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: history of present illness: the patient is an 83-year-old female with history of myelodysplastic syndrome, hypercholesterolemia with recent diagnosis of bilateral adrenal masses found during a workup for acute renal failure in an outside hospital, who was transferred from an outside hospital () after developing fever, tachycardia, and hypotension. apparently, patient presented on at with acute renal failure, hyperkalemic with k of 7.3 and hyponatremic with a sodium of 130. during workup of patient's acute renal failure at , patient had an abdominal ct, which showed bilateral adrenal masses measuring up to 7.5 cm in ap diameter on the left and 6 cm in ap diameter on the right. patient was then discharged and represented for an adrenal mass biopsy on , and was sent back to transitional care unit. on , then patient then developed tachycardia and fever at . chest x- ray was consistent with chf. patient was given nitro paste and lasix, and then became hypotensive to the 60's. dobutamine was started at outside hospital and patient received levofloxacin for a question of uti as well as vancomycin. she was also given a dose of solu-medrol for a question of adrenal insufficiency. prior to solu-medrol administration, serum cortisol was checked at outside hospital and was low at 13. patient also had an aldosterone checked at that time, which was low at 3.0, normal range is 4 to 31. patient was started on dobutamine and dopamine at the outside hospital. dobutamine was then discontinued and neo- synephrine was started. patient had only received a 250 cc normal saline bolus prior to the start of pressors. abdominal ct scan was performed, which showed no bleed. the patient was then at this point transferred to the medical intensive care unit for further management. on arrival to the micu, patient was on dopamine and neo- synephrine, and her blood pressure was 81/39, heart rate 120s, and was saturating 100 percent on nonrebreather. over the course of her micu stay for one night, patient was aggressively fluid resuscitated with 2-3 liters of normal saline and her pressors were weaned to off. she was continued on broad-spectrum antibiotics of vancomycin, levofloxacin for a question of urinary tract infection and sepsis. she also received 1 unit of packed red blood cells for a hematocrit of 26. she was continued on empiric stress-dosed steroids of 100 mg of iv hydrocortisone q.8. for question of adrenal insufficiency. stim test was not checked since the patient had received solu-medrol at an outside hospital. since patient's blood pressure was stable and she had no acute icu issues, patient was transferred to medicine floor on for further management. past medical history: 1. hypercholesterolemia. 2. myelodysplastic syndrome being managed by patient's outpatient oncologist, dr. . 3. bilateral adrenal masses recently diagnosed on at hospital. biopsy results from the adrenal glands revealed a poorly differentiated malignant neoplasm with vague epithelioid features, although no pigment is identified, the prominent nucleoli suggested the possibility of malignant melanoma, however, a germ cell neoplasm or large cell lymphoma could not be excluded. additional immunohistochemistry stains were sent and are still pending at the time of this dictation, and will not be available for at least a week. medications on admission: 1. lipitor 10 mg p.o. q.d. 2. neupogen 300 mg subq q.d. 3. vancomycin and levofloxacin started at outside hospital. allergies: no known drug allergies. social history: patient lives alone in , but prior to her transfer here, had been living at the transitional care unit after her adrenal gland biopsy. patient has a daughter and son, who are active in her care. her daughter's name is , phone number and is her healthcare proxy. also has a sister and son, who are close to her. physical examination: patient is afebrile, blood pressure 81/39, heart rate 120, saturating 100 percent on nonrebreather. in general, she was comfortable in no distress. heent exam: pupils are equal, round, and reactive to light, extraocular movements are intact, mucous membranes were dry. neck: supple, nontender, no increase in jvd. lungs: crackles at the bases left greater than right. cardiovascular: tachycardic with normal s1 and s2 and a 2/6 systolic murmur at the apex. abdomen: soft, nontender, and nondistended with normoactive bowel sounds. extremities: no edema. two plus dorsalis pedis pulses present bilaterally. neurologic is alert and oriented times three and moves all extremities with no focal deficits. labs at outside hospital: white blood cell count was 5.9, hematocrit was 28.3, platelets were 58, which appears to be the patient's baseline. sodium 130, potassium 4.0, chloride 93, bicarb 25, bun 20, creatinine 1.5, previously 3.1 on , glucose 110. calcium 8.3. ck 20 and troponin negative per outside hospital emergency department. urinalysis showed small bilirubin, trace ketones, large blood, 30 protein, negative nitrite, moderate leukocyte esterase, 25-30 white cells, red cells, 2 plus bacteria, and moderate epithelials. chest x-ray showed bilateral interstitial infiltrates increased consistent with . chest and abdominal ct on showed bilateral calcified pleural plaques consistent with prior asbestos exposure, calcified mitral annulus, large adrenal masses 7.5 cm on the left and 6 cm on the right consistent with metastases, enlarged