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: no known allergies / adverse drug reactions attending: chief complaint: nausea, vomiting major surgical or invasive procedure: pericardial window history of present illness: pt is a 48yo man with h/o rcc s/p right nephrectomy , with known brain, lung, and cardiac mets, on sutent chemotherapy and recently completed whole brain radiation, also with recent pericardial effusion and tamponade requiring emergent pericardial window, now p/w two weeks of nausea, vomiting, dry heaves, as well as progressively worsening generalized fatigue, weakness, and exertional dyspnea. he has also had associated headache and palpitations. he denies any abdominal pain or change in his bowel habits, or fevers or chills. he has noted his skin to be yellowing, which he attributes to his sutent; he also describes darkening yellow of his urine and lightening of the color of his stools, but denies acholic stools. he also denies any dysuria or hematuria, or melena or brbpr. the symptoms started 1-2 days prior to and have been progressively worsening since. he was unable to tolerate pos, so he went to his local ed, where he was treated with iv fluids and discharged home with a prescription for anti-emetics. however, given his continued symptoms, he was referred back to his local ed for evaluation of possible increased intracranial pressure, bowel obstruction, or infection, as the source of his symptoms. evaluation there revealed elevated lfts with transaminases in the 300s, rising ldh to the 500s, new and enlarging frontal brain mets on head ct, and new lung mets on chest/abdominal ct. he received decadron 10 mg and was transferred to ed for further evaluation. in ed, vs: temp 96.4f, bp 115/88, hr 85, r 17, sao2 95% ra. labs were notable for wbc 3.3 (78.5% pmns), hgb 8.5 / hct 26.5, plt 63; ptt 40.2, inr 1.8; na 132, hco3 21; alt 363, ast 269, alk phos 199, tbili 0.9, and lipase 57. his osh head ct was reviewed by radiology, with preliminary read showing "persistent but decreased right parietal edema and stable-appearing left frontal edema with interval resolution of right parietal post-operative changes. no evidence for new acute intracranial hemorrhage. mr is more sensitive for evaluation of known metastases and evaluation for new metastases." his osh abd/pelv ct is being loaded to radiology. he is admitted for further care. pt has no prior h/o liver disease, although he endorses a previous "nicked bile duct" at the time of his nephrectomy in . no recent sick contacts, travel, or uncooked food exposures. he denies any recent acetaminophen or other ingestions, including prescription or recreational drugs, otc meds, herbal meds, vitamin or hormone supplements. no significant etoh history, and denies ever using ivdu or intranasal drugs. no tattoos or piercings, or sexual exposures. no family history of liver disease. ros: as per hpi. also endorses ble swelling since stopping the lasix he was prescribed after his pericardial window, and occasional epistaxis over the last 1-2 weeks, left > right. otherwise negative. past medical history: oncologic history: renal cell carcinoma, clear cell histology stage iv - with right upper quadrant pain. at that time he underwent an ultrasound consistent with cholecystitis and also identification of a renal mass. subsequently, underwent a ct scan in roughly showing a 7.5-cm mass in the lower pole of the right kidney, two other solid lesions in the right kidney as well. at that time there was no evidence of distant metastatic disease. - he underwent cholecystectomy for his acute cholecystitis and roughly one month after cholecystectomy he underwent a right radical nephrectomy with dr. , which was complicated by injury to the bile duct necessitating transfer to for bile duct repair, which was successful. - r. radical nephrectomy showed three separate lesions consistent with clear cell carcinoma. dominant lesion was 6.5 cm, the other two were 2.3 and 1.2 cm respectively. renal cell carcinoma grade . margins were negative. one lymph node was negative as well. - when he developed symptoms of cough and exertional shortness of breath, improved with asthma tx, no imaging. - he presented with similar symptoms and was treated with prednisone and inhalers for a suspected possible asthma flare. - surveillance ct showed the presence of a small amount of pleural fluid on the right side. in addition, there was a lesion in