the discharge diagnosis: primary: acute kidney injury small bowel obstruction bacteremia . secondary: metastatic pancreatic cancer coronary artery disease peripheral vascular disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: it was a pleasure taking care of you at . you were transferred here from a hospital in , where you had been treated for pneumonia, nausea, vomiting, and fever. you were initially admitted to our icu given your fever, low blood pressure, and acute kidney injury. the testing done in and at this facility determined that you had experienced worsening of your pancreatic cancer, with new metastases in the liver. you had recently completed a course of chemotherapy, but given your kidney injury and infection, it was not possible to continue this treatment. the rapid progression of your disease despite chemotherapy did not support further treatment. our renal team saw you and did not recommend dialysis for your kidney failure. during your stay, you were treated with antibiotics for infection, iv fluids and bowel decompression for your bowel obstruction, and pain and nausea medications. you received a duodenal stent to keep your bowel open and to allow you to eat and drink. while here you were started on multiple medications. please follow the dosages that are attached. the medications are: - albuterol and iprotropium nebulizers to help with your breathing. - metoprolol to control your heartrate - ondansetron and olanzapine as needed to help with nausea - docusate and senna to help with constipation - aluminum hydroxide to prevent your phosphate from getting too high - pantoprazole to lower the acid in your stomach and prevent bleeds - lorazepam as needed to help with anxiety - potassium chloride to prevent low potassium levels - pentamidine once a month to prevent lung infections - oxycodone as needed for pain you should not take your hiv meds for the time being. if your condition improves, you can discuss possibly restarting these medications in the future with dr. . please follow-up with your providers as listed below. followup instructions: department: hematology/oncology when: friday at 10:00 am with: , rn building: campus: east best parking: garage department: hematology/oncology when: monday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: when: tuesday at 11:40 am with: , m.d. building: sc clinical ctr campus: east best parking: garage procedure: other endoscopy of small intestine endoscopic insertion of colonic stent(s) diagnoses: coronary atherosclerosis of native coronary artery tobacco use disorder malignant neoplasm of liver, secondary acute kidney failure with lesion of tubular necrosis adrenal cortical steroids causing adverse effects in therapeutic use cachexia bacteremia malignant neoplasm of head of pancreas old myocardial infarction pressure ulcer, lower back hemorrhage of gastrointestinal tract, unspecified hypovolemia hyperosmolality and/or hypernatremia obstruction of bile duct asymptomatic human immunodeficiency virus [hiv] infection status other abnormal glucose anemia in neoplastic disease mixed acid-base balance disorder secondary malignant neoplasm of retroperitoneum and peritoneum other acute and subacute forms of ischemic heart disease, other edema pressure ulcer, unstageable other obstruction of duodenum 

Answer: The patient is high likely exposed to