retroperitoneal lymph nodes, largest was 2.5 cm on the right and 2 cm on the left and multiple colonic diverticula. ekg at the outside hospital was sinus tachycardic at 150 beats per minute, 0.5- depressions in i and avl, left axis deviation, no q waves. assessment: this is an 83-year-old female with recent acute renal failure and a new diagnosis of bilateral adrenal masses, who presents with fever and tachycardia and hypotension. hospital course: 1. hypotension: patient's hypotension was thought to be most likely due to early sepsis most probably from a urinary tract infection given her fever and positive urinalysis. even though patient was diuresed at the outside hospital, it is most likely that she was hypovolemic, which would be explained by her tachycardia and hypotension. since she did not receive adequate fluid resuscitation at the outside hospital, the patient was aggressively fluid resuscitated in the medical intensive care unit with as much as 3 liters of iv fluids and blood pressure stabilized in the systolics of 90s to low 100s. patient's pressors were weaned to off in the medical intensive care unit as mentioned in the history of present illness, and her o2 saturations remained stable at 100 percent on 2 liters nasal cannula. upon transfer to the medicine floor, patient's cultures remained negative from blood and urine. patient is continued on levofloxacin and the vancomycin was discontinued since there was no obvious indication for continuing vancomycin. given the patient's septic picture, would recommend a 10 day course total for levofloxacin. patient will need five more days of levofloxacin to complete the 10 day course. patient's blood pressures upon discharge had been in the low 100s, which most probably is the patient's baseline blood pressure, and she has been hemodynamically stable. there is question of whether her hypotension may have been secondary to adrenal insufficiency, and this will be addressed below. 1. oxygen requirement: the patient had an oxygen requirement through most of her hospitalization, although upon discharge, her o2 saturations have been 94 percent on room air and 94 percent on room air after ambulation. it was thought initially that patient had mild chf, which was consistent with chest x-ray findings. however, patient did not show florid stigmata of heart failure on examination. in addition, the patient had a 2-d echocardiogram performed on , which revealed a normal systolic function and ef of greater than 55 percent with no abnormalities except for mild 1 plus mr. did have ck's and troponins cycled, which were negative for mi. given her o2 requirement, patient had a chest ct performed on , which was performed without contrast, and revealed small bilateral pleural effusions, multiple calcified pleural plaques on the right and left pleural surfaces most probably consistent with prior asbestos exposure. there is also a focal calcified granuloma within the right middle lobe, but no other discrete pulmonary nodules and no intraparenchymal mass lesions. she also had linear opacities right greater than left in the bases consistent with scarring. the ct also had cuts of the adrenal glands, which showed bilateral soft tissue densities in the adrenal glands right measuring 6.9 x 4.3 cm and the left measuring 4.1 x 4.2 cm. with these chest ct findings as well as the ct findings at the outside hospital, it is most likely that patient has had prior asbestos exposure and may have pleural plaques resulting from this. after speaking to family, the patient has apparently had a history of this granuloma in the past, and even had a thoracotomy performed, although further details are not available. since the patient's o2 saturations have been stable on room air, felt comfortable that her pulmonary status is stable. 1. bilateral adrenal masses and question of adrenal insufficiency: the patient had an outside hospital biopsy performed, which was concerning for carcinoma. the final immunohistochemistry stains would not be back prior to discharge since they were sent out from the outside hospital. there were no indications of metastasis on chest ct. but the final diagnosis of what type of cancer patient may have is still not available at this time. on admission, patient's family notified the micu team that patient, herself was not aware of the diagnosis of bilateral adrenal masses. during her stay during the medicine , a family meeting was called to inform the patient about her bilateral adrenal masses and the possibility of carcinoma. patient still does not seem to quite understand her diagnosis at this time, but patient has a very good primary care followup with dr. . dr. number is . patient also has an outpatient oncologist, dr. , who will follow up with the patient as an outpatient regarding the final immunohistochemistry stain and diagnosis and further treatment options. as far as the question of adrenal insufficiency, endocrine consult was called regarding patient's steroid taper. they suggested tapering her steroids from hydrocortisone 50 q.6 to 50 q.8 hours, and then dropping prednisone to 30 mg on and then 20 mg on . upon discharge, the patient should continue with this prednisone taper, and should likely be tapered to 10 mg on and 7.5 mg on , and should continue with 7.5 mg of prednisone until her outpatient endocrine follow-up appointment, which will be made by her primary care physician, . . patient did have stim test checked on , but