the left kidney that had actually decreased in size from 2.7 to 2.1 cm and another lesion in the left kidney that had increased in size from 9 mm to 1.7 cm. the nature of these lesions was not entirely clear. also, noted was pleural thickening and nodularity on the right lung. - doe and cough, cxr showed a large right pleural effusion. he had a 5-liter thoracentesis, which was revealed negative cytology. - ct showed numerous pleural based masses as well as remaining pleural fluid and he was referred to dr. and dr. in . - underwent thoracoscopy, biopsy. biopsies confirmed the presence of metastatic clear cell renal cancer positive for napsin-a, vimentin and pan-keratin. negative for ck7, ttf-1 and ck20. - c1w1 hd il-2, received doses, complicated by shock, volume overload, asthma flare. - c1w2 hd il-2, received doses complicated by shock, volume overload, arf. - week 7 ct with stable disease - week 11 ct with reduction in size of mets - c2w1 received doses, with 6 doses held due to development of shock and hypotension requiring pressor support. - c2w2 received 4 of 14 doses with doses held related to shock. - c2w7 ct with decreased pleural based mets, new concern for rv mass. this was confirmed on echo showing 5.4 cm x 2.4 cm rv mass. cardiac with similar findings. - c2w11 ct with stable disease, unchanged cardiac mass - cardiac with increased intracardiac met size, otherwise stable disease. - : ct showed progressive disease - c1 sunitinib 50 mg po daily 4 weeks on 2 weeks off, tolerated well with mild diarrhea only - c2 sunitinib 50 mg po daily 4 weeks on 2 weeks off, tolerated well with mild diarrhea and mild neuopathy - ct torso with stable to decreased size of the numerous pleural-based metastases. start c3 sunitinib 50 mg po daily 4 weeks on 2 weeks off - started sunitinib 50 mg po daily 4 weeks on 2 weeks off - presented with intractable nasuea. found to have bleeding brain mets. - resection of bleeding mets revealed a focus of residual tumor within the hemorrhage - showed progression of multiple additional metastatic lesions involving the bilateral frontal and left occipital lobe - ct torso with significant progression of disease. multiple pleural-based enhancing necrotic lesions have all increased in size. all target lesions have increased in size. progression of multiple lung nodules with multiple new nodules seen. increased right ventricular mass. new small pericardial effusion. new mediastinal lymphadenopathy. small nodule adjacent to the inferior portion of the liver which may represent peritoneal implant. multiple soft tissue nodules within the anterior abdominal wall, most consistent with metastatic disease. - whole brain radiation - developed shortness of breath and palpatations, found to have moderate to large pericardial effusion, tamponade requiring emergent pericardial window. other past medical history: - back surgery to l5-s1 in , with no hardware, done at hospital in - tonsillitis as a child - history of pneumonia as a child - history of cholecystectomy in - history of questionable bronchitis in and , which may have reflected actual disease recurrence - depression - gerd social history: lives with his partner. worked as a mortgage banker and has been unemployed and on disability since . former smoker, 15 pack year hx, quit . social etoh, denies illicits. family history: - mother: ra, dm, hypothyroidism - father: unknown to patient - daughter: hodgkin's lymphoma age 19 physical exam: vs: temp 96.4f, bp 106/78, hr 98, r 18, sao2 98% ra general: wa man in nad, comfortable, appropriate heent: nc/at, perrl/eomi, sclerae anicteric, dry mm, op clear neck: supple, no lad or thyromegaly lungs: decreased bs at bases bilat, o/w cta heart: rrr, nl s1-s2, + harsh systolic murmur throughout precordium abdomen: +bs, soft/nd, + mild ttp in ruq w/o rebound/guarding, no palpable masses or hsm extrem: wwp, 1+ ble edema to above ankles skin: no concerning rashes or lesions, no jaundice pertinent results: labs: wbc 3.3 (78.5% pmns), hgb 8.5 / hct 26.5, plt 63; ptt 40.2, inr 1.8; na 132, k 3.8, cl 98, hco3 21, bun 19, cr 1.2, gluc 116; alt 363, ast 269, alk phos 199, tbili 0.9, lipase 57, albumin 3.4 imaging: osh abd/plv ct: wet read pending osh ecg: nsr @ 85bpm, na/ni, rbbb morphology, non-ischemic st-segment changes precordially, no significant change from prior dated . :ct head w/o contrast (from osh)impression: persistent but decreased right parietal edema and