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: ampicillin / penicillins / dexamethasone attending: chief complaint: fall major surgical or invasive procedure: right distal femur fracture orif history of present illness: 49m hx. if active multiple myeloma (known disease throughout bilateral femurs, hips, sacrum, cervico-thoraco-lumbar spine, ribs) who sustained a fall this morning and has a displaced spiral oblique fracture of his left proximal femur. no injuries elsewhere per report.in the emergency room the patient is hemodynamically stable, alert and oriented, and he has moderate pain in his left thigh. past medical history: -multiple myeloma igg -rsv () -hypertension -depression/anxiety -chronic back pain -c1 burst fracture, now in c-collar -s/p vertebroplasties -s/p appendectomy -hyperthyroid, on propranolol for symptom control, now resolved social history: is married with two children. he is very involved with his family and coaches his son's teams. he previously worked as a sales manager, now disabled. he denies tobacco or illicit drug use, and only has alcohol very occasionally at social events and holidays family history: father: died in 7/. he had been chronically ill. mother: type ii diabetes mellitus : multiple myeloma uncle: disease physical exam: admission physical afvss nad rrr cta s/nt/nd rle: silt, motor intact. right thigh compartment is soft, but moderately swollen. staples are in place. no bleeding. no hematoma. no concern for compartment syndrome. transfer to bmt physical exam vitals - 102.0 po 120/70 130 18 92/ra general: thin, ill-appearing male lying in bed w neck brace, aox3 heent: perrl, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy chest: ctab over anterior chest no wheezes, no rales, no ronchi cv: s1 s2 normal in quality and intensity rrr no murmurs rubs or gallops abd: soft, non-tender, non-distended, bs normoactive. no rebound/guarding, neg hsm. neg sign. ext: lle very tense, pulses intact b/l, pressure bandaged from foot to hip, distal pulses in tact, good distal perfusion skin: no rash pertinent results: admission labs 02:15pm blood wbc-6.3# rbc-1.47*# hgb-5.7*# hct-16.7*# mcv-114* mch-38.6* mchc-33.9 rdw-20.3* plt ct-48* 02:15pm blood neuts-85* bands-6* lymphs-5* monos-2 eos-0 baso-0 atyps-0 metas-2* myelos-0 02:47pm blood pt-15.3* ptt-29.4 inr(pt)-1.3* 02:15pm blood glucose-140* urean-16 creat-0.9 na-136 k-4.1 cl-106 hco3-26 angap-8 02:15pm blood calcium-7.5* phos-3.8 mg-1.6 discharge labs 12:36am blood wbc-2.7* rbc-2.69* hgb-8.6* hct-24.6* mcv-92 mch-31.8 mchc-34.7 rdw-16.7* plt ct-38* 12:36am blood neuts-78* bands-0 lymphs-8* monos-9 eos-1 baso-3* atyps-1* metas-0 myelos-0 12:36am blood pt-14.6* ptt-34.0 inr(pt)-1.3* 12:00am blood gran ct-4480 12:36am blood gran ct-2106* 12:36am blood glucose-98 urean-16 creat-0.8 na-134 k-3.8 cl-99 hco3-30 angap-9 05:04am blood alt-12 ast-27 ld(ldh)-285* alkphos-41 totbili-0.7 12:36am blood alt-23 ast-27 alkphos-106 totbili-0.9 12:36am blood albumin-2.4* calcium-7.9* phos-3.8 mg-1.9 12:00am blood osmolal-273* 12:00am blood pep-abnormal b igg-2904* iga-25* igm-16* 06:19am blood vanco-11.2 02:19pm urine color-straw appear-clear sp -1.012 02:19pm urine blood-tr nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 02:19pm urine rbc-1 wbc-<1 bacteri-few yeast-none epi-<1 10:52am urine hours-random urean-430 creat-31 na-126 k-34 cl-150 10:52am urine osmolal-482 04:30pm urine u-pep-trace abno micro 6:50 pm blood culture 2 of 2 left. **final report ** blood culture, routine (final ): no growth. 2:19 pm urine source: cvs. **final report ** urine culture (final ): no growth. 6:50 pm blood culture 2 of 2 left. **final report ** blood culture, routine (final ): no growth. radiology l ext fluoro findings: multiple fluoroscopic images of the left femur demonstrate interval placement of an intramedullary rod with distal interlocking screw and a proximal pin fixating a fracture involving the proximal shaft of the left femur. there is improved anatomic alignment. the lytic lesions seen throughout the pelvis and femur is less well seen due to the technique. please refer to the operative note for additional details. chest xray no pneumonia, no pulmonary edema or appreciable pleural effusion. there is hazy opacification over both lateral chest walls, is probably due to soft tissue involvement of the pleural space in region of multiple myelomatous ribs. heart size is normal. dual-channel right central venous line, is longstanding, ending in the mid svc. leni impression: no evidence of dvt in right or left lower extremity. repeat chest xray findings: in comparison with the study of , there is little change. no evidence of acute