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: magnevist attending: chief complaint: lethargy major surgical or invasive procedure: biopsy of fluid collection history of present illness: 58m with hx of metastatic bladder ca s/p xrt completed carboplatin/gem , prostate cancer s/p brachytherapy, chf with lvef (30%), htn, dm, cri, admitted on to with lethargy, hypotension (baseline 90s) with sbps in the 70s-80s, and leukocytosis. transferred to from for further management. patient notes that he was recently discharged from for dyspnea and lightheadedness. was found to be anemic, likely chemotherapy with crit of 23.8. he received 3 units of prbcs to symptomatic relief. after being discharged on , patient again developed lethargy and loss of energy over the subsequent week and a half. visiting nurse came to see him for transitional issues, and patient found he needed help just to get up out of bed. diffiulty ambulating unless holding onto something. felt similar to s/ , patient. in addition, patient noted poor appetite and nausea. also felt thirsty and dehydrated. in addition, patient noted urinary incontinence, urinary frequency, but with low urine volumes of dark yellow color. felt that the urine smelled "very strong." because of these symptoms, went to . was found to have ua with 4+ bacteria, leuk esterase positive, 40 wbc. ucx adn bcx sent. ucx has since grown out 10-50,000 mixed gram positive flora. patient also with urinary retention on admission (no recent problems, per patient) and foley was placed, relieving patient of blood-tinged urine x600cc. was also found to have acute on chronic kidney failure with creatinine of 5.6 although without hyperkalemia. cxr was performed which was clear. labs were notable for anemia (explained as chronic) with crit in the low 20s and leukocytosis of 17,000, but without any evidence of ongoing blood loss. for likely uti, levofloxacin 250 mg daily was started. on the floors, patient became hypotensive with sbps in low 80s, adn was transferred to icu. patient also had rij placed and received total of 5l ns. neosynephrine was started as well by a house officer on the night before transfer, and bps were stable at > 100 (baseline in 90s). repeat cxr after fluids did not show any volume overload. also noted to have an episode of bradycardia (known history of tachy/brady). also reported to have bouts of nonsustained vtach and bouts of svts during icu stay, although also asymptomatic. creatinine improved with aggressive hydration. patient also says that his overall symptomotology improved whie in the icu. finally, on night before transfer, patient was found to have large quantity of liquidy brown stool; cdiff was sent, which was negative. on transfer, vs were: 98.2 100 99/54 29 99%ra on arrival to the micu, patient's vs. 98.3 81 109/73 21 100%ra past medical history: - metastatic bladder ca, s/p turbt , high-grade pt2bnxmx stage ii, mets to pelvic nodes, adrenals, lung, s/p cisplatin/gemcitabine to (5 cycles), carboplatin/gem to (3 cycles). - cad/chf w/ef 30%, s/p virtuoso ii dr icd. - hx of tachy-brady. - icd fired x6 on related to svt and nsvt. - prostate ca , 3+4=7 in cores (5% of core) s/p brachytherapy. - htn. - dm. - hyperlipidemia. - mild depression. - repair ruptured quadriceps tendon. social history: currently smoking a few cigarettes daily; is in a smoking cessation program. no alcohol or illicit drugs. lives at home alone and working at . family history: both parents died of cancer. hx of dm in family. physical exam: admission pe : vs: 98.3 81 109/73 21 100%ra general: alert, oriented, no acute distress heent: pale sclera, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: irregularly irregular, normal s1 + s2, no murmurs, rubs, gallops lungs: scant bibasilar crackles, otherwise clear to auscultation bilaterally abdomen: mild tenderness to palpation suprapubic. soft, non-distended, bowel sounds present, no organomegaly, no rebound or guarding . no cva tendernes. gu: + foley , blood tinged urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. discharge pe: pertinent results: 10:57pm pt-20.7* ptt-29.5 inr(pt)-2.0* 10:57pm plt count-129*# 10:57pm neuts-88.1* lymphs-5.4* monos-6.0 eos-0.5 basos-0.1 10:57pm wbc-22.2*# rbc-2.90* hgb-8.7* hct-26.7* mcv-92 mch-30.1 mchc-32.6 rdw-18.2* 10:57pm albumin-2.6* calcium-8.0* phosphate-2.2*# magnesium-1.4* 10:57pm alt(sgpt)-40 ast(sgot)-39 alk phos-143* tot bili-0.3 10:57pm estgfr-using this 10:57pm glucose-126* urea n-35* creat-1.6*# sodium-141 potassium-2.9* chloride-112* total co2-18* anion gap-14 imaging: cxr findings: in comparison with study of , the patient has taken a slightly better inspiration, which may account for the decrease in transverse diameter of the heart. dual-channel pacemaker device remains in good position. no vascular congestion or pleural effusion or acute pneumonia. right ij catheter has been introduced that extends to at least the mid portion of the svc where it is obscured by the pacer device. this was discussed with the icu team when they visited the radiology department this morning. echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is severely depressed (lvef = 25 %) with regional variation. significant contractile dyssynchrony is present, with a typical left bundle branch block activation sequence. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is slightly further reduced. significant left ventricular contractile dyssynchrony is present. ekg sinus tachycardia with frequent atrial and ventricular ectopy. intraventricular conduction delay. left anterior fascicular block. compared to the previous tracing of the rate has increased. there is frequent atrial and ventricular ectopy and continued diffuse low voltage. otherwise, no diagnostic interim change. intervals axes rate pr qrs qt/qtc p qrs t 117 0 122 354/453 0 -65 85 cxr : as compared to the previous radiograph, the right internal jugular vein catheter has been removed. the right picc line is in unchanged position. unchanged left pectoral pacemaker. the lung parenchyma shows no evidence of pneumonia or other pathologic change. no pulmonary edema. no pleural effusions. ct abd/pelvis impression: 1. marked progression of metastatic disease with interval increase in adrenal metastases and multiple nodules within the left pelvis as described above. small amount of free fluid in the right paracolic gutter. 2. new wedge-shaped hypodensity within the spleen most likely an infarct. 3. collapsed bladder with perivesicular stranding for which the differential includes infection, post-treatment changes, or tumor infiltration. 4. new mild bilateral hydroureteronephrosis. 5. stable bilateral renal cysts. 6. osseous metastases as described above with new lesions in t11 and l3 vertebral bodies. ct chest 1. new pulmonary nodule located in the right upper lobe, measuring 7 mm. 2. relatively stable metastatic disease within the abdomen and pelvis, including bilateral adrenal metastasis, retroperitoneal metastatic lymph nodes and pelvic inguinal chain lymph nodes, left mesorectal and left adductor node 3. bladder wall mass, consistent with known bladder carcinoma. 4. moderate to mild hydroureteronephrosis, not significantly changed from the prior study. there is no perinephric abscess. 4. no evidence of abdominal or pelvic abscess. 5. there is no intestinal obstruction. 6. numerous lytic osseous metastases. renal us 1. color flow seen in bilateral renal arteries and veins at the renal hilum. if detailed analysis of the artery and vein is needed including spectral doppler and resistive indices, please reorder the study. 2. moderate right hydronephrosis. resolution of left hydronephrosis. multiple bilateral parenchymal renal cysts which were previously seen on ct. 3. 6.5-cm heterogeneous nodule in the location of the right adrenal gland which correlates with known adrenal mass. 4. thickening of the anterior bladder wall consistent with patient's history of bladder cancer discharge labs: 06:50am blood wbc-18.8* rbc-2.50* hgb-7.7* hct-24.0* mcv-96 mch-30.8 mchc-32.2 rdw-16.1* plt ct-126* 06:50am blood glucose-105* urean-33* creat-1.9* na-138 k-4.2 cl-102 hco3-25 angap-15 06:30am blood alt-15 ast-13 ld(ldh)-232 alkphos-124 totbili-0.2 06:19am blood serotonin release assay- unfractionated heparin result: negative brief hospital course: mr. is a 58 yo m with pmhx of prostate ca and metastatic bladder ca with possible invasion into the r adrenal gland currently on palliative therapy, ischemic cardiomyoopathy, t2dm (insulin dependent), and tachy-brady syndrome who presented from osh to with sepsis and hypotension secondary to uti was managed with ivf and pressors who improved gradually with antibiotics and was discharged in stable condition to rehab. # septic shock/urosepsis: the patient presented from with evidence of sepsis from a urinary source requiring phenylephrine support. he was transferred on levofloxacin. weaning the patient from phenylephrine was initially difficult. due to his persistent pressor requriement and persistent leukocytosis, his antibiotics were changed to vancomycin and cefepime. he was given numerous ivf boluses for blood pressure support to baseline sbps in 90s, and his phenylephrine dose was eventually weaned. blood cultures were negative and urine culture grew 10-50,000 mixed gram positive flora. urine culture at grew corynebacterium sp. on the floor, cefepime was d/c-ed to narrow coverage of cram positive organisms/corynebacterium. patient continued to trigger on the floor primarily for hypotension, and was returned to the icu because of this. in the icu, patient received additional fluid resuscitation. given atypical organism causing uti, id was