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: neck pain, right sided weakness major surgical or invasive procedure: : ivc filter insertion : ivc filter removal picc line placement arterial line placement intubation and mechanical ventilation surgery : 1. c6 corpectomy. 2. kyphectomy c7. 3. open biopsy, deep bone. 4. anterior body fusion c5-c6, c6-c7, c7-t1. 5. interbody reconstruction c5 through t1. 6. anterior cervical plate instrumentation c5 through t1. surgery : 1. deep bone biopsy. 2. open treatment cervical fracture/dislocation. 3. posterior cervical arthrodesis c5-c6, c6-c7. 4. posterior thoracic arthrodesis c7-t1. 5. posterior instrumentation c5-t1. 6. iliac crest bone graft harvest for fusion. 7. allograft for fusion. history of present illness: the patient is a 64 y/o m with pmhx significant for spinal stenosis with multiple discectomies ~4yrs ago c/b wound infection, afib on coumadin, chf ef 25-30%, htn, who presents from rehab and transfered from osh for neck pain, r sided weakness, and concern for osteomyelitis. pt states that he has had increasing neck pain for the last 1-2d, with increased weakness in his right arm and leg. he states that he is able to walk several steps at a time at baseline, but that he has been unable to walk at all. his outside hospital ct was concerning for osteomyelitis. . on arrival to the ed, the patient's vs were 98.4 84 96/70 16 98% ra. exam was significant for inability to lift right arm above 30' as well as weakness with right hip and knee flexion. osh ct was reread by radiology, who noted destructive process centered at the c6-c7 intervertebral disc space, concerning for disciitis / osteomyelitis. mri was ordered for further evaluation. the patient was seen by ortho spine, who recommended admission to medicine with plans for possible or early next week. vs prior to transfer were 97.7 97 18 117/94 96 with 4l nc. . currently, the patient reports pain in his neck, radiating into the bilateral arms. he endorses 2 days of worsening neck pain and weakness on the right side. he also reports occasional blurred vision. he endorses nausea and vomiting earlier today. he also endorses urinary incontinence, which is long-standing but has been slightly worse recently. he also endorses having a cough recently. denies fevers or chills. . review of systems: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, dysuria, hematuria. past medical history: atrial fibrillation on coumadin chf (systolic) ef 25-30% spinal stenosis htn ? osa pulmonary htn antiphospholipid syndrome prior pe depression social history: denies tobacco, alcohol, or illicit drug use. reports that he used to work as anesthesia rn. has not worked for 4 years due to back issues. family history: father died of pancreatitis. mother died of cva. 1 brother died of hepatitis/liver failure. 1 other brother who is healthy. physical exam: admission physical exam: vs - temp 96.8 f, bp 128/99, hr 98, rr 20, o2-sat 94% 2l general - obese male, cervical collar in place, lying in bed, nad heent - nc/at, perrla, eomi, sclerae anicteric, dry mm, op clear neck - cervical collar in place lungs - cta anteriorly, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - irregular rhythm, no mrg, nl s1-s2 abdomen - obese, nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - no significant edema, 2+ dp pulses skin - no rashes or lesions note lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, cns ii-xii grossly intact, 4/5 strength in rue (shoulder extension, elbow flexion/extension) and rle (hip flexion, knee flexion/extension), in the lue and lle, strength on bilateral hand squeeze as well as bilateral foot dorsiflexion and plantarflexion, diminished sensation to lt in the rue and rle compared to the left, dtr's difficult to elicit discharge exam: vitals: 98.2 108/67 62 18 98% ra general: awake, alert, resting more comfortably, nad heent: sclera anicteric, mmm neck: -j collar in place, anterior cervical incision healing well, posterior cervical incision with overlying gauze c/d/i cv: irregularly irregular, no r/m/g lungs: ctab without wheezing/rales/rhonchi, good air movement bilaterally abdomen: obese, soft, non-tender, non-distended, bowel sounds present ext: warm, well perfused, 2+ pulses, trace lower extremity edema, chronic venous stasis changes neuro: strength 4+/5 in rue and rle, on left pertinent