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: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from icu, patient originally presented with acute shortness of breath. major surgical or invasive procedure: p-mibi, gastric emptying study. history of present illness: mr. is a 74 year old male with a history of htn, dm2, esrd on hd with atrophic l kidney, who presented to the ed on with a chief complaint of dyspnea on his way to hemodialysis. the patient is a poor historian, and it is difficult to get a history from him even with an interpreter, however the following was obtained: he had last received his regularly scheduled hd on . patient denies any history of chest pain, palpitations, or change in diet (no high salt intake). he does describe some nausea, emesis, and lack of apetite for the last few months. about 1 week ago he noted increased peripheral edema, and on the night prior to admission he began having increased sob. he denies any fevers. he describes a recent weight loss secondary to his nausea and decreased apetite, however he is uncertain of how much. he may have had some mild abdominal pain, but this is only over the last few days. on presentation to the ed, he was afebrile, with bp 220/148, hr 103, rr 30s, saturating 94-97% on 100%nrb. he was placed on bipap and ntg drip with good response: rr decreased to 20s, bp decreased to 173/115, and the patient was transfered to the micu for further management of what was felt to be most likely a chf exacerbation based on physical exam findings of volume overload. no recent echo reports, however patient had a stress test in with 9.5 minutes of protocol, no ischemia or ekg changes. the patient was transferred to the micu for further management of his chf exacerbation. a cxr showed moderate chf with small bilateral pleural effusions. ekg was without st,t wave changes. he received hd with good response - normalization of bp, iv nitro drip was weaned. received second hd (day after admission to icu), and was subsequently transferred to the floors. past medical history: htn dm2 nephrolithiasis, s/p bilateral ureteral stents in esrd on hd (m,w,f) atrophic l kidney liver biopsy c/w granulomatous hepatitis h/o infected r ij permacath s/p removal 3/04 l forearm avg social history: patient denies ever drinking alcohol, smoking, or doing drugs. married, but no children. lives at home where he says he has plenty of support, but won't elaborate regarding who the support is. has difficulty with transportation to dialysis, and is very interested in acquiring this transportation. family history: difficult to elicit, even with translator. physical exam: vs: 96.2, p 76, bp 126/81, r 16. gen: african american male, resting comfortably in bed, nad. heent: anicteric sclera, , pearl, pterygium in r eye. neck: no jvd, supple, no lymphadenopathy. cvs: rr, normal rate, no m/r/g. lungs: rales b/l at the bases. abd: normoactive bs. mild ruq tenderness, worse with inspiration. no organomegaly. extr: 1+ bipedal edema extending up to knees. palpable radial, dp pulses b/l. pertinent results: wbc-13.4*# rbc-4.15*# hgb-14.2# hct-44.5# mcv-107*# mch-34.3*# mchc-31.9 rdw-13.3 plt ct-226 neuts-66 bands-0 lymphs-29 monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 03:30pm blood wbc-8.1 rbc-4.27* hgb-14.5 hct-42.0 mcv-98 mch-33.9* mchc-34.5 rdw-13.8 plt ct-240 07:10am blood neuts-55.7 lymphs-27.5 monos-11.6* eos-4.6* baso-0.7 pt-12.2 ptt-24.0 inr(pt)-1.0 glucose-190* urean-42* creat-7.5* na-135 k-4.5 cl-95* hco3-24 angap-21* calcium-9.7 phos-5.8* mg-2.2 07:35am blood glucose-143* urean-40* creat-6.7*# na-138 k-3.9 cl-95* hco3-29 angap-18 07:05am blood alt-74* ast-28 alkphos-204* totbili-0.5 07:10am blood alt-54* ast-22 alkphos-196* totbili-0.5 07:35am blood alt-32 ast-19 alkphos-192* amylase-228* totbili-0.5 ck(cpk)-213*, ctropnt-0.33* ck(cpk)-160, ck-mb-5, ctropnt-0.42* ck-mb-4 ctropnt-0.41* 07:10am blood lipase-84* 07:10am blood caltibc-231* vitb12-1102* folate-16.9 ferritn-1297* trf-178* 07:10am blood triglyc-139 hdl-82 chol/hd-2.7 ldlcalc-115 07:10am blood tsh-1.3 07:10am blood free t4-1.7 echocardiogram : left to right shunt across the interatrial septum consistent with a stretched patient foramen ovale or small atrial septal defect. left ventircular wall thickness was normal. the left ventricular cavity size is normal. resting regional wall motion abnormalities include distal anterior and septal apical hypokinesis, inferior hypokinesis/akinesis and basal inferoseptal hypokinesis with mild hypokinesis elsewhere. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild mitral regurgitation. mild pulmonary artery systolic hypertension. trivial/physiologic pericardial effusion. brief hospital course: the patient was transferred to the micu for further management of his chf exacerbation. a cxr showed moderate chf with small bilateral pleural effusions. ekg was without st,t wave changes. he received hd with good response - normalization of bp, iv nitro drip was weaned. received second hd (day after admission to icu), and was subsequently transferred to the floors. 