consulted. cefepime was restarted. ct abdomen/pelvis was also performed, which showed worsening metastatic disease as well as bladder wall stranding which could be inflammatory/infectious process. patient remained stable and was transferred back from the icu. given thrombocytemia, patient's vancomycin was discontinued. patient continued to spike fevers and repeat blood and urine cultures were sent. *blood cultures showed no growth to date with several still pending on day of discharge. *urine cultures originally grew corynebacteria for which pt took cefepime for 10 days, completing a full course. pt continued to consistently spike fevers almost daily, up to 101-102f. this generally would occur aroun 10pm to midnight. ua was sent which revealed many bacteria many wbcs. there was concern for recurrent uti as pt started have symptoms of dilirium and pt was restarted on antibiotics, ceftriaxone. id followed pt and after two days of ceftriaxone, antibiotic was discontinued given pt's rise in creatinine to 2.0 and conern for ain. # acute kidney injury: the patient presented to with that resolved rapidly with hydration. a renal ultrasound performed there showed stable mild hydronephrosis. ct abdomen and pelvis showed bilateral hydroureteronephrosis. urine output was maintained. cr began to trend upwards and leveled off at 2.0. renal was consulted and recommended a renal ultrasound, urine eos, and urine electrolytes. urine electrolytes showed fena of 1.5%, indeterminate for intrinsic process. given that pt's bump in creatinine occured at the same time pt was put on cephalosporins, there was concern for acute interstial nephritis. pt's urine eos were positive therefore ceftriaxone for recurrent utis was discontinued. on day of discharge creatinine was 2.1 (baseline 1.2-1.3). # metastatic bladder cancer: ct of abdomen and pelvis showed progression of disease, including increase in size of adrenal nodules, nodules in pelvis, lytic lesions at l2 (previously seen) and t11 and l3 (new). bladder collapsed with surrounding stranding read as infection vs. tumor infiltration. patient's outpatient oncology team (drs. and ) aware and met with patient and his family during admission. patient and his daughter understand his poor prognosis from his malignancy and would like to avoid aggressive treatment and focus on pain control and symptom management. they agreed to transition to hospice. # dilirium: for several days the week of pt appeared somewhat more confused from his baseline. his mental status was often alert and oriented to person but not place and time (whereas pt was always axox3 prior to this). pt some mornings thought he was in a football stadium and that it was decemeber. also pt's daughter reported that he would call her in the middle of the night sounding confused. this confusion resolved two days prior to the day of discharge. the differential for his dilirium includes infection (ie possible given pt's refractory fevers, leukocytosis, and recurrent utis) or overmedication with narcotics (very possible as well given pt's pain regimen in hospital was increased). it seems there might be a fine line between managing pt's pain with narcotics adequately and allowing him to be mentally alert and oriented x 3. however pt's mental status improved without any adjustment in pain regimen. # thrombocytopenia: patient with mild thrombocytopenia on admission (129) likely related to chemotherapy. counts dropped during admission, reaching nadir of 54 on . differential included drug effect from vancomycin, so vanc was discontinued. heparin dependent antibodies were sent, which returned strongly positive. serotonin release assay was negative suggestive that hit was not etiology. platelets returned to baseline prior to discharge. # atrial fibrillation with tachy-brady syndrome: the patient was maintained on his home digoxin, but his metoprolol was held in the setting of his hypotension. the patient had occasional episodes of tachycardia to the 120s. he had no episodes of bradycardia. when patient returned to icu, patient's digoxin dose was increased to 0.25 and he remained hemodynamically stable. on the floor, patient was persistantly tachy in the 100s-110s, with occasional episodes of tachy to the 120s-140s. tele showed frequent pvcs and occasional non-sustained (10 beats or less) runs of v-tach. metoprolol was restarted at low dose on . # chf: because of history of chf, fluid resuscitation was performed judiciously. echo during stay showed ef of 25% and ventricular dyssynchrony. patient did not show signs of volume overload. # anemia: the patient's anemia was thought to be related to chemotherapy. he also had hematuria due to his bladder cancer throughout his stay. he was occasionally symptomatic, feeling lethargic. he was transfused 1u prbcs on two occasions with good resolution of symptoms and