this was in light of hydrocortisone levels and her cortisol levels were 94.2 and then 88.4. the endocrine consult had recommended stim test even in the light of hydrocortisone therapy. on prior to patient's 20 mg dose, an a.m. cortisol and acth was checked, and these results are still pending. it was still unclear if the patient has a primary adrenal insufficiency at this time since she has conflicting data. on prior to adrenal biopsy, the patient did have an elevated potassium and low sodium levels, but her random cortisol checked at that time was normal at the outside hospital at 17. however, patient did present with hypotension on , but her k at that time at the outside hospital was normal going against primary adrenal insufficiency. it is possible that her hypotension may all have been secondary to sepsis and it is difficult to interpret the low cortisol level of 13, that was drawn at that time in the setting of an acute infection. in addition, patient has been on high-dosed steroids now, and the likelihood that she will become adrenally insufficient is probable. the masses in the adrenal glands in films do not help indicate adrenal insufficiency since this may likely be metastasis as well from lymphomas or lung carcinoma. thus, at this time, patient will continue as mentioned above with a prednisone taper of 20 mg on mg on , 7.5 mg on , and continue with those until outpatient endocrine followup. she will continue with fludrocortisone 0.05 mg p.o. q.d. times a total seven day course to end on . an a.m. cortisol and acth are still pending from , and this should be followed up with her primary care physician. addition, endocrine consult requested a 24-hour urine collection for metanephrines, bma, and catecholamines to rule out pheochromocytoma, however, this was determined this could be done as an outpatient. the pheochromocytoma was the most unlikely. 1. increased blood sugars: the patient had high blood sugars at the start of her steroid therapy, which have begun to decrease given her taper of steroids. she has not required as much insulin at the time of discharge, but she will still require q.i.d. fingersticks given that she is still on a prednisone taper. it was attempted to teach the patient diabetic teaching with insulin, however, patient has difficulty understanding how to administer the insulin. she will need assistance with insulin teaching and diabetes management while she is on the prednisone taper. 1. hypothyroidism: the patient had an elevated tsh at 8.3, t4 of 6.4, and t3 of 54. endocrine consult did comment on these values, and decided that the tsh was uninterpretable in the setting of acute infection. patient should have a tsh repeated in weeks by her primary care physician. 1. acute renal failure: patient's creatinine was elevated on admission to 1.7 at the outside hospital, although it had been as high as 3.1 on . upon discharge, patient's creatinine is now 1.4 and has been stable. patient often requires additional fluids to supplement her p.o. intake, and patient may have a component of prerenal in her acute renal failure. a fena and urine electrolytes were checked, and the fena was calculated to be 1.1 percent, which is not especially helpful in this setting. it is likely that patient may have had some atn with her episodes of hypotension in the beginning of and then again on , and patient's renal tubules may be recovering from this insult. would recommend following patient's creatinine frequently as an outpatient and supplementing while patient is in a rehab facility with iv fluids 1 liter every other day if patient appears dry on exam and is not taking sufficient p.o. the patient may likely have some element of chronic renal failure from the acute tubular necrosis, but this maybe patient's new baseline creatinine. disposition: the patient will require either a skilled- nursing facility or rehab facility for help with insulin teaching as well as medication administration. physical therapy did work with the patient and felt that she was doing well from an ambulation and mobility standpoint. discharge diagnoses: 1. urosepsis. 2. hypotension. 3. bilateral adrenal masses. 4. possibility of adrenal insufficiency. 5. acute renal failure. 6. hyperglycemia. discharge condition: stable. discharge status: to skilled-nursing facility or rehab. discharge medications: 1. levofloxacin 250 mg p.o. q.d. x5 more days. 2. heparin 5000 units subq q.8h. while patient is at rehab facility. 3. sliding scale insulin. 4. atorvastatin 10 mg p.o. q.d. 5. senna. 6. colace 100 mg p.o. b.i.d. 7. protonix 40 mg p.o. q.d. 8. prednisone taper 10 mg p.o. q.a.m. on and 7.5 mg on . 9. fludrocortisone 0.05 mg q.d. x3 more days. follow-up plans: 1. the patient should follow up with her primary care physician, . in one week. at this time, the patient will most likely have her immunohistochemistry stain results back from the adrenal mass biopsy. 2. the patient should follow up with her primary oncologist, dr. within the next two weeks. 3. the patient will need an endocrine follow-up appointment, which will be scheduled by patient's primary care physician, . to be at a location closer to the patient's home. , procedure: transfusion of packed cells diagnoses: acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified unspecified septicemia hyposmolality and/or hyponatremia severe sepsis septic shock acute diastolic heart failure 

Answer: The patient is high likely exposed to