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: heparin agents attending: chief complaint: monitoring s/p mechanical thrombectomy and extensive venous angioplasty le dvts by ir . major surgical or invasive procedure: mechanical thrombolysis/angioplasty of dvt w/ repositioning of ivc filter (, ) transfusion of 2u ffps and 2u prbcs xrt history of present illness: 78 y.o male h.o intradural extramedullary mass (adenocarcinoma) (originally presented as sudden back pain, progressively worsening ascending paralysis) s/p thoracic laminectomy t4-7 and mass resection , surgery complicated by hemorrhage resulting in paraplegia, s/p ivc filter for pe ppx. pt underwent attempted retrieval of ivc filter , however femoral and common iliac veins were seen to be thrombosed and procedure was aborted. pt went to rad onc today (brain/spine radiation) at whic time he was noted to have worsening scrotal and le edema and decision was made to have pt come in for thrombolysis to recannulize the femoral/iliac vessels with potential ivc filter retrieval/replacement. pt transferred to medicine for monitoring of hematuria, hct, monitor for pe. . of note, he has been on coumadin 4mg and dalteparin and inr was noted to be 3.5 preprocedure. . in ir pt had extensive thrombectomy with recanalization of thrombosis in popliteal, femoral, iliac, and ivc with mechanical device using angiojet and balloon angioplasty. there was good angiographic result with some residual thrombosis. no thrombolytics were used. his ivc filter was left in place. during the procedure, his sbps ranged from 120s-140s and hr in the 80s-90s. . initially, upon admission to the medicine service, sbp was 112/64. however, soon after being admitted to the medicine service he triggered for hypotension with blood pressure as low as 80/p. on the floor, he was also noted to be persistently tachycardic 104-108. a stat hct was sent and revealed a drop from 29.5 immediately post procedure to 23.6. he received 1l normal saline bolus with transient increase in sbps to 90s, then returning to high 80s. although b/l lower extremities were swollen, there was no clear e/o hematoma in popliteal regions nor in groin. t+s was sent and he was ordered for ffp and prbcs and transferred to the icu for further monitoring and care. . upon arrival to the micu a portable u/s showed no trauma to the popliteal veins in the popliteal fossa. . initally on the floor, the patient reported nausea which has since resolved, band-like numbness across abdomen (unchanged) and paresthesias of b/l le (unchanged.) he denied abdominal pain and leg pain, although sensation limited as above. otherwise, no fevers, chills, sob, cp, palpitations, abdominal pain, v/d/dysuria, +notable hematuria, -joint pains, -headache, -new paresthesias. past medical history: - recently diagnosed with adenocarcinoma (intradural/extramedullary). mets to brain (mult cystic enhancing lesions seeon on mri.) ct torso showing mult densities in the lungs, diffuse metastatic bony disease. thought to be from lung primary vs.prostate. - paraplegia (from hemorrhagic complication of thoracic laminectomy) - s/p ivc filter placement - prostate ca s/p xrt, horomonal therapy (approximately -) social history: the patient was last at a rehab facility. formerly lived at home with his wife. family very involved in his care. oldest son, () is his health care proxy. is a retired fisherman. no tobacco use. no ethanol use. family history: his mother died of blood dyscrasias, while his father died of an unspecified cancer. he has 6 brothers and 3 sisters and they are healthy. his 6 sons are healthy. physical exam: gen-lying in bed, nad, cooperative vitals-t 100.3, bp 112/64 hr 110, rr 18, sat 97% on 2l heent-nc/at, l.eye appears larger than r. perrla, eomi, anicteric, mmm. neck: no jvd, no lad chest-b/l ae no w/c/r heart-s1s2 rrr no m/r/g abd-+bs, +multiple ecchymotic areas ( fragmin?), soft, nt, nd, -guarding/rebound. groin-r.groin-no masses, no bruits, bandage c/d/i ext-no c/c +edema up to pelvis. +b/l ankle boots in place. 0/5 motor strenght, but sensation intact to touch. 1+palpable dp pulses, warm extremities. +compression stockings over popliteal area. neuro-aaox3, cn 2-12 intact, motor b/l ue. pertinent results: admit labs: ------------ 06:00pm wbc-6.0 rbc-3.22* hgb-10.0* hct-29.5* mcv-92 mch-31.1 mchc-34.0 rdw-12.7 06:00pm plt count-277 12:26pm pt-33.6* inr(pt)-3.5* 01:48am blood glucose-136* urean-18 creat-0.6 na-136 k-6.0* cl-103 hco3-28 angap-11 01:48am blood alt-29 ast-84* ld(ldh)-1258* alkphos-100 totbili-2.2* 01:48am blood calcium-7.9* phos-4.8* mg-2.1 03:21am blood hapto-40 01:09am urine color-yellow appear-cloudy sp -1.024 01:09am urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-1 ph-6.5 leuks-mod 01:09am urine rbc-* wbc->50 bacteri-mod yeast-none epi-0-2 01:09am urine castgr-0-2 casthy-0-2 1:09 am urine source: catheter. **final report ** urine culture (final ): pseudomonas aeruginosa. >100,000 organisms/ml.. staph aureus coag +. >100,000 organisms/ml.. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | staph aureus coag + | | cefepime-------------- 4 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s <=0.5 s imipenem-------------- <=1 s levofloxacin---------- 0.25 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s oxacillin------------- <=0.25 s penicillin------------ =>0.5 r piperacillin---------- 8 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=0.5 s . other labs: ------------ 11:22am blood cortsol-5.2 01:24pm blood cortsol-25.4* 04:37am blood psa-5.7* 04:20pm basic coagulation (fibrinogen, dd, tt, reptilase, bt) fibrinogen, functional 516* mg/dl 150 - 400 d-dimer 1699* ng/ml 0 - 500 04:20pm basic coagulation (fibrinogen, dd, tt, reptilase, bt) fibrin degradation products 0-10 ug/ml 0 - 10 heparin dependent antibodies positive comment: positive for heparin pf4 antibody by . (optical density 2.3) . pta venous 1:48 pm procedure and findings: after explaining the risks and benefits of the procedure, informed consent was obtained from the patient (after translation) and from his healthcare proxy (son). the patient was placed prone on the angiographic and both popliteal areas were prepped and draped in standard sterile fashion. a preprocedure timeout was performed. after injection of 1% lidocaine and using ultrasound guidance, access was gained into the right popliteal vein with a micropuncture needle. a 0.018 guidewire was advanced through the micropuncture needle into the distal superficial femoral vein under fluoroscopic guidance. a micropuncture needle was exchanged for a 4.5 french micropuncture sheath. venogram was obtained with injection of contrast through the micropuncture sheath, which demonstrated thrombosis extending from the popliteal vein to the femoral vein. a 0.035 bentson guidewire was advanced through the micropuncture sheath into the high ivc under fluoroscopic guidance. a micropuncture sheath was exchanged for a 6 french vascular sheath. a 5 french kumpe catheter was advanced into the iliac vein and svc and a venogram was obtained, which demonstrated thrombosis in the right iliac vein and ivc, below the ivc filter. after injection of 1% lidocaine and using ultrasound guidance, access was gained into the left popliteal vein with a micropuncture needle. a 0.018 guidewire was advanced through the micropuncture needle into the femoral vein. a micropuncture needle was exchanged for a 4.5 micropuncture sheath. a venogram was obtained with injection of contrast through the micropuncture sheath, which demonstrated thrombosis extending from the popliteal to femoral vein. a 0.035 wire was advanced through the micropuncture sheath into the high ivc under fluoroscopic guidance. a micropuncture sheath was exchanged for a 6 french vascular sheath. mechanical thrombectomy was performed from the ivc to both popliteal veins with the angiojet thrombectomy device. venogram after mechanical thrombectomy was obtained with injection of contrast through right vascular sheath, which demonstrated multiple stenoses/residual mural thrombosis of the left popliteal and left femoral vein. it was decided to do balloon dilatation from ivc to both popliteal veins. balloon dilatation was performed from both iliac veins to both popliteal veins with 6 mm x 4 cm balloons. after then, balloon dilatation was again performed from the ivc to both femoral veins with 8 mm x 4 cm balloons. venograms after balloon dilatation was obtained with injection of both popliteal veins sheaths, which demonstrated marked interval improvement of venous flow with small residual mural thrombosis. iliac venogram was then obtained through a 5 french omniflush catheter which was placed in the left common iliac vein, which demonstrated marked improvement in the thrombosis and venous flow from the iliac vein into the ivc. popliteal vein sheaths were removed and manual compression was held for 10 minutes until hemostasis was achieved. a compression dressing was applied at both popliteal vein puncture sites. moderate sedation was provided by administering divided doses of 25 mcg of fentanyl and 0.5 mg of versed throughout the total intraservice time of 55 minutes during which the patient's hemodynamic parameters were continuously monitored. complication: hematuria developed right after the procedure and is likely due to hemolysis from the angiojet thrombectomy. good hydration should be mantained and creatinine checked. impression: thrombosis involving the bilateral popliteal, femoral and iliac veins and ivc, below the ivc filter. successful recanalization of thrombosis in popliteal, femoral, iliac, and ivc with mechanical thrombectomy using angiojet and balloon angioplasty, with good angiographic result and some residual mural thrombosis. . ct low ext w/o c bilat 12:02 am ct of the abdomen with no iv contrast administration: the visualized portion of the lung bases demonstrate dependent atelectatic changes and a small bilateral pleural effusion. small axial hiatal hernia is also visualized. the visualized portion of the heart and great vessels