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: nitroglycerin attending: chief complaint: mental status changes major surgical or invasive procedure: none history of present illness: hpi: 63 yo metastatic carcinoid, htn, hyperlipidemia, s/p recent admission to (d/cd ) who presents with altered mental status. pt was admitted to with doe and orthopnea. pt had a rll pna with b/l effusions (transudative on tap) and chf. he was found to have a decreased ef to 35-40%, and p-mibi showed moderate reversible defects in the apex and septum. cardiac catheterization on showed mild coronary artery disease (prox rca 40%, mid-lad 50%, 20% stenosis at d2), elevated rv and lv filling pressures, severely depressed ef, moderate pulm htn, mild aortic stenosis (mean gradient 10) with a restrictive defect. course was complicated by arf secondary to overdiuresis as well as contrast nephropathy, and shock liver. . pt was transferred to rehab from . he developed some altered mental status and confusion on . he also was found to be hypoxic yesterday to 80s on ra with improvement with diuresis. today, pt desatted to 80% at rehab, "was blue in the face", and had altered mental status. he was transferred to . head ct report showed central and peripheral atrophy, though no mass or hemorrhage. pt was then transferred here as most of his care is here. he was noted to be a&o x 2 initially in ed, then x 0. he was able to speak small amounts and follow commands initially. . in ed, vs: t: 101.6, hr: 94, bp: 126/52; rr:17; o2: 88ra, 100 4l. an lp was performed and pt was given ceftriaxone 2 grams iv x 1, vancomycin 1 gram iv x 1, dexamethasone 13.5 mg iv x 1. initial abg 7.55/29/123/26. . of note, per daughters report, pt had confusion, paranoid ideations in days prior to d/c from (no d/c summ yet). also with this at rehab. never had this before. past medical history: 1. metastatic carcinoid tumor, dx'ed , was on a study drug for a year and a half (ended about a year ago) and was on octreotide for a few months earlier this year but stopped because of diarrhea 2. hypertension 3. hyperlipidemia 4. carotid endarterectomy 5. depression/anxiety 6. cellulitis 4 weeks ago, given keflex iv at , now resolved 7. dm2/prediabetic state: random blood sugar was high, was on glyburide for a brief time but made his sugars low so stopped 8. anxiety attack (collapsed), diagnosed in as mi 9. basal cell carcinoma (chest, low back, mohs on cheek and ) social history: lives alone, has two daughters distant tobacco use (25 pack-years, quit 30 years ago), distant etoh use (quit 28 yrs ago), no drugs family history: early cad physical exam: pe: t:99.3; bp: 124/46; hr: 72; rr: 33; o2: 99 3l gen: unresponsive; can follow some verbal command heent: right pupil >left ~5:4 cm. reactive to light. corneal reflexes intact. when light is shined in eye, eyes deviate to the left upperward direction. neck: jvd ~8 cm to earlobe. cv: iii/vi systolic murmur best llsb lungs: ?crackles at bases anteriorly. good air movement. abd: midline scar. ecchymoses. +small masses under scar ext: no edema. dp 2+ neuro: as per heent. pt able to wiggle toes when asked. he is nonverbal and cannot follow all commands. cn unable to be tested. cannot follow command. +b/l clonus in le. babinski: left upgoing? right downgoing; patellar reflexes 3+. biceps, brachio . pertinent results: radiology: cxr- cardiac silhouette enlarged. b/l hilar fullness. b/l pleural effusions. retrocardiac opacity in lll. . persantine mibi -moderate reversible defects in the apex and septum. hypokinesis of the septum and apex with a calculated ejection fraction of 42%. transient ischemic dilatation of the left ventricle. . blood: 01:54pm neuts-76.5* lymphs-18.8 monos-4.0 eos-0.3 basos-0.4 01:54pm wbc-10.2 rbc-3.72* hgb-11.4* hct-35.3* mcv-95 mch-30.7 mchc-32.4 rdw-15.0 01:54pm alt(sgpt)-57* ast(sgot)-35 alk phos-105 amylase-44 tot bili-2.5* 01:54pm glucose-112* urea n-42* creat-1.7* sodium-135 potassium-4.9 chloride-96 total co2-24 anion gap-20 02:04pm lactate-3.2* 02:04pm po2-123* pco2-29* ph-7.55* total co2-26 base xs-4 03:30pm ammonia-41 . 