results: admission labs: 02:00pm blood wbc-7.2 rbc-3.80* hgb-11.1* hct-32.7* mcv-86 mch-29.3 mchc-34.0 rdw-16.9* plt ct-226 02:00pm blood neuts-79.4* lymphs-9.3* monos-5.8 eos-5.2* baso-0.2 02:00pm blood pt-46.7* ptt-51.3* inr(pt)-4.6* 02:00pm blood glucose-85 urean-31* creat-1.2 na-133 k-4.5 cl-99 hco3-26 angap-13 other pertinent labs: 12:04pm blood fibrino-682* 03:18am blood esr-69* 04:26am blood esr-126* 03:14pm blood esr-95* 04:25am blood esr-118* 06:15am blood esr-85* 03:18am blood crp-38.7* 04:26am blood crp-93.3* 02:02am blood crp-54.9* 04:25am blood crp-223.9* 06:15am blood crp-46.7* 06:15am blood ck(cpk)-201 06:15am blood ck-mb-3 ctropnt-<0.01 06:40pm blood ck(cpk)-60 06:40pm blood ck-mb-1 ctropnt-<0.01 probnp-4840* 02:00am blood alt-11 ast-18 ld(ldh)-175 ck(cpk)-41* alkphos-59 totbili-1.0 02:00am blood ck-mb-2 ctropnt-<0.01 04:26am blood alt-7 ast-14 ld(ldh)-128 alkphos-64 totbili-0.3 12:55am blood calcium-9.5 phos-4.0 mg-2.0 discharge labs: 05:23am blood wbc-4.8 rbc-3.14* hgb-8.9* hct-26.6* mcv-85 mch-28.5 mchc-33.6 rdw-16.9* plt ct-276 05:23am blood pt-35.5* ptt-96.9* inr(pt)-3.5* microbiology: blood cultures 2/11, , , : negative urine cultures 2/11, : negative c6 bone tissue culture : gram stain negative, culture negative, anaerobic culture negative, acid fast culture negative (prelim), acid fast smear negative, fungal culture negative (prelim), koh prep negative c6 bone biopsy tissue culture: gram stain negative, culture negative, anaerobic culture negative, fungal culture negative (prelim), koh prep negative universal pcr : bacterial pcr results: no bacterial dna detected with 16s rdna primer set. fungal pcr results: no fungal dna detected with 28s rdna and its primer sets. pathology: c6 vertebral body : 1. bone, c6 vertebral body, excision (a): fragments of viable and non-viable bone and cartilage. granulation tissue. no definitive evidence of osteomyelitis. 2. intervertebral disc, cervical, excision (b): fibrocartilage with degenerative change. see note. fragments of viable and non-viable bone and cartilage. note: in part 2, there is a detached cluster of neoplastic cells, favored to be neoplastic epithelial cells, present. as this cluster of cells is present on another level, it is present in the tissue block. given the apparent lack of a history of neoplasia, as well as the appearance of this cluster of cells on the slide, it is favored to be a contaminant from another case. (discussed with pathology and felt to be a contaminant from another sample). c6 vertebral body : results pending at time of discharge imaging: ct c-spine w/o contrast: laminectomy changes at c3-c6 with osseous destructive process centered around the c6-c7 intervertebral disc space concerning for vertebral osteomyelitis and discitis. mri c-spine is recommended for further evaluation. cxr : substantial cardiomegaly. no evidence of acute disease. mr w/ and w/o contrast : 1. no significant changes are demonstrated since the prior examinations, persistent abnormal signal identified at c6/c7 level, with moderate pattern of enhancement and retropulsion. 2. kyphotic deformity at c6/c7 level, causing anterior thecal sac deformity, these findings are concerning for discitis, osteomyelitis. epidural thickening with moderate pattern of enhancement, likely consistent with a combination of prominent epidural veins and dural thickening, no frank evidence of epidural collection is identified. unchanged prevertebral soft tissue swelling extending from c4 through c7 levels. 3. multilevel degenerative changes throughout the cervical spine as described above. there is no evidence of focal or diffuse lesions within the cervical spinal cord; however, the examination is limited due to patient motion. mri brain : 1. no acute intracranial process, specifically no evidence of intracranial infection or infarction. 2. mild chronic small vessel ischemic disease. 3. a lesion which lies superiorly to the right parotid is likely an enlarged lymph nodes, although a parotid tumor cannot be excluded. could correlate clinically and with prior imaging studies. 4. no stenosis, occlusion, or aneurysm visualized within the cerebral vasculature. tte : the left atrium is moderately dilated. the right atrium is markedly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the lv ejection fraction appears depressed (? 