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: ativan / prochlorperazine attending: chief complaint: dlbcl, inability to keep up with transfusion requirements major surgical or invasive procedure: none history of present illness: mr. is a 61-year-old man with a history of diffuse large b-cell lymphoma status post six cycles of r-chop between and , status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate, and s/p 3 cycles of eshap chemotherapy and two doses of intra-thecal ara-c. his last cycle of eshap was . mr. is well known to the service, his last admission being from to and complicated by fever and neutropenia secondary to clostridium difficile infection (stool c. diff negative prior to discharge), typhlitis, vre urosepsis, upper and lower extremity dvts, and atrial fibrillation with rapid ventricular rate. he was discharged to and returns because of a falling platelet count and inability to keep up with his transfusion needs while maintaining anticoagulation with lovenox. since discharge the patient reports that he has had difficulties with episodes of dry heaves and was started on marinol the day prior to transfer. he has also had some mild abdominal discomfort intermittantly that improves somewhat with eating. he has had a few episodes of diarrhea as well. he has not had any frank fevers, however, his wife notes that his temperature has been rising somewhat. he has had variable po intake, at times eating well and at times eating little to nothing at mealtimes. the swelling in his upper and lower extremities has decreased remarkably and he has lost nearly 30 pounds of weight. he states he was placed on oxygen 2 days ago, but has not had any shortness of breath. he has been working with physical therapy at , but is not up walking yet. ros: as above. in addition, he notes no upper respiratory symptoms (runny nose, sore throat), cough, reflux, shortness of breath, chest pain, blood per rectum, dysuria, rashes, arthralgias. past medical history: oncologic history: mr. initially presented to an outside hospital in with a 30-pound weight loss over the prior 6 months. he was worked up and found to have a soft tissue mass in the cardiac ventricles involving the myocardium and extending into the interatrial septum. he was also noted to have multiple pulmonary nodules, bilateral pleural effusions, a pericardial effusion, large bilateral adrenal masses, and diffuse soft tissue masses involving both kidneys. the hospital course was complicated by the development of tamponade physiology, and the patient ultimately underwent a pericardial window. a renal biopsy on confirmed diffuse large b-cell lymphoma (stage 4b), and a pericardial biopsy on also was consistent with large b-cell lymphoma. he was diffusely immunoreactive for cd20 and co-expressed bcl-2 and bcl-6. cd43, cd5, tdt, bcl-1, s100 were negative. lmp for ebv was negative. cd10 and cd30 were weekly expressed. in addition, a bone marrow biopsy demonstrated bone marrow involvement by lymphoma. the patient was initiated on r-chop on and received six cycles between and and is also status post five cycles of high-dose methotrexate and one dose of intrathecal methotrexate. ct abdomen on showed evidence of new liver lesion concerning for disease recurrence. ct guided liver biopsy on was positive and on further evaluation was found to have involvement in his heart, chest wall and retropharyngeal space. he also was assumed to have it in his csf, even though the first lp had only one aytpical cell. he received a total of 3 cycles of eshap chemotherapy and two doses of intra-thecal ara-c. his last cycle of eshap was . no discrete hepatic lesions were noted on ct abdomen on . flow cytometry showed indefinite evidence of lymphomatous involvement of the csf. he was followed by neuro-oncology in-house who recommended no further it ara-c and to follow his neurologic symptoms clinically, and to re-refer him back to his outpatient neuro-oncologist (dr. if he had any worsening confusion or neurologic symptoms. given that he had received 3 x it chemo and 3 cycles of high-dose ara-c, it was felt to be sufficient for cns prophylaxis. other medical history: # large b cell lymphoma as above # recent c diff colitis # hx of dvts, upper & lower extremities, on lovenox # strep viridans bacteremia (1 bottle; picc-associated? treated w/ ceftriaxone/pcn/ceftriaxone x4 weeks total) # erythema nodosum, right forearm () # intermittant atrial fibrillation with rvr # cardiogenic syncope # history of febrile neutropenia # typhlitis # vre urosepsis # nephrolithiasis # anemia # gerd past surgical