an appropriate increase in hct. # diarrhea: patient developed loose liquid stools the night before transfer to . stool studies were sent at as well as . patient was found to be cdiff negative without bacterial pathogen, without fecal leukocytes. stool guaiac was performed, which was initially positive (when patient's inr was 2.0); it was subsequently negative. after negative workup, it was felt that diarrhea was likely secondary to antibiotic use. care was taken to make up for insensible losses with fluid repletion. # coagulopathy: patient presented to with inr of 2.0. thought to be secondary to antibiotic use compounded by poor po intake. patient received 5 mg vitamin k po and coagulopathy resolved. patient did have one guaiac positive stool which was thought to be brought on by this transient coagulopathy. #code/ goals of care: dnr/dni. patient and his daughter would like transition his care to focusing more on comfort and controlling his symptoms. he should be transitioned to hospice after acute rehab. transitional issues: - fevers: patient continued to have intermittent fevers to 101.5 in the days prior to discharge. no infectious source was identified. the source of his fevers was thought to be from his cancer. patient and his daughter elected not to have further aggressive treatment or work-up. medications on admission: preadmission medications listed are correct and complete. information was obtained from patientpharmacywebomr. 1. digoxin 0.125 mg po daily 2. eplerenone 25 mg po daily 3. 70/30 14 units breakfast 70/30 14 units dinner 4. morphine sr (ms contin) 30 mg po q8h 5. morphine sulfate ir 15 mg po q4h:prn pain 6. phenazopyridine 200 mg po q8h:prn bladder pain duration: 3 days 7. furosemide 20 mg po daily continue as you were taking at home, please take daily. 8. metoprolol succinate xl 200 mg po daily 9. prochlorperazine 5-10 mg po q6h:prn nausea 10. docusate sodium 100 mg po bid hold for loose stools discharge medications: 1. digoxin 0.125 mg po daily 2. docusate sodium 100 mg po bid hold for loose stools 3. 70/30 14 units breakfast 70/30 14 units dinner 4. morphine sr (ms contin) 60 mg po q8h hold for oversedation, rr<12 5. morphine sulfate ir 15 mg po q3h:prn pain please hold for rr<12, altered mental status 6. prochlorperazine 5-10 mg po q6h:prn nausea 7. metoprolol succinate xl 100 mg po daily 8. senna 1 tab po bid:prn constipation 9. acetaminophen 650 mg po tid 10. polyethylene glycol 17 g po daily:prn constipation 11. bisacodyl 10 mg po/pr daily:prn constipation discharge disposition: extended care facility: rehabilitation and nursing of discharge diagnosis: primary: uti with sepsis; metastatic bladder cancer; delirium discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , you were admitted to the hospital with a low blood pressure and fatigue, which was severe enough that you needed to go the intensive care unit for close monitoring. you were found to have a urinary tract infection and were given iv fluids and antibiotics. you also had severe back pain, most likely due to metastatic cancer in your spine, and your pain medications were adjusted. you also received a single radiation treatment for your back pain. you also had frequent fevers throughout your hospitalization. we evaluated you for a source of infection but no source was located. we discussed your goals of care and you would like to focus more on symptoms and feeling comfortable. you will go to a rehab facility to get stronger and you can transition to hospice care when appropriate. followup instructions: please keep the following appointments: procedure: venous catheterization, not elsewhere classified closed biopsy of skin and subcutaneous tissue other radiotherapeutic procedure diagnoses: abnormal coagulation profile tobacco use disorder acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified septicemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation personal history of malignant neoplasm of prostate chronic kidney disease, unspecified other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia long-term (current) use of insulin septic shock antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use chronic systolic heart failure acute glomerulonephritis with other specified pathological lesion in kidney automatic implantable cardiac defibrillator in situ do not resuscitate status secondary malignant neoplasm of lung sinoatrial node dysfunction examination of participant in clinical trial secondary malignant neoplasm of bone and bone marrow secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes secondary malignant neoplasm of adrenal gland malignant neoplasm of bladder, part unspecified other secondary thrombocytopenia antineoplastic chemotherapy induced anemia unspecified disorder of muscle, ligament, and fascia 

Answer: The patient is high likely exposed to