35 percent). there is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm. the right ventricle also appears hypokinetic. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. bilateral lower extremity ulratsound : limited assessment of the peroneal veins bilaterally, otherwise no evidence of dvt in the bilateral lower extremities. cxr : as compared to the previous radiograph, the patient has received a cervical fusion. the endotracheal tube has been removed, the nasogastric tube is also removed, but the right picc line remains in unchanged position. unchanged moderate cardiomegaly with small areas of atelectasis but no evidence of pneumonia or other pathological changes. no pneumothorax. brief hospital course: 64m with afib on coumadin, chf with ef 35%, antiphospholipid antibody syndrome, multiple dvts and pes, htn, cervical spinal stenosis s/p c3-c7 laminectomies and c3-c4 fusion c/b mssa wound infection, who was transferred from with 1-2 days of increased neck pain, r sided weakness, with imaging evidence of c6-c7 discitis/osteomyelitis. # osteomyelitis: patient with history of cervical spinal stenosis s/p c3-c7 laminectomies and c3-c4 fusion c/b mssa wound infection that required prolonged antibiotics. he was admitted with increased neck pain, r sided weakness, and with imaging evidence on ct c-spine of c6-c7 discitis/osteomyelitis. was seen by ortho-spine in the ed and placed in a j cervical collar due to his unstable c-spine. he was afebrile, without leukocytosis, and numerous blood cultures were negative. antibiotics were initially held per id consult while awaiting cultures, and given the clinical stability of the patient from an infectious standpoint. mri with and without contrast was obtained on third attempt, requiring general anesthesia due to patient discomfort in the scanner and motion artifacts. mri/mra of the brain revealed no evidence of intracranial pathology, including septic emboli. tte showed no evidence of endocarditis, and tee was not obtained due to low suspicion of endocarditis. origin of the infection was not clear, possibly related to the prior mssa infection in . history, physical, and work-up revealed no other infectious source that could have led to the osteomyelitis. due to the proximity of the infection to the carotids, neuro ir decided they would not be able to obtain an ir-guided biopsy. thus, the patient needed an operative biopsy, which was delayed due to the patient's afib with rvr and antiphospholipid antibody syndrome (discussed below). . his first procedure was an anterior stabilization and operative biopsy, involving c6-7 corpectomies and anterior c5-t1 fusion on . the procedure went well. he was left intubated following the procedure, and required brief micu admission notable for hypotension and afib with rvr. his heparin gtt was restarted 48 hours after the surgery, and the patient was kept in the micu for the first day after restarting the heparin for frequent neuro checks, as there was concern for high risk of bleeding post-operatively. he did not develop any new neurologic deficits, and was stable for transfer back to the medicine floor. cultures from the biopsy were negative, and pathology from c6 vertebral body biopsy revealed no definitive evidence of osteomyelitis. the patient received cefazolin peri-operatively, and was continued on this antibiotic after the surgery. however, after cultures remained negative, id consult recommended again holding antibiotics and obtaining repeat cultures when the patient went back to the or on for posterior stabilization. the patient underwent deep bone biopsy, open treatment cervical fracture/dislocation, posterior cervical arthrodesis c5-c6, c6-c7, posterior thoracic arthrodesis c7-t1, posterior instrumentation c5-t1, iliac crest bone graft harvest for fusion, and allograft for fusion on . again, he tolerated the procedure well. was again briefly admitted to micu post-op, but stable for transfer to the floor the following day. patient was placed back on cefazolin perioperatively, though cultures from the repeat biopsy also remained negative. universal pcr for bacterial and fungal pathogens was sent, and was negative. given increasingly low suspicion for active infection, id recommended stopping all antibiotics on . they will see patient in follow-up in several weeks, and will monitor cbc, esr, and crp at the 2-week and 4-week marks. with