pneumonia, vascular congestion, or pleural effusion. diffuse myelomatous changes within the ribs and other bony structures are again seen. central venous line remains in place. impression: little change brief hospital course: ortho summary mr. after a fall at home. he was evaluated by the orthopaedic surgery service and found to have a left femur fracture. he had to be admitted to the icu for a low hematocrit (16), where he was transfused and monitored hemodynamically. he was admitted, consented, and prepped for surgery. on he was taken to the operating room and underwent an orif of his right femur fracture. post operatively he received approximately 7 units of blood because his hematocrit kept trending down (to the low 20s.) and he was tachycardic. at this point the hematology service was consulted and they felt this patient's hematologic management (given complicated history of multiple myeloma) may be best served on their service. therefore on he is being transferred to the . bmt course : this is a 49y m w h/o recurrent igg multiple myeloma following his allogeneic transplant currently on revlimid and cyclophosphamide (last dose w known disease throughout bilateral femurs, hips, sacrum, cervico-thoraco-lumbar spine, ribs) presented to an osh s/p mechanical fall with l femur fracture. he denies other injury including head strike or loss of consciousness. now s/p orif on with persistent anemia and thrombocytopenia and transferred from ortho to bmt. he was started postop on lovenox sq on w intended 4week course by ortho but dc'd when hct nonresponsive to transfusions. plan per ortho is tdwb on lle with transfer to bmt service for management of hematologic disturbance. pt febrile since and started empirically on vanco, cefepime on transfer to bmt. # fever: ddx includes pe, infectious etiology, post-op complication, ateletasis, or post-transfusion rxn. hickman looks erythematous wo purulence or tenderness and improved appearance after initiation of abx. wound intact. chest xray negative. giving incentive spirometer. vanco trough on = 11 but team elected to keep dose same to avoid nephrotoxicity give low suspicion for infection. he continued on vancomycin and cefepime. urine cx negative. leni negative. pt continued to have low grade temps on the abx but was hd stable and appeared to be clinically improving. lovenox was re-initiated on . he completed a 7 day course of vancomycin and cefepime with negative cultures. fever was attributed to resorption of hematoma. incentive spirometry was encouraged. his fever curve improved after abx and was afebrile off antibiotics. he continued to have low grade temps but never hemodynamically unstable. . # anemia/thrombocytopenia: concern is for persistent bleed into the lle and possible risk for compartment syndrome however intact pulses on both sides and per ortho recs, compartment syndrome is a near impossibility in thigh. would also consider other hematologic consumptive processes such as (dic/hus-ttp/itp), decrease production (baseline mm) and/or sequestration process but most likely is oozing related to thrombocytopenia on lovenox. had been getting prbcs throughout stay wo platelets. restarted lovenox on . he was monitored w serial cbcs and transfused w goals for hct>24, plt>50. home aspirin was held during stay and at time of discharge w decision deferred to outpt evaluation. he was continued on lovenox while bed bound given high risk for dvt. anticoagulation should be continued at rehab until pt is ambulating. . # lle fracture: s/p fall at home w decreased bony integrity diffuse multiple myeloma. s/p orif on (l tfn). pt worked with the pt daily however he was very hesitant to mobilize given his pain. pain control with dilaudid pca, fentanyl patches, home methadone and home gabapentin. he was also written for dilaudid breakthrough doses prior to pt and bandage changes. bowel regimen: senna, colace, start miralax and bisacodyl and pt stooled daily. plan for post-pathologic fracture radiation therapy for standard 2 weeks post-operative. pt has appointment for mapping at radiation oncology on with dr. on 5. he will require transportation from rehab to radiation appointments. also has an appointment with orthopedics for staple removal and evaluation. . # multiple myeloma: on rivlimid and cytoxan (last dose 4/20). he was monitored w daily cell counts. prophylaxis with acyclovir, bactrim from home regimen. he was unable to tolerate a skeletal survey in house given his severe leg pain and current instability. he will be referred for skeletal survey as an outpatient. medications on admission: acyclovir - 400 mg tablet - 1 (one) tablet(s) by mouth three times a