appear normal. the liver, spleen, left adrenal gland, gallbladder, pancreas, common bile duct, stomach, and loops of small bowel and large bowel appear normal. the right adrenal gland contains an adenoma measuring 18 x 17 mm. both kidneys contain multiple hypodense lesions which most likely represents cysts. the aorta has normal appearance. the ivc stent is noted in the infrarenal region. contrast is still noted in ivc suggesting residual clot. both kidneys are excreting the contrast material. the patient demonstrates signs of fluid overload. ct of pelvis with no iv contrast administration: the bladder has thickened wall and contains a foley catheter. the prostate is normal in appearance. the rectum and sigmoid colon contain oral contrast. small amount of free fluid is noted within the pelvis. no evidence of retroperitoneal bleeding is visualized. ct of the lower extemity: there is significant amount of fluid accumulation within the scrotum and penis related to venous obstruction. diffuse fluid accumulation in soft tissues are noted. bone windows: no concerning lytic or sclerotic lesions are seen. impression: 1. no retroperitoneal bleeding is noted. 2. there is copious fluid accumulation in the soft tissues and most prominantly in the scrotum. this is most likely related to venous occlusion. persistent contrast in the venous system is most likely related to the residual clot. 3. right adrenal adenoma as described. 4 . axial hiatal hernia.. . liver or gallbladder us (single organ) 3:27 pm right upper quadrant ultrasound: the liver is normal in echotexture with no focal lesions. there is no intra- or extra-hepatic biliary dilation. the portal vein is patent with anterograde flow. the common duct measures 4 mm. there is no ascites. sludge layers within the gallbladder, with no echogenic gallstones identified. the gallbladder wall is not thickened, and the gallbladder is only mildly distended. there is no pericholecystic fluid. impression: 1. gallbladder sludge without evidence of acute cholecystitis. 2. normal hepatic echotexture. no evidence of biliary dilatation. . discharge labs: --------------- 07:20am complete blood count white blood cells 9.4 k/ul 4.0 - 11.0 red blood cells 3.85* m/ul 4.6 - 6.2 hemoglobin 11.8* g/dl 14.0 - 18.0 hematocrit 34.7* % 40 - 52 mcv 90 fl 82 - 98 mch 30.7 pg 27 - 32 mchc 34.1 % 31 - 35 rdw 13.9 % 10.5 - 15.5 basic coagulation (pt, ptt, plt, inr) platelet count 292 k/ul 150 - 440 07:20am basic coagulation (pt, ptt, plt, inr) pt 12.9 sec 10.4 - 13.4 note new reference range as of 12:00a ptt 30.3 sec 22.0 - 35.0 inr(pt) 1.1 0.9 - 1.1 07:20am renal & glucose glucose 102 mg/dl 70 - 105 urea nitrogen 16 mg/dl 6 - 20 creatinine 0.4* mg/dl 0.5 - 1.2 sodium 136 meq/l 133 - 145 potassium 4.2 meq/l 3.3 - 5.1 chloride 100 meq/l 96 - 108 bicarbonate 29 meq/l 22 - 32 anion gap 11 meq/l 8 - 20 chemistry albumin 2.8* g/dl 3.4 - 4.8 calcium, total 8.0* mg/dl 8.4 - 10.2 phosphate 3.9 mg/dl 2.7 - 4.5 magnesium 2.0 mg/dl 1.6 - 2.6 alanine aminotransferase (alt) 33 iu/l 0 - 40 asparate aminotransferase (ast) 18 iu/l 0 - 40 stool c. diff () - positive blood cx () - negative x 2 sets brief hospital course: 78 y.o man with recently diagnosed adenocarcinoma (unclear primary, lung vs. prostate likely) s/p t4-7 laminectomy c/b hemorrhage, resulting in paraplegia, s/p ivf filter, with increased le/scrotal edema today now s/p mechanical thrombolysis/angioplasty of dvt and repositioning of ivc filter. . 1) hypotension patient had decreased bp after procedure, necessitating icu transfer. likely related to peri-procedural complication given time course and acute blood loss. no clear source of aneurysm or hematoma b/l popliteal and right groin on bedside u/s performed by ir. ct scan done and did not show rp bleed. bp improved after fluid and blood transfusion (got 2u prbcs and 2u ffp). had cosyntropin stim test which did not show any evidence of adrenal insufficiency. bp fluctuated intermittently during course of hospitalization. he did receive intermittent doses of lasix (iv and po) which also affected blood pressure. on discharge, sbp was in mid-90s to low-100s. patient did not have symptoms of lightheadedness of dizziness. . 2) hematuria had hematuria post-procedure which is common occurrence due to jets in thrombectomy which can cause hemolysis. this subsequently resolved. hematuria later recurred after he received lepirudin (see below). he was seen by the urology service who recommended intermittent flushes or cbi (250-500cc up to twice a day as needed). upon discontinuation of lepirudin, hematuria resolved and further flushes were not needed. he will need follow up with urology after discharge. . 