regard to the patient's cervical spine stability, he will wear the j collar until ortho-spine follow-up in weeks. his pain was controlled during the admission with acetaminophen, gabapentin, tramadol, methadone, and oxycodone prn pain. he was placed on a dilaudid pca post-operatively. home tizanadine was used to help control muscle spasms. of note, his ecg was monitored for qtc prolongation with patient on both methadone and tizanadine. he worked with pt/ot, and acute rehab was recommended. # atrial fibrillation: the patient was on warfarin for anticoagulation, and carvedilol for rate control prior to admission. he had initial bursts of rvr on arrival to the floor, which improved with his home carvedilol. after mri obtained under general anesthesia, the patient was transferred to the micu in the setting of afib with rvr with rates in 120s-150s and sbps 90s-100. he received metoprolol 5mg x3 without response in the pacu. his cxr showed question of rml atelectasis; no signs of pulmonary edema or obvious infiltrate. ekg c/w afib with rvr but no signs of ischemia. in the micu, the patient was started on a diltiazem drip with good control of heart rate, and the patient was started on po metoprolol. he briefly required pressors. his carvedilol was d/c-ed in order to reduce alpha blockade in setting of relative hypotension. was weaned off dilt gtt with good control of heart rate on metoprolol 25 mg tid and sbp>100. after transfer back to the floor from the micu, he maintained good hr control on this dose of metoprolol. following his first surgery, c6-7 corpectomies and anterior c5-t1 fusion, the patient was again transferred to the micu for afib with rvr and hypotension with sbp in the 70s. he received fluids and dilt drip, resulting in good rate control. he was successfully extubated and rate control was transitioned to metoprolol 25 mg tid with sbp>100. after transfer back to the floor from the micu, he maintained good hr control on metoprolol, though dose was increased to 37.5mg tid prior to discharge. . # antiphospholipid antibody syndrome/anticoagulation management: patient has history of antiphospholipid antibody syndrome, rue dvt, and pex3. inr was supratherapeutic on arrival to the hospital. coumadin and aspirin were held given his supratherapeutic inr, and pending surgical procedures. heme/onc was for assistance with anticoagulation management peri-operatively. he was maintained on heparin drip initially. inr was reversed with vitamin k and ffp. due to the need to be off of anticoagulation peri-operatively for his spine surgeries, a temporary ivc filter was placed by ir on . heparin drip remained off 6 hours before and 48 hours after the surgery on . after the first procedure, the patient was monitored with frequent neurologic exam checks, especially after resuming therapeutic anticoagulation. heparin drip was continued with goal ptt 80-100 between his two c-spine surgeries. his inr trended up despite not receiving coumadin, and he received additional vitamin k prior to his second c-spine procedure. heparin drip was again discontinued before the second surgery, and restarted after the second procedure. after the second procedure, the patient was again monitored with neurologic exam checks, especially after resuming therapeutic anticoagulation. his ivc filter was removed on , and his warfarin was resumed that same day. he should continue on the heparin gtt until inr has been therapeutic at 2-3 for >48 hours. inr was 3.5 on day of discharge, and warfarin was held. if inr therapeutic on , heparin gtt can be discontinued. would recommend restarting warfarin at 3mg daily once inr <3. # chronic schf: prior ef documented as 25-30%; tee this admission revealed ef 35%. patient did not have any evidence of exacerbation this admission. he was initially continued on home medications, but later in his course his furosemide/lisinopril were held in the setting of hypotension due to afib with rvr and narcotics use. these medications can be restarted as bp will allow in the outpatient setting. at this time, will plan to restart furosemide on discharge. of note, as above his beta blocker was switched from carvedilol to metoprolol this admission for better hr control. . # htn: bp remained well controlled during admission, with occasional episodes of lower sbp in the 90s-100s. these lower pressures were attributed