history: # amputation of right 2nd digit after electrical accident social history: social history: (per omr) the patient is married and has one son. is a retired engineer. + 60 pk year history of tobacco, but quit in of , just prior to his diagnosis of lymphoma due to symptoms of profound weakness. drinks socially, ~ 2 drinks per month. no illicit drug use. one son is alive and healthy, and is also a physician. has been able to accomplish basic adls with minimal assistance, but is dependent on advanced adls. family history: fhx: family history: (per omr) father - died of mother - sle, dm, cad; died age 75 brother - cardiac arrythmias brother - prostate ca son - healthy physical exam: v/s: t 99.0, bp 112/78, hr 78, rr 18, 97% on 2l nc gen: thin, pale, male in nad heent: sclera anicteric, left pupil 4 mm, right pupil 3 mm, both pupils reactive to light. mmm, op clear. neck: no lymphadenopathy, left ij central line with dried blood under the dressing chest: decreased bs bilaterally without wheezes, rhonchi, or crackles. cv: rrr, normal s1 and s2, no murmurs or extra heart sounds appreciated abd: +bs, soft, non-tender, no hepatosmplenolmegaly ext: warm, well perfused. 2+ edema in the left le and 1+ edema in the right upper extremity. 2+ dp pulse on right, not appreciable on left secondary to edema. skin: sacral ulcer, no rashes noted neuro: a&o x 3, decreased strength throughout. unable to dorsiflex ankles bilaterally. reflexes 0-1+ bilaterally throughout. pertinent results: admission labs: 03:34pm blood wbc-0.5*# rbc-3.04* hgb-9.8*# hct-27.1* mcv-89 mch-32.3* mchc-36.2* rdw-16.3* plt ct-38* 03:34pm blood neuts-24* bands-2 lymphs-62* monos-8 eos-0 baso-2 atyps-0 metas-2* myelos-0 03:34pm blood pt-13.4 ptt-26.7 inr(pt)-1.1 03:34pm blood gran ct-129* 03:34pm blood glucose-111* urean-12 creat-0.5 na-140 k-4.8 cl-103 hco3-31 03:34pm blood alt-9 ast-15 ld(ldh)-265* alkphos-82 totbili-0.6 03:34pm blood albumin-3.0* calcium-8.5 phos-2.3* mg-1.7 microbiology: 4:45 pm stool consistency: soft source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). imaging: cxr - the left internal jugular line tip is at the cavoatrial junction. cardiomediastinal silhouette is stable. there is interval development of bilateral pleural effusions and bibasal atelectasis. there is also increased opacity in the right upper lung that is seen in addition to the known cavity demonstrated on chest ct. no pneumothorax is demonstrated. small bilateral pleural effusions are present that appears to be increased since the prior study. rue ultrasound - impression: 1. overall unchanged appearance of right upper extremity dvt extending through the subclavian, axillary, and brachial veins. peripheral flow in the subclavian and brachial veins indicates nonocclusive thrombus in these vessels. however, thrombus remains occlusive in the axillary vein. 2. occlusive thrombus in the basilic vein, not well visualized previously, but likely unchanged. 3. persistent respiratory variability of the left subclavian vein indicates the svc remains patent, without occlusive central propagation of right subclavian thrombus. ecg - normal sinus rhythm. axis is minus 40 degrees. possible biatrial enlargement. poor r wave progression in leads v1-v4. non-specific st-t wave changes diffusely. compared to the previous tracing of there is no diagnostic interval change. consider left ventricular hypertrophy. cxr - the left central venous line tip is at the cavoatrial junction. cardiomediastinal silhouette is unchanged including left ventriculomegaly. the lung volumes are unchanged, slightly decreased compared to more remote prior studies. the known severe emphysema with bibasilar opacities, pleural effusion and known right upper lung consolidation appears to be unchanged as well. there is no evidence of interval development of pulmonary edema. cxr - findings: in comparison with the study of , there is again evidence of chronic pulmonary disease with bilateral pleural effusions and atelectatic changes at the bases. the retrocardiac opacification is somewhat more prominent than on the previous study. central catheter remains in place. ct torso with contrast - impression: 1. new moderate bilateral pleural effusions with associated atelectasis. there is no new consolidation within the lung parenchyma to suggest presence of pneumonia. 2. unchanged appearance of right upper lobe consolidation with central cavitation. 3. previously identified left chest wall mass and cardiac masses are not visualized on the current study, consistent with continued interval improvement in lymphoma. 