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: lisinopril / atazanavir / fresh fruit / cephalosporins / raltegravir / maraviroc attending: chief complaint: bacteremia major surgical or invasive procedure: femoral line placement biopsy of skin bronchoscopy history of present illness: 54f with hiv (off art now) c/b oi, ckd, dm, hepatitis c, recurrent uti, and h/o cocaine/opiate abuse with recent cocaine relapse, presents from rehab with recurrent cons bacteremia, c. diff. infection, and acute mental status changes. patient recently presented to ed on with severe desquamating rash and was transferred to burn unit with a question of syndrome. rash was determined to desquamating lichenoid hypersensitivity rxn likely related to arvs, cephalosporins, and/or drugs of abuse, which was treated by stopping art and cephalosporins and applying topical clobetasol. she had marked improvement of her skin lesions and was hd stable, so was transferred to the floor on with aggressive wound care. she was noted to have a pruritic macular rash on in setting of re-starting her arvs on her torso, arms, and back with no mucosal involvement or desquamation, so arvs were immediately stopped. she was seen by allergy that thought she may be experiencing drug-induced lupus secondary to increased hydralazine dose, which was also held. notably, she also developed a cons line infection at with positive blood cx w/gpc in clusters and subsequent tx with vanco. she was transferred to rehab on and placed on po vanco. at , notable events included: * she developed a second cons line infection in the setting of fevers and chills on with positive cxs for gpc in clusters. she was started on iv vancomycin (they did not pull the line at that time) * they were planning on echo for concern of endocarditis, but have not done yet. * ?cushings from clobetasol withdrawal after drv/r/abc/3tc was started, so art was again stopped * multiple electrolyte abnormalities (low mg, k, po4), corrected at time of transfer. * she was transfused at for hct down to 23 and now 30. * developed fever and diarrhea - started on po vancomycin in the setting of positive c diff stool cxs * she is still having diarrhea despite ongoing po vancomycin. * developed chest pain early this week, better with slntg, trop 0.04. see by cardiology (dr. who reportedly rec'd ett and she was given an appointment to follow-up with dr. . * she has developed delirium and hallucinations and pulled her own line (i think she has had similar episodes in the past, but needs to be evaluated) * has has had pain in her hips thought be musculoskeletal. she was ultimately transferred to for therapy of bactermia, c. diff, and altered mental status. on arrival to the floor, the patient was unable to recount her history or communicate as she was moaning in pain. past medical history: past medical / surgical history: - hiv, diagnosed in , on haart (cd4 742, vl<20 ). - castleman's disease - hepatitis c - no response to peg-ifn/ribavirin - shingles - migraines - htn - dm ii - history of mrsa - recurrent uti - recurrent nephrolithiasis - hsv - pancytopenia haart medications - ckd baseline creatinine 2.85-3.0, followed by dr. (nephrolithiasis, pyelonephritis & perinephric abscess c/b perinephric hematoma during stenting ) social history: lives at home in . has 3 children: one son is her hcp, one daughter with hydrocephalus/seizure disorder is in a nursing home ( pediatric care), 3rd child (female) died in childhood from complications of hiv. - worked as a counselor (no longer working) - former heavy smoker, currently 1 pack q2 weeks. - former etoh abuse, none since - former ivdu, none since - recent cocaine use () family history: - father died of mi - mother with diabetes - sister with lung cancer at age 38 and was a heavy smoker. - brother with diabetes physical exam: admission: vs t 97.7 (axillary), bp 153/?, hr 96, rr , o2 sat 100%ra gen- in acute distress (moaning in pain), unable to speak due to pain heent- eyes shut closed with purulent discharge, unable to assess eom/sclera, diffuse labial desquamation, unable to assess op neck supple, no jvd, no lad pulm cta anteriorly, unable to assess posteriorly (pt could not sit up) cv rrr normal s1/s2, no mrg abd soft nt nd ext wwp 2+ pulses palpable bilaterally, no c/c/e neuro cns2-12 intact, motor function grossly normal skin diffuse, desquamating rash over entire body. numerous areas of blistering, broken skin. discharge: af tm 100.4 bp 126/51 (70) hr 76 pox 97 on prvc fio2 60 peep 10 ppeak 25 390 cc x 28 (ardsnet ventilation) gen: intubated, sedated heent - eye closed with purulent discharge neck: supple, no jvd, no lad pulm: cta anteriorly abd: soft, non-tender, non-distended ext: wwp 2+ pulses bilaterally, no c/c/e, left femoral line neuro: sedated skin: diffuse, desquamating rash over entire body. numerous areas of blistering, broken skin. + erythroderma pertinent results: i. labs a. admission 11:58pm blood wbc-8.3# rbc-3.45* hgb-10.4* hct-33.2* mcv-96 mch-30.2 mchc-31.4 rdw-17.7* plt