3) extensive lower extremity dvts/heparin-induced thrombocytopenia although ivc filter had been replaced and mechanical thrombectomy achieved some level of success, the patient had extensive residual clot burden from ivc filter to the popliteal veins. further interventions were discussed with interventional radiology. they felt that repeat mechanical thrombectomy would not be beneficial. only definitive treatment would be thrombolytics, however these would be contraindicated given brain mets. case also discussed with vascular surgery who did not feel there would be a surgical option. given the likely failure of coumadin (inr was therapeutic when clot developed), coumadin was stopped and the patient was placed on lovenox at the recommendation of the heme-onc service. a factor xa level was checked and was therapeutic. however, over the course of his lovenox therapy, the patient's platelet count decreased from 264 to 125 over the course of 8 days. lovenox was stopped and the patient was started on lepirudin and heparin dependent antibodies were sent off. the patient developed the hematuria (as above) on lepirudin, however his hct was stable. heparin antibody subsequently came back positive (optical density of 2.3 which is grossly positive). given these findings, the patient should never be given heparin products. he was switched over to fondaparinux, which he tolerated well (no evidence of a decrease in blood clots). . 4) lower extremity and scrotal edema this is secondary to extensive clot burden. legs and scrotum were elevated and teds were used. lasix was started to try to mobilize some fluid. although patient had good urine output with lasix, edema was essentially unchanged. lasix had to be intermittently stopped due to low blood pressures. he should continue with compression stockings and lasix as tolerated to help with the edema. . 5) metastatic adenocarcinoma - unclear primary (lung vs. prostate) w/ paraplegia mets involving brain, spine, bone. he completed his radiation therapy of the brain and spine and completed the . he was also continued on dexamethasone. a psa was checked and was 5.7. per report, it was <1 sometime last year. this was discussed with oncology, who did not necessarily feel this indicated recurrence of the prostate ca. the patient will need to follow up in thoracic oncology, the brain tumor center, and urology (either his primary urologist, dr. or urology at ). prior to discharge, he was seen by his neuro-oncologist, dr. who will also follow up with him as an outpatient. in discussing the case with dr. of radiation oncology, the plan will be to do a slow taper of the patient's dexamethasone over the next few weeks. he is currently on 1mg , and will be decreased by 0.5mg per week unless directed otherwise by the doctors in the tumor center. . 6) sacral decub/scrotal skin breakdown the patient had a stage ii sacral decubitus ulcer as well as some scrotal skin breakdown. he was seen by the wound care nurse who made recommendations on wound care which were implemented. . 7) urinary tract infection - mssa/pseudomonas he was diagnosed with a urinary tract infection and treated with a 2-week course of ciprofloxacin (last dose on ). . 8) anemia after his transfusion, the patient's hct remained stable between 34-36. . 9) c. diff colitis the patient developed diarrhea while on antibiotics. stool for c. diff was positive. the patient was started on flagyl 500mg tid for c. diff. he should remain on this until (2 weeks after last dose of cipro was given). the patient had intermittent passage of jelly-like stool, thought to be secondary to the infection. . 10) goals of care discussions held with multiple members of the family, including son , who is the health care proxy, regarding overall goals of care. the palliative care team was also involved. overall disease process/prognosis was also discussed with patient via the hospital interpreter. the patient will be discharged rehabilitation nursing center in . during the course of this rehabilitation and through further discussions with the patient's team of doctors , the family will decide about home hospice. this will be facilitated through the palliative care service here. medications on admission: tylenol mom fleet enema dulcolax supp celexa 10mg daily dexamethasone 1mg mvi colace 100mg fragmin units sc bid coumadin 3mg daily percocet 5/325 1 q4hprn protonix 40mg daily ambien 10mg qhs discharge medications: 1. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 2. dexamethasone 0.5 mg tablet sig: as directed tablet po as directed for 4 weeks: take 1mg for 7 days. then take 1mg in the morning and 0.5mg in the evening for 7 days. then take 0.5mg for 7 days. then take 0.5mg once daily for 7 days. then stop medication. 3. hexavitamin tablet sig: one (1) cap po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 6. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 7. petrolatum ointment sig: one (1) appl topical (2 times a day). 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 9. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 weeks: last dose on . 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 12. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 13. zolpidem 5 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 14. fondaparinux 7.5 mg/0.6 ml syringe sig: one (1) injection subcutaneous daily (daily). 