stable-appearing left frontal edema with interval resolution of right parietal post-operative changes. mr is more sensitive for evaluation of known metastases and evaluation for new metastases. . abdominal u/s: no evidence of biliary dilation, solid metastases in the liver, or portal vein thrombus. . : cardiac echo: large circumferential pericardial effusion with echo findings suggestive of early tamponade physiology. large right ventricular mass causing a mild functional tricuspid stenosis. mildly dilated ascending aorta. normal left ventricular systolic function. large left pleural effusion. compared with the findings of the prior study (images reviewed) of , the pericardial effusion is now large with findings suggestive of early tamponade physiology. clinical correlation advised. . cxr: previously visualized endotracheal tube and nasogastric tube have since been removed. again visualized is evidence of nodular pleural thickening bilaterally but more prominent on the right in keeping with pleural metastases. bilateral pleural effusions, small to moderate on the right and moderate on the left, persist. cardiomediastinal silhouette remains moderately enlarged and suggestive of a persistant pericardial effusion but stable. retrocardiac and left lower lobe opacity persists and is likely representative of a combination of the left pleural effusion and left basal atelectasis. there is, however, no evidence of new -dation or pneumothoraces. brief hospital course: a/p: 48yo man with metastatic rcc s/p nephrectomy, previously on sutent for brain, lung, and cardiac mets, s/p wbxrt and recent emergent pericardial window, initially presented with two weeks of nausea, vomiting, fatigue, and weakness, found to have progressive disease and reaccumulation of pericardial effision s/p repeat window . . #pericardial effusion/tamponade s/p repeat window large pericardial effusion seen on echo with consideration for early tamponade. patient with previous pericardial window with ct surgery. patient had repeat pericardial window on with subxyphoid approach. the effusion was loculated, so all fluid could not be removed. on the drainaige was minimal, so the drain was removed. significant oozing from site required holding anticoagulation and suture placement. he was stable after suture placement without further oozing and restarted on enoxaparin and asa. he will continue gentle diureses every other day as outpatient for one week pending further evaluation by his primary oncology team in the outpatient setting. . #rcc with multiple metastasis including the brain with resulting cerebral edema. continued decadron 4mg q6 with taper as outpatient. keppra for seizure prophylaxis. sutent discontinued as disease progression.on lovenox and asa for cardiac mass and prevention of thromboembolism. these were held briefly for suture placement needed for oozing from his pericardial surgical wound. discussions with the patient's primary oncology team , dr and dr . for now plan is to hold all treatments and when stable he will return to clinic for further discussion of potential treatments if performance status improves. palliative care consulted. . # right ventricular metastasis requiring anticoagulation: enoxaparin & asa held briefly for suture placement needed for oozing from his pericardial surgical wound. . #transaminitis - likely a congestive hepatitis due to the pericardial effusion and tr due to a known rv mass. lft's were trending down at discharge and will be monitored as an outpatient. . # nausea/vomiting: well-controlled currently with anti-emetics. continued prn anti-emetics with ativan. reglan and compazine held due to interaction with citalopram. . #hyperglycemia - secondary to steroids. minimal, covered by insulin sliding scale as an inpatient that was discontinued at discharge. . # anemia: stable, likely myelosuppression and blood loss. his labs indicate possible iron deficiency so will start on trial of ferrex oral supplement daily as an outpatient. require transfusion shortly. . # thombocytopenia: likely myelosuppression. he is stable. will follow as outpatient. . code: full. medications on admission: - sutent - furosemide 20mg daily x7 days (completed) - kcl 20meq po daily x7 days (completed) - levetiracetam 500mg po bid - enoxaparin 90mg sq - metoprolol 25mg po tid - hydromorphone 2-4mg po q4hrs prn pain - gabapentin 300mg po qhs - citalopram 10mg po daily - lorazepam 1mg q6hrs prn nausea, anxiety - albuterol inhaler - tiotropium 18mcg inhalation daily - butalbital-acetaminophen-caff tid prn headache - pantoprazole 40mg q12hrs - compazine 5mg q6hrs prn nausea - reglan prn nausea - docusate 100mg po bid - loperamide prn diarrhea - decadron 2 mg discharge medications: 1. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. enoxaparin 100 mg/ml syringe sig: ninety (90) mg subcutaneous (2 times a day). 3. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 4. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 4-6 hours. 6. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) inhalation inhalation once a day. 7. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: tablets po three times a day as needed for headache. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold for loose stools or diarrhea. 9. ativan 1 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea, anxiety, insomnia. disp:*90 tablet(s)* refills:*0* 10. dilaudid 2 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. disp:*60 tablet(s)* refills:*0* 11. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 12. dexamethasone 2 mg tablet sig: two (2) tablet po every eight (8) hours for 2 days: then take two tablets every 12 hours for 2 days, then take 1 and 1/2 tablets every 12 hours for 2 days, then take 1 tablet every 12 hours for 2 days. disp:*40 tablet(s)* refills:*1* 13. bactrim 400-80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 14. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 15. lasix 20 mg tablet sig: one (1) tablet po every other day for 3 doses. disp:*6 tablet(s)* refills:*0* 16. ferrex 150 150 mg capsule sig: one (1) capsule po once a day. disp:*30 capsule(s)* refills:*2* discharge disposition: home with service facility: vna and hospice discharge diagnosis: pericardial effusion with tamponade renal cell cancer with metastases including brain mets with edema and cardiac mass requiring anticoagulation low platelets elevated liver function tests nausea and vomiting high blood sugar discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for nausea, vomiting, fatigue, and weakness and were found to have reaccumulation of the fluid around your heart. you underwent a repeat pericardial window surgery to drain this fluid which you tolerated well except for oozing of blood at the operative site requiring placement of a surgical . because of your bleeding, your enoxaparin blood thinner and aspirin were held until the bleeding stopped. your liver function tests were elevated but are returning to normal range now. this was probably due to the fluid around your heart. . you should call dr. office on tuesday for a follow up appointment at ( . the following changes have been made to your medications: stop metoprolol (toprol-xl) stop sunitinib (sutent) stop metaclopromide (reglan) stop prochlorperazine (compazine) stop pantoprazole (protonix) decrease fursemide (lasix) to 20 mg every other day for 3 doses. do not take your first dose at home until tuesday . decrease potassium to 20 meq every other day for 3 doses. do not take your first dose at home until tuesday . start famotidine 20 mg twice daily start bactrim one tablet daily start ferrex iron pill daily followup instructions: you should call dr. office on tuesday for a follow up appointment at ( . department: cardiac surgery when: tuesday at 1:45 pm with: , md building: lm campus: west best parking: . garage . department: neurology when: monday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: radiology when: monday at 10:35 am with: radiology building: campus: east best parking: garage procedure: pericardiotomy closure of skin and subcutaneous tissue of other sites pericardiotomy closure of skin and subcutaneous tissue of other sites diagnoses: esophageal reflux adrenal cortical steroids causing adverse effects in therapeutic use secondary malignant neoplasm of other specified sites depressive disorder, not elsewhere classified nausea with vomiting secondary malignant neoplasm of brain and spinal cord cerebral edema antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use encounter for palliative care secondary malignant neoplasm of lung drug induced neutropenia personal history of malignant neoplasm of kidney other specified diseases of pericardium hepatitis, unspecified other abnormal glucose anemia in neoplastic disease cardiac tamponade other pancytopenia 

Answer: The patient is high likely exposed to