06:03am blood wbc-7.8 rbc-3.51* hgb-10.6* hct-33.8* mcv-96 mch-30.2 mchc-31.4 rdw-15.6* plt ct-218 05:53pm blood k-4.2 06:03am blood glucose-107* urean-62* creat-1.6* na-137 k-4.5 cl-99 hco3-27 angap-16 11:32pm blood alt-22 ast-22 ld(ldh)-134 alkphos-75 amylase-25 totbili-0.9 05:50am blood ck-mb-notdone ctropnt-0.01 probnp-* 11:32pm blood albumin-1.9* mg-2.4 uricacd-7.3* 08:28pm blood albumin-3.5 calcium-9.1 phos-5.7* mg-1.9 08:28pm blood osmolal-297 05:16am blood tsh-10* 06:03am blood t4-4.7 t3-42* calctbg-0.98 tuptake-1.02 t4index-4.8 free t4-0.8* 06:59am blood type-art temp-37.7 po2-86 pco2-43 ph-7.38 calhco3-26 base xs-0 intubat-not intuba 08:22am blood lactate-2.2* . csf: 04:35pm cerebrospinal fluid (csf) wbc-0 rbc-4* polys-0 lymphs-75 monos-25 04:35pm cerebrospinal fluid (csf) protein-35 glucose-73 ld(ldh)-47 . . brief hospital course: brief overview: 63 yo male with metastatic carcinoid, htn, dm, chf, recently discharged from after prolonged course pneumonia, admitted to the icu with ms changes, now with improving mental status but continued edema and s/s heart failure r>l thought to be from carcinoid heart. the patient was transfered to the floor from the icu as his mental status improved. he was treated with diuretics for heart failure, placed on telemetry, electrolytes monitored, and had good uop after an initially poor uop. the patient appeared to be doing well and then went into v tach, v fib, and eventually died after a prolonged resuscitation attempt. . 1. mental status change - the differential diagnosis of etiology of encephalopathic state was thought to include serotonin syndrome, underlying pneumonia and bacteremia and acute renal failure (consistent with asterixis). encephalitis/ meningitis was initially entertained, but was thought to be unlikely as csf was negative. the patient was found to becteremic by blood cx on ( positive gpc). the pt was covered with vancomycin. the cultures turned out to be growing mrse and vancomycin was continued. the patient remained afebrile and cultures thereafter remained negative. ssri was stopped to prevent worsening of seratonin state. ativan was initially used on the floor to sedate the patient when he was agitated/anxious, however this was held after one day as it was noted to increase his sedation/confusion. as the patient diuresed, infection cleared, and meds were held, he became more oriented and more alert. whereas he had some paranoia regarding cia agents on admission to the icu and in the day prior, these delusions resolved on transfer to the floor. . 2. fluid status- the patient was known to have an ef of 35% on a prior echocardiogram. he had received a total of 5l of fluid in the icu to support pressure working under the assumption that the patient was intravascularly dry but total volume overloaded. repeat echo showed an ef at this hospitalization of 20-25%. severe tr and elevated r-sided pressures were thought to be from carcinoid heart. his lungs remained somewhat dull to ausc/percussion, but he exhibited no crackles. based on his large jvd and edema and these lung findings, it was thought that he continued to have the r heart failure physiology seen on echo at this hospitalization and on cath at the past hospitalization. on the floor, he was anxious initially and received ativan prn initially. due to sedation effect, this was held starting on . shortly after arriving on the floor, his breathing took on - pattern and it was felt that he was volume overloaded both intra and extra-vascularly. he was diuresed with iv lasix at increasing doses with poor response. the cardiology team was consulted and suggested initiation of iv hydral and nitrates. these were started at low doses to increase forward flow. the doses were titrated up over two days, as was lasix until uop increased. the pt was oob to chair on with help from pt. he was mentating well and continued to diurese. goal diuresis was 0.5-1 l net negative per day. by he had reached that goal with fluid restriction in place. labs were monitored to check electrolytes during diuresis. the pt was put on telemetry to monitor cardiac rhythm given extensive heart failure. on the night of , the patient went into a poorly tolerated vt which quickly degenerated into v fib. a code blue was called and resuscitation was attempted unsuccessfully for over 30 minutes. the patient was declared dead and the code blue was called off. . 3. pt continually had heart rates 90s-100s. he remained afebrile. ddx was thought to include intravascular volume depletion, pe, and anxiety. ct angio ruled out pe and leni's ruled out le dvt. the patient was initially having bb held but was restarted on bb at low dose when tx to the floor. the hr remained somewhat fast. at that point, the pt was thought to be tachycardic chf exacerbation in order to maintain co. . 