15. furosemide 40 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<95. 16. ondansetron hcl (pf) 4 mg/2 ml solution sig: four (4) mg injection q8h (every 8 hours) as needed for nausea. 17. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 18. aquaphor ointment sig: moderate amount topical twice a day: dry tissue, forehead, left upper chest, b/l lower extremities. also to scalp as needed for discomfort. . discharge disposition: extended care facility: rehab discharge diagnosis: 1) lower extremity deep venous thrombosis 2) lower extremity and scrotal edema secondary to above 3) adenocarcinoma of unclear primary with lesions in lung, spine, and brain 4) urinary tract infection (mssa/pseudomonas) 5) stage ii sacral decubitus ulcer w/ skin breakdown of scrotum 6) prostate cancer 7) hematuria 8) c. diff colitis 9) hypotension - intermittent 10) scalp pain - likely secondary to xrt 11) heparin-induced thrombocytopenia discharge condition: afebrile, vital signs stable. still with significant lower extremity and scrotal edema. discharge instructions: you have an extensive blood clot going down most of the lower half of your body. due to this clot blocking the return of blood flow from your legs and scrotum, you have developed significant leg and scrotal swelling. attempts to remove the clot through mechanical means were only partially successful. the definitive treatment of thrombolysis can't be done because you have metastatic lesions in your head and would be at very high risk for bleeding. it appears that the coumadin you were previously taking did not work to prevent the spread of clots. therefore, you were switched to a diffent blood-thinning medications, lovenox. unfortunately, you developed a reaction to this medicine (decrease in your platelet counts - heparin induced thrombocytopenia), for this reason you were changed to another medication, fondaparinux. you will need to remain on this medication indefinitely. you will need to watch for signs of bleeding, such as blood in your urine or stool. . you were treated for a urinary tract infection with ciprofloxacin for 2 weeks. as a result of receiving necessary antibiotics, you developed c. difficile colitis (an infection in your colon). you were started on another antibiotic for this (flagyl). this antibiotic will need to be continued until (2 weeks after your cipro was stopped). . you completed the course of radiation therapy to the brain and spine. you will need to follow up in the brain tumor clinic as well as the thoracic oncology clinic. . call your doctor or return to the emergency room if you should develop chest pain, shortness of breath, worsening headache, blurry vision, increased weakness or numbness, or significant bleeding. followup instructions: thoracic clinic: . please call to set up a follow-up appointment. . brain tumor/radiation oncology: you will be contact by the brain clinic for a follow up appointment on . alternatively, if you do not hear from the clinic, you can call to schedule an appointment with dr. of radiation oncology and dr. of neuro-oncology. . primary care: dr. . . please call to arrange follow up after discharge from rehab. . urology: dr. . (. you will need to set up a follow up appointment with him to follow up on your hematuria (blood in urine), management of your foley catheter, and your elevated psa found during this hospitalization. alternatively, if you would like to consolidate all of your care at , you can schedule an appointment with dr. , (. . palliative care: . (. can call to further discuss options for palliative care. procedure: angioplasty of other non-coronary vessel(s) phlebography of femoral and other lower extremity veins using contrast material suture of cranial and peripheral nerves procedure on four or more vessels angiocardiography of venae cavae diagnoses: other iatrogenic hypotension abnormal coagulation profile urinary tract infection, site not specified acute posthemorrhagic anemia personal history of malignant neoplasm of prostate diaphragmatic hernia without mention of obstruction or gangrene secondary malignant neoplasm of brain and spinal cord methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site intestinal infection due to clostridium difficile other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation pressure ulcer, lower back other specified disorders of biliary tract personal history of venous thrombosis and embolism other postprocedural status headache encounter for palliative care anticoagulants causing adverse effects in therapeutic use secondary malignant neoplasm of lung acute venous embolism and thrombosis of deep vessels of proximal lower extremity other malignant neoplasm without specification of site secondary malignant neoplasm of bone and bone marrow paraplegia pseudomonas infection in conditions classified elsewhere and of unspecified site benign neoplasm of adrenal gland other venous embolism and thrombosis of inferior vena cava edema edema of male genital organs 

Answer: The patient is high likely exposed to