1) chf - the patient was still mildly volume overloaded on pe upon arrival to the floors, with mild bipedal edema and rales at the right base, he received hemodialysis m,t,w with more than 11 kg fluid removed, and is without signs of failure on physical exam currently. as to the cause of the chf exacerbation, renal feels that patient may not have been having enough fluid removed at hd since patient has recently lost weight, and therefore dry weight may have been overestimated, and therefore they weren't removing as much fluid as they should have been. they do not feel that the patient needs to be on lasix, as they will remove fluid via hd, which he will continue as an outpatient m,w,f. cardiac enzymes were ordered to rule out a myocardial infarction as a cause of his chf, with troponin t elevated, however in this patient with renal failure, a tni would be more useful. ck-mb has been wnl. we also ordered an echocardiogram in order to evaluate his pump function, which showed diffuse hypokinesis of the left ventricle, as described in the pertinent results section. as the patient has never had a stress test before, we ordered a p-mibi in order to further evaluate his cardiac risk, which was a poor study secondary to failure of the patient to achieve greater than 60% of his maximum heart rate, and was stopped after 4 minutes. in light of this, the interpretation of perfusion defects is somewhat unreliable. no perfusion defects were seen on this limited study. what was able to be determined, however, was that his ef was only 26%, indicating a cardiomyopathy. cardiology recommends a dobutamine echo as an outpatient to further evaluate his coronary vasculature. we started him on aspirin 325 mg po qday. 2) esrd - patient currently receiving hd and being followed by renal. most likely secondary to his dm, and htn. we felt that addition of an ace-i would be beneficial in this patient with diabetes, chf, and htn, and started lisinopril 2.5 mg qday, discontinuing his calcium channel blocker in order to allow for this addition. we also started him on nephrocaps 1 tab po qday, phoslo 2 tabs tid for phosphate binding, and renagel. we continued his epogen, and held a couple of doses secondary to normal hematocrit. he continued to put out some of his own urine. 3) htn - patient's b.p. was elevated in the micu, however has been well controlled on the floors, and was responsive to fluid removal. as discussed above, we discontinued his calcium channel blocker (nifedipine cr 30 mg po qday), and started lisinopril 2.5 mg po qday. we also decreased his atenolol to once a day in order to add the lisinopril. 4) lipids - this patient was continued on lipitor 10 mg po qd. we obtained a lipid profile to help evaluate his cardiovascular risk, which showed: chol 225, ldl 115, tg 139, hdl 82, ratio 2.7. this is a surprisingly good lipid profile, with quite high hdl, and therefore his lipitor dose was maintained and not increased, especially in light of his mild transaminitis. 4) nausea/abdominal pain - the patient seems to have been having some nausea, with decreased apetite and weight loss prior to this hospitalization. he says these have resolved since admission, however, and may have been related to uremia. a gastric emptying study was performed which was normal, making gastroparesis less likely in this diabetic patient. of note, the patient was noted to have changes consistent with chronic pancreatitis on a mri of the abdomen in , and this may be the cause of his recurrent nausea and vomitting. the patient is being scheduled for an appointment with dr. in gastroenterology to further evaluate his nausea and vomiting. he may want to consider a trial of pancrelipase. 5) granulomatous disease: the patient has a history of granulomatous hepatitis on liver biopsy, and in light of his nausea, we did a hepatic/biliary ultrasound which showed some heterogeneity of the liver, with no distinct masses, no choledocholithiasis or cholecystitis. his ast and alt were found to be 28, and 74, respectively, on , and 22, 54 on , with an alp > 200. he has had a transaminitis in the past, which was what brought him to the attention of gastroenterology. his prior course: a hepatic ultrasound on showed a heterogeneous liver with multiple small nodules and cirrhosis versus metastatic disease as the primary cause, as well as bilateral renal calculi. a follow up mri on showed a heterogeneous liver, and a liver biopsy revealed a granulomatous hepatitis. additionally, this patient has been found to have a polyclonal hypergammaglobulinemia, and a ct of the abdomen/pelvis on showed multiple buttock granulomas. the patient has also been found to have bilateral hilar and mediastinal lymphadenopathy on ct consistent with a diagnosis of sarcoidosis. in summary, it seems most likely that this is a patient with sarcoidosis, when taking all evidence into account: bilateral hilar and mediastinal lymphadenopathy, restrictive pfts, granulomatous hepatitis, buttock granulomas, perhaps the chronic nephrolithiasis, and now with a