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: simvastatin / tape "x10yd / hydrochlorothiazide / eptifibatide / cellcept attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation mechanical ventilation arterial line placement internal jugular venous line placement ultrasound guided renal biopsy bronchoscopy with bronchoalveolar lavage history of present illness: 60 m w/ esrd wegener's granulomatosis s/p kidney transplant () on tacro/cellcept, severe cad s/p five-vessel cabg with pfo closure and s/p multiple previous pcis (most recently in ), schf (ef=35%), copd, paf, htn, hld p/w cough productive of whitish sputum, sinus tightness, and muscle pain. he was recently discharged after a 3-day stay for evaluation of dyspnea and productive cough when he was found to have positive influenza a dfa and was treated w/ 5 day course of osetalmavir. . in the ed vs: , exam was notable for elevated jvd, tachypnea and bibiasilar rales. he required 4l o2 and sao2 was 93%. cxr revealed a new retrocardiac opacity and labs were notable for a leukocytosis to 15 and bnp of 30,000. o2 was increased to 6l and pt was satting 93%. he had a bnp of 30,000 (double what it was last month) and was given 20mg iv lasix with 500cc uop. he was empirically tx w/ vanc/levo for pna per cxr. he was also found to be in af w/ rate in 100s, as high as 120s, so was given 25 mg metoprolol. he was also given iv potassium for a k=2.9. . in the ed, initial vs: 100 110 118/76 20 93% 4l . in the icu, pt states his breathing is very difficult, and feels like when he had flu, except doesn't have the same fatigue/myalgias he had at that time. also endorses diarrhea (nonbloody, nonmelenotic) 4x/day. . denies cp, palpitations, lower extremity edema or orthopena. has not increased pillows (baseline 2). denies dietary or medication noncompliance. . ros: denies night sweats, vision changes, sore throat, chest pain, abdominal pain, nausea, vomiting, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: - major depression - chf ef%35-40% - paroxysmal atrial fibrillation, not on coumadin - esrd s/p living donor (sister) renal transplant in - cad: s/p cabg cabg x 5 (lima-->lad, svg-->d, svg-->om, svg-->r-pl-->r-plv) and pfo closure, (occluded om and rca grafts) - s/p acute mi with palmaz lad and rca stents - s/p rotablation and hepacoat stent to the d1 in , treated with brachytherapy for instent restenosis in - s/p taxus stent in rpl in - s/p two cypher stents placed in the rca - cath in with 60-70% ostial stenosis of lad, moderate diffuse disease of lcx, 60% proximal of rca with in stent restenosis with a 70% in the pl branch taxus stent - denies h/o dm; however, sugars have been elevated in past - chronic angina - hypertension - hypercholesterolemia - wegener's granulomatosis (renal/pulmonary involvement) diagnosed s/p cytoxan/prednisone x 1y initially, anca neg. since (chronic proteinuria); now s/p renal transplant in - idiopathic pericarditis - gerd - anxiety - gout - umbilical hernia repair - restless leg syndrome - basal cell carcinoma social history: - married for 30+ years with very recent separation from spouse - 3 adult children whith whom he is very close, and put them all through college - bachelor's degree in finance - was a teacher for numerous years, which he loved and then used to work in computer sales until his disease progressed - on ss/ssdi - loves to play music and write (except cannot motivate himself to do so currently) - remote history of smoking, quit 30 years ago, no alcohol or ilicits. family history: there is no family history of premature coronary artery disease or sudden death. mother had cva at 46. sister with scleroderma and another sister with . physical exam: admission physical exam: vs: af, 97 109/65 28 sao2 high 80s-low 90s on 100% face tent + 3l nc gen: pleasant man, speaking full sentences w/o heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear, no throat erythema, no sinus tenderness. neck supple, no lad, no thyromegaly. cv: irregularly irregular , faint. no rubs or gallops. jvp=10cm. lungs: b/l bases with decreased bs, rhonchi, wheezes b/l. no rales, good air movement biaterally. abdomen: nabs. soft, nt, nd. no hsm ext: trace edema, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. + reflexes, equal bl. normal coordination. gait assessment deferred psych: listens and responds to questions appropriately, pleasant . transfer physical exam: gen: nad, very sleepy and difficult to arouse heent: sclera anicteric, op clear, mmm cv: irregularly irregular lungs: clear anteriorly abd: soft, patient reports diffuse tenderness on palpation, non-distended ext: no edema neuro: cn ii-xii intact, full strength in all extremities (although requires significant prompting to lift right lower extremity), alert to person and place, odd affect pertinent results: admission labs: 12:10am blood wbc-15.2*# rbc-4.08* hgb-11.6* hct-34.6* mcv-85 mch-28.5 mchc-33.6 rdw-15.0 plt ct-181 12:10am blood neuts-88.7* lymphs-7.7* monos-2.4 eos-0.8 baso-0.3 07:54am blood pt-14.7* ptt-24.8 inr(pt)-1.3* 12:10am blood glucose-139* urean-37* creat-2.4* na-139 k-2.9* cl-105 hco3-19* angap-18 07:54am blood alt-20 ast-19 ld(ldh)-222 ck(cpk)-76 alkphos-73 totbili-0.9 07:54am blood albumin-3.5 