to narcotics use, and occasionally occurred in the setting of afib with rvr. patient was asymptomatic. in this setting, his home carvedilol was changed to metoprolol, which was uptitrated to a dose of 37.5mg tid prior to discharge. his home lisinopril can be started back following discharge if bp remains stable. furosemide will be restarted on discharge. . # depression: continued sertraline. . transitional issues: -given low suspicion for active infection, patient will not be discharged on antibiotics. -patient needs cbc, esr, and crp checked at 2 weeks and 4 weeks, with results sent to clinic. id follow-up scheduled for . -patient has ortho follow-up with dr. scheduled for , though this appointment may be moved. should wear j collar until that time. -patient restarted on warfarin . please monitor inr daily and adjust warfarin dose accordingly. please continue heparin gtt with goal ptt 80-100 until inr therapeutic () for >48 hours. if inr therapeutic on , can d/c heparin. as inr 3.5 on day of discharge, would recommend continuing to monitor inr and restarting at 3mg daily once inr <3. -please continue to reassess pain and increase/taper narcotic regimen as needed. patient may benefit from a pain consult after discharge if narcotics requirements continue to be an issue. -patient's lasix and lisinopril held this admission given relatively lower bp (90s-100s) and that patient appeared euvolemic. can be restarted in outpt setting as tolerated, and would recommend restarting lasix at this time. -mri during admission revealed enlarged lymph node superior to right parotid gland (though differential includes warthin's tumor or adenoma). should be compared to prior imaging and followed up after discharge. -on pathology report of c6 vertebral body biopsy, note was made of a detached cluster of neoplastic cells, favored to be neoplastic epithelial cells. this cluster of cells was favored to be a contaminant from another case (discussed with pathology). -pathology and finalized culture data from c6 biopsy still pending at time of discharge and will need to be followed-up. medications on admission: lisinopril 2.5 mg omeprazole 20 mg daily mvi daily aspirin 81 mg daily (per patient, not taking) colace 100 mg carvedilol 12.5 mg tid oxycodone 5-20 mg qid prn pain acetaminophen 650 mg q4h prn pain lasix 20 mg daily gabapentin 600 mg tid (per patient, dose was higher but causing confusion) sertraline 100 mg daily tizanidine 4 mg tid methadone 15 mg qid warfarin 5-7.5 mg daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. gabapentin 300 mg capsule sig: two (2) capsule po q8h (every 8 hours). 3. methadone 10 mg tablet sig: two (2) tablet po three times a day. 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. sertraline 50 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 7. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 11. oxycodone 5 mg tablet sig: four (4) tablet po q4h (every 4 hours) as needed for pain. 12. heparin (porcine) in ns intravenous 13. heparin, porcine (pf) 10 unit/ml syringe sig: ten (10) ml intravenous prn (as needed) as needed for line flush. 14. tizanidine 2 mg tablet sig: two (2) tablet po tid (3 times a day) as needed for muscle spasm. 15. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 16. furosemide 20 mg tablet sig: one (1) tablet po once a day. 17. anticoagulation please check inr and if <3 restart warfarin at 3mg daily, goal inr 18. oxycodone 5 mg tablet sig: five (5) tablet po twice a day as needed for breakthrough pain: may take extra 5 mg dose up to twice daily prior to working with pt for breakthrough pain. discharge disposition: extended care facility: - ( hospital of and islands) discharge diagnosis: primary diagnoses: c-spine osteomyelitis and instability antiphospholipid antibody syndrome atrial fibrillation with rapid ventricular response secondary diagnoses: chronic systolic congestive heart failure depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , you were admitted to the hospital for neck pain and right-sided weakness. ct and mri scans of your neck were obtained. there was concern for an infection in the bones in your neck (osteomyelitis), and the orthopedic-spine and infectious disease doctors . you underwent surgery two times (one procedure done from the front of the neck and one from the back of the neck) with the orthopedic doctors