4.arf- creatinine baseline was 1.1 - 1.3. the patient had a creatinine between 1.5 and 2.0 at this hospitalization. it was thought to be elevated due to poor forward flow in the setting of low ef. however, the pt also received a pe protocol chest ct, which may have further stressed the renal function. fena was measured to be low consistent with a prerenal picture from vol depletion or poor forward flow, and pointed away from atn. the creatinine seemed to peak in the icu as more fluid was given and began to descend as fluid was tapered. after arriving on the floor, small amounts of lasix were given for diuresis with poor response. uop was low at 200-300cc/shift. there was a second peak in the creatinine as diuresis was increased and hydral/nitrates were added to the regimen. this was followed by a trend downward as the patient's uop increased on and 2 so that he was reaching a goal of net 0.5 to 1 l negative. he was taking po well and had a 1-1.2l fluid restriction applied to limit his intake of fluids. . 5. respiratory pt had a respiratory alkalosis on admission. breathing pattern was shallow and then apnic, but not -. likely psychosis and fever. there was also a gap acidosis in setting of elevated lactate, which resolved prior to his arrival on the floor. on the morning of , the respirations appeared more labored, o2 sat dipped temporarily, and the patient appeared more somnolent. abg was done and revealed a normal blood gas. lactate was elevated, but decreased on a f/u with a venous lactate the next day. elevated lactate was thought to be due to hypoperfusion diffusely rather than an infectious process as the pt was afebrile. . 5. dm2- the pt had known dm2 and was put on a diabetic diet and a sliding insulin scale with regular insulin. sugar was well controlled. . 7. pt was on beta blocker and lasix at home. in the icu, both were held for tachycardia of unknown etiology and proposed intravascular volume depletion, respectively. bp was low in the unit and the pt received fluids for support. by the time he was transferred to the floor, he was normotensive and was started on a bb for cardioprotection (low dose given heart failure). lasix was used to diurese and likely had little effect on bp. hydral/nitrates were started per cardiology recs and bb was lowered . 8. cad-s/p mi in past. continued baby asa, statin. held beta blocker initially as above, and then restarted. the patient initially ruled out for mi. he was monitored on telemetry. . 9. psychiatry- the patient has a history of depression and anxiety. on paxil as outpt, held as above secondary to possible serotonin syndrome. pt had been on medication long-term, however, he may have had increased serotonin in system if carcinoid has progressed. pt was also having continued paranoid ideations. however, was much improved and became cooperative and less anxious appearing. . 10. carcinoid cancer- the patient had known metastasis to the liver with evidence of carcinoid heart on catheterization. he was on experimental protocols in past at . he has been on octreotide as an outpatient and had stopped. restarting this treatment was considered, but the family declined. . the patient died after unsuccessful resuscitation for ventricular tachycardia that degenerated into ventricular fibrillation. . medications on admission: 1. paroxetine hcl 30 mg tablet qd 2. bisacodyl 10 mg suppository qhs.prn 3. insulin regular human 100 unit/ml as directed 4. sodium chloride 0.65 % aerosol, sprays nasal tid, prn 5. docusate sodium 100 mg capsule po bid 6. aspirin 81 mg tablet, qd 7. pantoprazole sodium 40 mg tablet(e.c.) po q24h 8. heparin sodium (porcine) 5,000 unit/ml tid sc. 9. lactulose 10 g/15 ml, 30 ml po q8h prn 10. furosemide 40 mg tablet 1 po bid 11. toprol xl 25 mg tablet sustained release qd po 12. atorvastatin calcium 20 mg qd discharge disposition: expired discharge diagnosis: the patient died in the hospital. discharge condition: expired procedure: venous catheterization, not elsewhere classified spinal tap incision of lung cardiopulmonary resuscitation, not otherwise specified diagnoses: pneumonia, organism unspecified acidosis coronary atherosclerosis of native coronary artery malignant neoplasm of liver, secondary congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified septicemia severe sepsis atrial fibrillation other chronic pulmonary heart diseases paroxysmal ventricular tachycardia other and unspecified hyperlipidemia alkalosis ventricular fibrillation diseases of tricuspid valve chronic diastolic heart failure malignant neoplasm of ill-defined sites within the digestive organs and peritoneum 

Answer: The patient is high likely exposed to