calcium-7.9* phos-3.7 mg-1.2* . discharge labs: . microbiology: bal: no bacterial growth, no , no pcp, afb, no cmv **all blood, urine, and sputum cultures were negative** . imaging: ct sinus: bilateral sphenoid sinus, frontal sinuses, and ethmoidal air cell mucosal thickening. bilateral mucus-retention cysts or polyps in the maxillary sinuses. . ct chest: progression of bibasilar consolidations and pleural effusions concerning for progression of pneumonia. opacities previously noted in the right middle lobe, however, have resolved. cardiomegaly, but no evidence for chf. increased mediastinal lymphadenopathy, likely reactive in the setting of a progressive pneumonia. distended gallbladder. . renal txp us: no hydronephrosis. resistive indices ranging from 0.63 to 0.73, slightly increased as compared to the previous study. patent main renal artery and renal vein. . ct head: left middle cerebral artery distribution infarction without evidence of mass effect or hemorrhage. . tte: no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. lv systolic function appears depressed. the apex is akinetic. no masses or thrombi are seen in the left ventricle (definity contrast used). the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is no pericardial effusion. . carotid us: no evidence of stenosis on the right. the left system was not visualized due to presence of a central line. brief hospital course: 60 m w/ esrd wegener's granulomatosis s/p kidney transplant on tacro/cellcept, severe cad s/p five-vessel cabg w/ pfo closure in and s/p multiple previous pcis,(most recently in ), schf (ef=30%), paf, htn/hld gout, and depression/anxiety p/w 3 weeks of productive cough and sob. . # hypoxic respiratory distress: mr. was admitted from the ed in respiratory distress w/ increasing o2 requirement, likely post-infectious bacterial pna given recent admission for influenza. he was covered broadly for hcap with vanc/zosyn/levofloxacin. there was also likely a component of volume overload that contributed to his respiratory dysfunction given ivf and antibiotics given in ed in the setting of pt's poor forward flow (chf w/ ef~30%). due to increasing work of breathing, patient was intubated later on the admission day . chest ct on demonstrated bibasilar consolidations and pleural effusions concerning for progression of pneumonia. as anca returned moderately positive (see below), patient underwent bedside bronchoscopy on to rule out bronchial or alveolar hemorrhage. bronchoscopy revealed erythematous airways but no obvious hemorrhages. bal was negative for pcp, , afb, cmv, fungus or micro-organisms. patient's vent settings continued to be weaned and he was extubated on . unfortunately, during a speech and swallow evaluation the following day, he had a significant aspiration event, which shortly required reintubation secondary to respiratory distress. he was liberated from the ventilator on following the placement of a large bore ng tube. he did well following extubation. he completed a 7 day course of levofloxacin for aspiration pneumonia. he was diuresed with lasix as needed and received nebs/mucolytics as needed. he underwent another speech and swallow evaluation and was able to tolerate pos he was stable on room air at discharge. recommend continuation of incentive spirometry and ambulation with pt . # acute on chronic renal insufficiency: mr. baseline cr was 2.4 as he is s/p renal transplant () and his creatinine slowly increased during his admission, with cr peak at 5.4. this was thought to be atn from poor perfusion due to hypotension and hypoxemia. the renal transplant team followed the patient closely during his hopsital course, monitoring his renal function and immunosuppression with tacrolimus and mycophenolate. tacro levels were checked daily and adjusted accordingly. pt's urine sediment was consistent w/ atn showing muddy brown casts but no acanthocytes indiciative of glomerular injury. due to a reported moderately positive anca sent from , there was concern for recrudescence of wegener's granulomatosis and patient underwent urgent bedside renal biopsy on . he was given ddvap 1 hr prior to biopsy given uremic platelets as well as 6 units of platelets. cardiology was consulted to determine whether patient could safely go off / for biopsy but given pt's multiple cardiac risk factors and severe cad, he was kept on /, with only sc heparin being held for the biopsy. biopsy was consistent with atn without evidence of wegener's or rejection, but final pathology is pending. creatinine started to trend down after peak of 5.4 on and was 3.7 at discharge. all medications were renally dosed. he should continue sodium bicarbonate supplementation. he should continue to have creatinine monitored as well as tacrolimus trough (weekly) and should follow-up with renal as an outpatient. . # atrial fibrillation: pt has hx paroxysmal atrial fibrillation. prior records show that he was initially anticoagulated on coumadin until when it was discontinued due to severe epistaxis requiring transfusions as well as difficulty controlling his inr. pt's rate was initially controlled on home metoprolol 150mg but he frequently was tachycardic in atrial fibrillation and required some additional iv