your neck and hopefully to prevent further pain and weakness. we did cultures of your blood and of the bone removed from your neck, which revealed no evidence of infection. you received iv antibiotics after the spine procedures, but the infectious disease doctors not feel you need to continue on antibiotics after you leave the hospital. you received pain medication, and you worked with physical therapy to start regaining your strength and mobility. because of your history of antiphospholipid antibody syndrome and multiple prior blood clots, we the hematology doctors to help manage your anticoagulation. your inr was high on admission and too high for surgery, so we stopped your coumadin and reversed your anticoagulation. you received heparin while the coumadin was stopped. you also had an inferior vena cava (ivc) filter placed prior to the spine procedures, due to the need to stop the heparin temporarily for the procedures. the inferior vena cava filter was removed after your two spine procedures. after all of these procedures, we re-started your coumadin. you will take coumadin after discharge. with regard to your atrial fibrillation, your heart rate was high on several occasions. this improved with changing your rate control medications, intravenous fluids, and better pain control. due to your lower blood pressure, we held your furosemide and lisinopril while you were here. you should discuss restarting these medications with your doctor after you leave the hospital, but it is reasonable to restart your furosemide (lasix) at this time. we made the following changes to your medications: - stopped carvedilol (coreg) - stopped lisinopril -changed gabapentin dose (neurontin) -changed methadone dosing -changed warfarin dosing -started metprolol (for heart rate control) -started senna and bisacodyl as needed for constipation -started miconazole powder as needed for skin irritation -started heparin (until your inr is at the right level) -started oxycodone 20mg every four hours as needed for pain (with an additional 5mg twice daily as needed for breakthrough pain when working with pt) we did not make any other changes to your medications. please continue to take them as you have been doing. please discuss with your doctor whether you should be taking aspirin (this medication was on your medication list, but you do not recall taking it recently). please keep follow-up appointments as below. followup instructions: name: , : internal medicine address: , , phone: **please discuss with the staff at the facility the need for a follow up appointment with your pcp when you are ready for discharge.** department: orthopedics when: wednesday at 9:10 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: spine center when: wednesday at 9:30 am with: , md building: campus: east best parking: garage ***it is recommended you follow up with dr in 3 weeks time, however this appt is 2 weeks out. the office may call you at home with an appt for a week later than above. procedure: interruption of the vena cava other excision of joint, other specified sites other cervical fusion of the anterior column, anterior technique excision of bone for graft, other bones repair of vertebral fracture biopsy of bone, other bones biopsy of bone, other bones other cervical fusion of the posterior column, posterior technique insertion of interbody spinal fusion device fusion or refusion of 2-3 vertebrae fusion or refusion of 2-3 vertebrae other operations on vessels central venous catheter placement with guidance diagnoses: obstructive sleep apnea (adult)(pediatric) congestive heart failure, unspecified hyposmolality and/or hyponatremia atrial fibrillation other chronic pulmonary heart diseases depressive disorder, not elsewhere classified pulmonary collapse acute respiratory failure morbid obesity chronic systolic heart failure long-term (current) use of anticoagulants personal history of venous thrombosis and embolism hypoxemia primary hypercoagulable state acute osteomyelitis, other specified sites venous (peripheral) insufficiency, unspecified pathologic fracture of vertebrae benign essential hypertension other and unspecified disc disorder, cervical region personal history of pulmonary embolism body mass index 40.0-44.9, adult unspecified disease of spinal cord kyphosis, postlaminectomy 

Answer: The patient is high likely exposed to