day albuterol sulfate - 2.5 mg/3 ml (0.083 %) solution for nebulization - 1 solution(s) inhaled every six (6) hours as needed for cough azithromycin - 250 mg tablet - 2 tablet(s) by mouth on day 1, then 1(one) tablet on days 2 - 5. clonazepam - 0.5 mg tablet - 1 (one) tablet(s) by mouth twice a day as needed fentanyl - 100 mcg/hour patch 72 hr - 3 patch(s) q36h (every 36 hours) fluticasone - 110 mcg/actuation aerosol - 2 aerosol(s) inhaled twice a day for 2 weeks rinse mouth after inhalation folic acid - 1 mg tablet - 1 tablet(s) by mouth once a day gabapentin - 400 mg capsule - 1 capsule(s) by mouth three times a day gelclair - gel in packet - use one packet for oral swish and spit once to twice per day as needed for as needed for mouth sores heparin (porcine) in ns - (discharge med) - 10 unit/ml kit - 3 kit(s) once a day flush each lumen with 10 cc of normal saline then follow with heparin flush. lenalidomide - (prescribed by other provider) - 25 mg capsule - 1 (one) capsule(s) by mouth once a day and increase to 50 mg daily as directed. lidocaine - 5 % (700 mg/patch) adhesive patch, medicated - two adhesive patches once a day as needed for pain. apply patches to left upper back on 12 hours, then off 12 hours lorazepam - 0.5 mg tablet - tablet(s) by mouth every eight (8) hours as needed for nausea methadone - 10 mg tablet - 1 tablet(s) by mouth four times a day as needed for pain nystatin - 100,000 unit/ml suspension - 5 mls by mouth four times a day, swish and spit ondansetron - 4 mg tablet, rapid dissolve - 1 tablet(s) by mouth q 8h as needed for nausea oxycodone - 30 mg tablet - 1 (one) to 1.5 (one and a half) tablet(s) by mouth every four (4) hours as needed for breakthrough pain. pantoprazole - 40 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day propranolol - 10 mg tablet - 1 (one) tablet(s) by mouth once a day saliva substitution combo no.2 - solution - rinse with 30 mls three times a day as needed for dry mouth sodium chloride 0.9 % - (discharge med) - 0.9 % syringe - 3 syringe(s) once a day flush each lumen with 10 cc of normal saline daily followed by heparin. sulfamethoxazole-trimethoprim - 400 mg-80 mg tablet - 1 tablet(s) by mouth once a day tacrolimus - (dose adjustment - no new rx) - 0.03 % ointment - apply to lips once a day as needed tizanidine - 4 mg tablet - 0.5 (one half) to 1(one) tablet(s) by mouth hs (at bedtime) venlafaxine - 37.5 mg capsule, ext release 24 hr - 1 (one) capsule(s) by mouth once a day medications - otc aspirin - (prescribed by other provider) - 81 mg tablet, delayed release (e.c.) - 1 (one) tablet(s) by mouth once a day bisacodyl - (prescribed by other provider) - 5 mg tablet, delayed release (e.c.) - 2 tablet(s) by mouth twice a day as needed for constipation codeine-guaifenesin - 100 mg-10 mg/5 ml liquid - 5 - 10 mls by mouth every six (6) hours as needed for cough docusate sodium - (prescribed by other provider) - 100 mg capsule - 2 capsule(s) by mouth every twelve (12) hours as needed for constipation multivitamin with minerals - (otc) - capsule - 1 (one) capsule(s) by mouth once a day polyethylene glycol 3350 - 17 gram powder in packet - 17 grams by mouth (about 1 heaping tablespoon/1 packet) per day dissolved in 4 to 8 ounces of water, juice, soda as needed for constipation. discharge medications: 1. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 2. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 4. gabapentin 400 mg capsule sig: one (1) capsule po q8h (every 8 hours). 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: three (3) ml ml inhalation q6h (every 6 hours) as needed for wheezing. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. methadone 10 mg tablet sig: one (1) tablet po q6h (every 6 hours). 8. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 9. oral wound care products gel in packet sig: fifteen (15) ml mucous membrane tid (3 times a day) as needed for mouth sores. 10. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily) as needed for upper back. 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for nausea. 12. propranolol 10 mg tablet sig: one (1) tablet po daily (daily). 13. saliva substitution combo no.2 solution sig: thirty (30) ml mucous membrane tid (3 times a day) as needed for dry mouth. 14. venlafaxine 37.5 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po daily (daily). 15. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) gram po daily (daily) as needed for constipation. 16. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day). 17. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch transdermal q48h (every 48 hours). 18. enoxaparin 30 mg/0.3 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours). 