4. resolution of wall thickening involving the cecum and ascending colon. 5. cholelithiasis within the gallbladder neck, but no ct evidence of acute cholecystitis. 6. bilateral renal cortical thinning, most consistent with scarring. 7. unchanged adrenal fullness. 8. extensive atherosclerotic disease of the distal aorta, with unchanged bilateral common iliac artery aneurysms and significant intramural clot on the right. echo - the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , no change. cxr - impression: regression of previously identified bilateral pleural effusion. unfortunately, no lateral view has been obtained which could identify the presence or absence of remaining pleural effusion accumulating in the posterior sinuses in this patient in standing position. pulmonary report spirometry, lung volumes, dlco study spirometry 11:03 am pre drug post drug actual pred %pred actual %pred %chg fvc 4.74 4.52 105 4.36 96 -8 fev1 3.10 3.18 98 2.76 87 -11 mmf 2.24 3.03 74 1.90 63 -15 fev1/fvc 65 70 93 63 90 -3 lung volumes 11:03 am pre drug post drug actual pred %pred tlc 7.24 6.88 105 frc 4.65 3.88 120 rv 2.59 2.36 110 vc 4.83 4.52 107 ic 2.59 3.00 86 erv 2.06 1.52 136 rv/tlc 36 34 104 he mix time 2.50 dlco 11:03 am actual pred %pred dsb 9.31 26.50 35 va(sb) 6.22 6.88 90 hb 9.50 dsb(hb 11.36 26.50 43 dl/va 1.83 3.85 47 ct torso with contrast - impression: 1. significant interval decrease of bilateral pleural effusions. multiple small focal nodularities, consistent with tree-in- appearance, predominantly in the right lung but also seen in the left lung, concerning for infectious process. unchanged surgical sutures and apical scar in the right lung. 2. no acute changes in the abdomen compared to the ct torso performed 10 days ago. unchanged left-sided common femoral/iliac dvt. ivc filter in expected. position. unchanged gallstones without evidence of acute cholecystitis. slightly prominent pancreatic duct. brief hospital course: mr. is a 61 year old male with diffuse large b cell lymphoma, s/p multiple cycles of treatment, most recently his third cycle of eshap chemotherapy with a history of upper and lower extremity dvts, atrial fibrillation with rvr, and recent c. difficile colitis who was admitted with neutropenia and thrombocytopenia and inability to keep up with his transfusion requirements. #. diffuse large b cell lymphoma - the patient is s/p multiple cycles of chemotherapy, including several cycles of intrathecal chemotherapy that were felt sufficient for cns prophylaxis. the patient had a ct scan on that demonstrated a dramatic remission of his formerly bulky disease. repeat ct scan on failed to identify recurrent lymphoma. however, when the patient developed hypercalcemia and delerium it was felt that his diffuse large b cell lymphoma had likely recurred. his hypercalcemia eventually responded to pamidronate, fluids and calcitonin. however, his delerium did not fully resolve. given the patient's likely disease recurrence despite multiple rounds of chemotherapy, it was felt that the patient was unlikely to benefit from additional chemotherapy. in discussion, with the patient and his family, it was decided not to pursue additional diagnostic studies such as a lumbar puncture or a bone marrow biopsy. the patient's care was shifted towards comfort measures and he passed aways peacefully on with his family at his side. # the patient had multiple other medical issues that required treatment during this admission. he was neutropenic secondary to his most recent eshap therapy. his is anc nadired at 37. he was placed on neutropenic precautions while he remained neutropenic. the patient required multiple transfusions of platelets during this admission. his platelet levels eventually recovered as his neutropenia resolved. the patient had a history of rue dvt and was noted to have a thrombus in his right iliac artery aneurysm. his dose of lovenox had to be lowered in order to continue anticoagulation while the patient's platelets were so low. during this hospitalization, he completed treatment for his previously documented afib and his symptoms resolved. #. atrial fibrillation with rvr - the patient has a history of intermittant afib with rvr, particularly in response to lasix. the patient was initially kept on the metoprolol regimen that he came from on. after a couple of days in the hospital the patient had a rising oxygen requirement and was given several small doses of lasix to remove extra fluid from his multiple transfusions. he over went into afib with rvr in the middle of the night and usually responded to 25-50 mg po of