lopressor. on he was changed to 100mg metoprolol q6h, which helped somewhat, and he was also loaded with amiodarone on , with a significant improvement in his rate control. his cardiologist, dr., was contact for advice on continuing the amiodarone and a formal cardiology consult was initated. additionally, he was started on a heparin drip for bridge to coumadin given stroke (see below). he will be discharged on amiodarone 200 mg daily and metoprolol 100 mg q6. he should follow-up with cardiology as an outpatient. . # lmca infarct: on while examining patient to determine mental status for potential extubation, it was noted that patient's affect was abnormal, he did not track past midline and was not following commands. his right side was noted to be weaker than the left and he seemed to have some right-sided neglect but this was difficult to assess given sedation. a stat head ct revealed an infarct in the left middle cerebral artery territory, that was likely several days old per radiology without mass effect, midline shift or hemorrhage. neurology was consulted who felt the patient's exam was out of proportion to the size of the infarct and that his mental status changes could be secondary to toxic/metabolic encephalopathy. neurology also recommended repeat tte w/ bubble study which showed no lv or atrial thrombus and no clear pfo although this was a limited study. neurology felt that the source of the infarct was likely embolic and he was started on a heparin gtt/coumadin. pt/ot worked with patient and he will be discharged to rehab facility. he will be discharged on coumadin with inr goal 2.0 - 3.0 and should continue to have coag panel monitored . # diarrhea: mr. suffered from significant diarrhea while hospitalized. he had several negative stool cultures and cdiff tests. it was felt that this diarrhea was attributable to his immunosuppressant, mycophenolate. he has had this issue in the past and was successfully switched to a different formula, however this formulation was not available in a form that could be given while he was intubated. a flexiseal was placed to help protect his skin from breakdown given his volume of stool. after passing the speech and swallow evaluation, the diet was advanced and his normal formulation of mycophenolate was restarted. the rectal tube was removed. he should follow-up with the renal team as an outpatient . #abdominal wall hematoma: on transfer from the unit to the medical floor, it was observed that the patient complained of significant pain on palpation of his rlq (location of renal graft). a kub was unremarkable. renal us was performed and was initially read as a renal hematoma w/ concern for ?renal aneursym. transplant surgery recommended a ct scan which revealed that the hematoma was actually an abdominal wall hematoma with concern for active bleeding from r inferior epigastric artery. due to a drop in hct, the patient was taken for ir embolization on . he tolerated the procedure well without complication. he was transfused prbc and his hcts remained stable. his heparin gtt/coumadin was held for the procedure and was restarted 4 hours after the procedure per ir recs. . # chronic sinus congestion: mr main concern on admission was his chronic debilitating sinus congestion which has been evaluated extensively as an outpatient. he underwent ct sinus on revealed sinus air cell tickening. was not consulted in the icu given patient's multiple pressing issues. it is recommended that he follow-up with as an outpatient. . #cad/chf: patient has extensive cardiac history including 5 vessel cabg and multiple pci as well as a history of chf. and aspirin were continued throughout his hospital stay. he received iv lasix for diuresis while in the unit and was transitioned to his home dose of lasix. lisinopril was held given his renal issues described above. nifedipine was initially held and was gradually re-introduced at a low dose. he should be seen by cardiology for further medication adjustments and consideration of cardiac rehab in the future. . # depression: his home zoloft was continued. he was evaluated by psychiatry as an inpatient in the contect of agitation/delirium. haldol was started and will be continued at discharge per recommendatino of the accepting facility. we recommend weaning it off over the next week as the patient continues to improve. the patient has an extensive history of depression in the past and is at risk for post-stroke depression. he should have follow-up with neurology/social work. medications on admission: aspirin - 325 mg daily atorvastatin - 10 mg daily azelastine - 137 mcg aerosol 2 puffs clopidogrel ] - 75 mg daily fluticasone - 50 mcg spray sprays qdaily furosemide - 40 mg daily ipratropium bromide - (not taking as prescribed) - 21 mcg spray lisinopril - 40 mg tablet - 2 tablet(s) by mouth once a day (?? dose per patient) metoprolol succinate - 150 mg metronidazole - 0.75 % lotion mycophenolate sodium - 360 mg tablet, 2 tabs nifedipine - 90 mg daily pantoprazole - 40 mg pioglitazone - 15 mg sertraline - 150mg daily tacrolimus - 1.5 mg cholecalciferol (vitamin d3) - 1,000 unit daily generix t - tablet - 1 tablet(s) by mouth daily guaifenesin senna discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. astelin 137 mcg aerosol, spray sig: two (2) nasal twice a day. 4. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 5. fluticasone 50 mcg/actuation spray, suspension sig: sprays nasal (2 times a day). 6. lasix 40 mg tablet sig: one (1) tablet po once a day. 7. ipratropium bromide nasal 8. metronidazole 0.75 % lotion sig: one (1) application topical twice a day as needed for as needed . 9. mycophenolate sodium 360 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po twice a day. 10. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 11. sertraline 50 mg tablet sig: three (3) tablet po daily (daily). 12. cholecalciferol (vitamin d3) 1,000 unit capsule sig: one (1) capsule po once a day. 13. generix sig: one (1) once a day. 14. mucinex oral 15. senna oral 16. nifedipine 30 mg tablet extended release sig: one (1) tablet extended release po daily (daily). disp:*30 tablet extended release(s)* refills:*2* 17. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm: monitor inr weekly and adjust dose accordingly. disp:*30 tablet(s)* refills:*2* 18. amiodarone 200 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 19. metoprolol tartrate 50 mg tablet sig: two (2) tablet po q6h (every 6 hours): hold for heart rate < 60 or sbp < 100. disp:*240 tablet(s)* refills:*2* 20. tacrolimus 1 mg capsule sig: one (1) capsule po q12h (every 12 hours): renally adjust dose. disp:*30 capsule(s)* refills:*2* 21. insulin lispro 100 unit/ml solution sig: as directed subcutaneous asdir (as directed). disp:*30 ml* refills:*2* 22. haloperidol 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) for 2 weeks. disp:*30 tablet(s)* refills:*1* 23. sodium bicarbonate 650 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 24. calcium acetate 667 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* discharge disposition: extended care facility: - discharge diagnosis: primary: atrial fibrillation with rvr stroke acute tubular necrosis pneumonia, post-infections bacterial pneumonia, aspiration secondary: end stage renal disease s/p transplant congestive heart failure coronary artery disease s/p cagb and multiple pci depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you mr . you were admitted to the hospital with difficulty breathing which was likely due to a post-infectious bacterial pneumonia given your recent bout of influenza. because it was so difficult to breathe, you required mechanical ventilation (breathing machine) and were treated with antibiotics. you also had a stroke while you were in the hospital and you were started on anticoagulation medications. your renal function worsened and you had a renal biopsy which showed acute tubular necrosis. your renal function gradually improved. you were found to have an abdominal wall hematoma and you underwent an interventional radiology procedure to stop the bleeding. the following changes were made to your medications: -start amiodarone 200 mg once a day -start warfarin 2.5 mg once a day. this dose may be adjusted based on your inr. you should have your inr checked weekly -stop metoprolol succinate. - start metoprolol tartrate 100 mg every 6 hours. -stop lisinopril -decrease nifedipine to 30 mg once a day -stop pioglitazone -start insulin according to sliding scale -decrease tacrolimus to 1 mg twice a day -start sodium bicarbonate 650 mg twice a day -stop sevelamer -start calcium acetate 667 mg three times a day -start haloperidol 0.5 mg twice a day - the duration of this medication will be determined by your primary physician. . please continue your other home medications followup instructions: the following appointments have been made for you: department: cardiac services when: tuesday at 11:40 am with: , md building: campus: east best parking: garage department: neurology when: tuesday at 7:00 pm with: , m.d. building: campus: east best parking: garage you have been placed on a cancellation list for this appointment. department: west clinic (nephrology) when: wednesday at 12:00 pm with: , m.d. building: de building ( complex) campus: west best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus closed [percutaneous] [needle] biopsy of kidney arteriography of other intra-abdominal arteries transcatheter embolization for gastric or duodenal bleeding diagnoses: acidosis acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified toxic encephalopathy acute posthemorrhagic anemia chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation hematoma complicating a procedure depressive disorder, not elsewhere classified hypopotassemia chronic kidney disease, unspecified other and unspecified hyperlipidemia acute respiratory failure pneumonitis due to inhalation of food or vomitus antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use diarrhea cerebral embolism with cerebral infarction hyperosmolality and/or hypernatremia surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation acute on chronic systolic heart failure late effects of cerebrovascular disease, aphasia complications of transplanted kidney unspecified sinusitis (chronic) bacterial pneumonia, unspecified hemiplegia, unspecified, affecting dominant side wegener's granulomatosis chronic hypotension 

Answer: The patient is high likely exposed to