19. methyl salicylate-menthol ointment sig: one (1) appl topical prn (as needed) as needed for to affected area. 20. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily). 21. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 22. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po daily (daily) as needed for constipation. 23. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 24. hydromorphone 10 mg/ml solution sig: one (1) pca injection asdir (as directed): hydromorphone (dilaudid) 0.25 mg ivpca lockout interval: 6 minutes basal rate: 0.12 mg(s)/hour 1-hr max limit: 2.5 mg(s) use basal rate from -0600 . 25. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 26. potassium chloride 20 meq/50 ml piggyback sig: one (1) sliding scale intravenous prn (as needed): per handout included in dc paperwork. 27. magnesium sulfate 4 % solution sig: one (1) sliding scale injection prn (as needed): per sliding scale included in dc paperwork. 28. heparin flush (10 units/ml) 2 ml iv prn line flush tunneled access line (e.g. hickman), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 29. hydromorphone (dilaudid) 2 mg iv once:prn prior to pt hold for sedation, rr<12 30. ondansetron 8 mg iv q8h:prn nausea 31. tizanidine 4 mg tablet sig: 0.5-1 tablet po at bedtime. 32. saline flush 0.9 % syringe sig: one (1) syringe injection once a day as needed for prn line flush: once a day flush each lumen with 10 cc of normal saline daily followed by heparin. . 33. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day: hold while on lovenox. discharge disposition: extended care facility: hospital for continuing care- discharge diagnosis: right distal femur fracture acute bleeding requiring icu admission and transfusion presume coagulopathy in the setting of multiple myeloma discharge condition: aao x 3 regular diet discharge instructions: it was a pleasure caring for you at . you were admitted for a leg fracture related to your multiple myeloma. activity continue to be touch down weight bearing in your lle. continue to be weight bearing as tolerated in rle, and bilateral upper extremities. general if you have any increased pain, swelling, or numbness, not relieved with rest, elevation, and or pain medication, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. medications: 1) lovenox: blood thinner, you should take this for 4 weeks or until you are out of bed and ambulating. 2) you have been prescribed a narcotic pain medication. please take only as directed and do not drive or operate any machinery while taking this medication. there is a 72 hour (monday through friday, 9am to 4pm) response time for prescription refill requests. there will be no prescription refills on saturdays, sundays, or holidays. please plan accordingly. 3) continue any home medications wound care: - keep incision clean and dry. - do not soak the incision in a bath or pool. - staples should be taken out in 2 weeks from surgery. this can be done at your first post-operative visit on . you will need to follow up with your outpatient oncologist. given the nature of your fracture, we recommend a post-operative course of radiation to strengthen the bone. you have an appointment to see a radiation doctor listed below. the following changes were made to your medications: started dilaudid pca (to be continued and weaned at rehab) started lovenox, this will need to be continued 4 weeks after your surgery (), and ambulating started dilaudid iv prior to pt sessions hold your low dose aspirin while you are on lovenox injections. followup instructions: department: bmt chairs & rooms when: tuesday at 10:30 am department: hematology/oncology when: tuesday at 10:30 am with: , bsn building: sc clinical ctr campus: east best parking: garage department: radiation oncology when: at 2:00 pm with: dr. ( campus: east department: hematology/bmt when: thursday at 11:30 am with: , rnc building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 9:20 am with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 9:40 am with: , np building: campus: east best parking: garage procedure: closed reduction of fracture with internal fixation, femur diagnoses: thrombocytopenia, unspecified unspecified essential hypertension acute posthemorrhagic anemia hematoma complicating a procedure bone marrow replaced by transplant other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation other disorders of neurohypophysis other and unspecified coagulation defects fall from other slipping, tripping, or stumbling closed fracture of shaft of femur unspecified otitis media multiple myeloma, in relapse 

Answer: The patient is high likely exposed to