metoprolol tartrate. on the patient was in afib with rvr, assymptomatic and hemodynamically stable, for multiple hours and did not respond to 50 mg po metoprolol. cardiology was informally consulted and they recommended returning to the patient's prior regimen of metoprolol succinate 200 mg daily and metoprolol tartrate 50 mg q midnight and stopping diuresis. the patient responded very well to this regimen initially. however, after the patient had difficulties with hypercaclemia, he became more delerious and stopped eating and drinking. the patient became more hypotensive despite fluid and electrolyte repletion. pt had sustained afib with rvr and required transfer to icu on . he required neo gtt to maintain his map >60. digoxin loading was attempted; however, his hr did not respond. he was then tried on amiodarone. during this time, a family discussion was held and it was decided to transition goals of care to comfort. he actually converted into nsr upon transfer back to service, off neo, on . . #. hypoxia - the patient did not require oxygen during his previous admission, however, he was on 2l nc when trasfered from the osh. the patient was noted to become hypoxic, particularly at night, requiring increased amounts of oxygen (up to 4l nc) to keep his o2 sats greater than 90%. chest x-rays and ct-chest showed no evidence of infection, but did show new bilateral pleural effusions compared to imaging from his prior admission in addition to his previously known lung disease. interventional pulmonology was , however, they did not feel that the effusions were large enough to drain. lasix was used to try to remove some of the extra fluid and the patient's oxygen requirement did decrease such that his o2 sats were 95% or greater sitting up during the day, however, he continued to require oxygen while lying in bed and sleeping. a repeat echo was performed, however, it showed no change from his prior study appoximately a month earlier. pulmonology was consulted repeat x-ray showed improvement in the patient's effusions, and his oxygen requirement resolved on its own, likely a delayed effect of diuresis, requiring several days for fluid shifts to transpire. the patient also underwent pulmonary function testing due to concern for emphysema based on ct scan and prior smoking history and need for such testing if stem cell transplant were to be considereed. the patient was noted to have a very low dlco. it was felt that this was most likely multifactorial, arising from emphysema, underlying lung disease and scar from his prior pneumonia, and possibly chronic thromboembolic disease given his known dvts. medications on admission: neutraphos 2 grams tid metoprolol tartrate 100 mg reglan 10 mg po qidachs reglan 10 mg iv bid prn nausea protonix 40 mg daily acyclovir 400 mg po q8h fluconazole 200 mg po daily multivitamin, 1 tab daily flagyl 500 mg iv q8h zofran 8 mg q6h prn nausea simethicone mylanta 80 mg, 1 tab qid prn marinol 5 mg q4h prn nausea magnesium sulfate 1g iv q6h methadone 2.5 mg tid kcl 40 meq tid lidoderm patch 5% to back 12 hours on and 12 hours off filgrastin 300 mcg sc daily for anc < lovenox 60 mg q12h (held on morning of admission) discharge medications: none discharge disposition: expired discharge diagnosis: primary diagnoses: 1. diffuse large b cell lymphoma s/p 3rd cycle of eshap chemotherapy 2. thrombocytopenia secondary to chemotherapy 3. neutropenia secondary to chemotherapy 4. hypoxia secondary to pleural effusions 5. atrial fibrillation with rapid ventricular rate 6. deep venous thromboses 7. c. difficile colitis discharge condition: expired discharge instructions: none followup instructions: none md procedure: transfusion of packed cells transfusion of platelets diagnoses: acidosis thrombocytopenia, unspecified anemia of other chronic disease esophageal reflux unspecified pleural effusion atrial fibrillation other malignant lymphomas, unspecified site, extranodal and solid organ sites hypotension, unspecified intestinal infection due to clostridium difficile infection with microorganisms without mention of resistance to multiple drugs antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use pressure ulcer, lower back hypoxemia methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site hyperosmolality and/or hypernatremia backache, unspecified leukocytosis, unspecified hypercalcemia neutropenia, unspecified unspecified psychosis acute venous embolism and thrombosis of unspecified deep vessels of lower extremity pressure ulcer, stage iii other seborrheic keratosis 

Answer: The patient is high likely exposed to