cardiomyopathy on echo and stress test. we discussed the risks versus benefits of steroid therapy in this patient in light of the possible myocardial involvement (though we do not know that this is due to sarcoidosis), however even if the myocardial involvement were due to sarcoidosis we do not believe steroids would be indicated. not only have steroids not been conclusively shown to be effective in sarcoidosis, but they also would not improve any fibrosis that has already developed causing the organ dysfunction that he has. most importantly, this is a 74 year old male with diabetes, hypertension, and renal failure - steroids could exacerbate his diabetes, his hypertension, and worsen his volume overload. it is therefore recommended to simply continue observation. a dobutamine echo has been recommended by cardiology to further evaluate whether or not this cardiomyopathy is due to ischemia or another process (such as sarcoidosis). if it is due to ischemia, he may be a candidate for a cath. dr. should make these arrangements should he deem them appropriate. 5) dm - his diabetes was managed with an insulin sliding scale while in the hospital, and finger stick readings were generally less than 200. he seemed to have in the 200s every night at 10 pm, and the patient says that he does take medication for his diabetes at home, however he was unable to tell us what it was. we continued his insulin sliding scale, and he will be restarted on his outpatient diabetes medications by dr. when he sees him next week. 5) gu - we continued this patient's detrol while in the hospital. he had a couple of episodes of incontinence after we removed the foley catheter that he had while in the micu. a ua revealed both yeast, and bacteria, and we know he has had persistent yeast in the urine in the past. we started a course of levaquin, renally dosed, to treat the uti. he received a loading dose of 500 mg while in the hospital, and will continue 250 mg po q 48 hours after leaving the hospital, his second dose being tomorrow (). he has been asymptomatic. 6) prophylaxis: he was given subcutaneous heparin tid. 7) pt: the patient was able to walk up and down 2 flights of stairs, and down the hallway without assistance. he took them slowly and carefully, somewhat weakened from the last few days of bedrest, though not unsteady. he feels ready to go, and has a wife at home for support. in summary: more than 11 kg of fluid removed via hd this admission. chf exacerbation resolved. this patient should most likely have a dobutamine echocardiogram set up as an outpatient. he should also have an appointment with dr. set up (i am unable to do this now as it is the weekend) - i am not sure if he will be able to do this on his own - maybe dr. can help to facilitate this. he will continue dialysis m,w,f. he is on a 14 day course of levaquin (7 doses) for a uti. he was started on lisinopril. his ccb was stopped, atenolol was decreased to qday. he was started on aspirin. an echo and stress test showed diffuse left ventricular hypokinesis, most likely a cardiomyopathy. a diagnosis of sarcoidosis is strongly suspected after reviewing all of the information, however would not start steroids. medications on admission: atenolol 50 mg detrol 4 mg qhs humalin lasix 80 mg qod on non-hd days nifedipine 30 mg po qd protonix 40 mg po qd lipitor 10 mg po qd discharge medications: 1. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po qd (once a day). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. sevelamer hcl 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). disp:*90 tablet(s)* refills:*2* 5. tolterodine tartrate 4 mg capsule, sust. release 24hr sig: one (1) capsule, sust. release 24hr po at bedtime. disp:*30 capsule, sust. release 24hr(s)* refills:*2* 6. atenolol 50 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 7. lisinopril 5 mg tablet sig: 0.5 tablet po qd (once a day). disp:*15 tablet(s)* refills:*2* 8. levofloxacin 250 mg tablet sig: one (1) tablet po every other day for 14 days: 7 doses. disp:*7 tablet(s)* refills:*0* discharge disposition: home with service facility: family & services discharge diagnosis: chf exacerbation. esrd. dm2. likely sarcoidosis. discharge condition: stable discharge instructions: take all of your medicines as directed. do not take your nifedipine (procardia) anymore. take atenolol only once a day. new medications: lisinopril, aspirin. take levofloxacin (levaquin) every other day for a total of 7 doses. return to the hospital if you become short of breath again. see dr. next wednesday () at 3:15. followup instructions: provider: , . next wednesday () at 3:15. call to change. gastroenterology: . call to make an appointment. procedure: hemodialysis diagnoses: urinary tract infection, site not specified congestive heart failure, unspecified sarcoidosis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other specified forms of chronic ischemic heart disease chronic pancreatitis diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled 

Answer: The patient is high likely exposed to