ct-100*# 11:58pm blood neuts-65 bands-4 lymphs-14* monos-8 eos-8* baso-0 atyps-1* metas-0 myelos-0 11:58pm blood plt smr-low plt ct-100*# 04:54am blood wbc-7.5 lymph-18 abs -1350 cd3%-81 abs cd3-1093 cd4%-35 abs cd4-469 cd8%-45 abs cd8-613 cd4/cd8-0.8* 11:58pm blood glucose-45* urean-44* creat-2.3*# na-141 k-5.3* cl-112* hco3-19* angap-15 06:29am blood alt-26 ast-35 ld(ldh)-272* alkphos-82 totbili-0.4 11:58pm blood albumin-2.5* calcium-8.1* phos-3.6 mg-2.0 06:29am blood crp-46.4* 06:29am blood vanco-24.8* 12:13am blood type- temp-37.1 po2-51* pco2-34* ph-7.32* caltco2-18* base xs--7 12:13am blood lactate-2.0 12:13am blood freeca-1.18 b. discharge 04:12am blood wbc-9.1 rbc-3.19* hgb-9.6* hct-31.4* mcv-98 mch-30.1 mchc-30.6* rdw-17.6* plt ct-101* 04:12am blood neuts-89* bands-1 lymphs-7* monos-2 eos-1 baso-0 atyps-0 metas-0 myelos-0 04:12am blood plt ct-101* 06:53pm blood glucose-82 urean-49* creat-3.1* na-134 k-5.0 cl-111* hco3-15* angap-13 06:53pm blood calcium-6.9* phos-4.4 mg-2.0 07:37pm blood type-art temp-36.7 rates-18/4 tidal v-450 peep-5 fio2-100 po2-76* pco2-33* ph-7.22* caltco2-14* base xs--13 aado2-603 req o2-99 -assist/con intubat-not intuba 04:45pm blood type-art po2-107* pco2-35 ph-7.21* caltco2-15* base xs--13 12:13am blood type- temp-37.1 po2-51* pco2-34* ph-7.32* caltco2-18* base xs--7 07:37pm blood lactate-2.4* k-4.9 ii. microbiology blood culture blood culture, routine-pending inpatient urine urine culture-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient swab gram stain-final; wound culture-preliminary {staph aureus coag +}; anaerobic culture-final , swab gram stain-final; wound culture-preliminary; anaerobic culture-final , blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient eye gram stain-final; respiratory culture-final {staph aureus coag +, escherichia coli} inpatient eye gram stain-final; respiratory culture-preliminary {staph aureus coag +, escherichia coli, proteus mirabilis}; fungal culture-preliminary inpatient blood culture blood culture, routine-preliminary {proteus mirabilis, gram positive coccus(cocci)}; anaerobic bottle gram stain-final inpatient blood culture blood culture, routine-preliminary {proteus mirabilis, escherichia coli, gram positive coccus(cocci), gram negative rod #3}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final 11:58 pm blood culture blood culture, routine (preliminary): proteus mirabilis. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . intermediate to aztreonam sensitivity testing performed by . escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . resistant to aztreonam sensitivity testing performed by . gram positive coccus(cocci). reported to and read back by j. reske- # 0915. gram negative rod #3. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | escherichia coli | | ampicillin------------ <=2 s =>32 r ampicillin/sulbactam-- <=2 s 16 i cefazolin------------- =>64 r cefepime-------------- <=1 s ceftazidime----------- <=1 s =>64 r ceftriaxone----------- <=1 s =>64 r ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s piperacillin/tazo----- s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s =>16 r anaerobic bottle gram stain (final ): gram negative rod(s). reported to and read back by # 1157. aerobic bottle gram stain (final ): gram negative rod(s). iii. radiology cxr post-intubation after tube re-position endotracheal tube tip projecting approximately 4 cm above the carina. decreased density layering along the minor fissure, which may be projectional. cxr post-intubation interval intubation with endotracheal tube tip projecting approximately 4.5 cm above the carina. esophageal catheter with weighted tip projecting over the left upper quadrant likely within the stomach. mild cardiomegaly, as noted previously. small amount of density layering along the minor fissure, increased compared to prior. ct head impression: 1. no evidence of acute intracranial process. 2. increased soft tissue density overlying the left frontal bone. correlation with physical exam is recommended. tte the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. left ventricular systolic function is hyperdynamic (ef>75%). the right ventricular cavity is mildly dilated with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. moderate (2+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. mild to moderate (+) mitral regurgitation is seen. due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (coanda effect). the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. impression: near-hyperdynamic left ventricular systolic function. at least mild-to-moderate mitral regurgitation, directed posteriorly. moderate aortic regurgitation. moderate tricuspid regurgitation. severe pulmonary hypertension. compared with the prior study (images reviewed) of , the degrees of mitral regurgitation, tricuspid regurgitation and pulmonary hypertension have increased. brief hospital course: 54f with hiv (cd4 469 on , vl undetectable on , was on haart since but discontinued due to recent hospitalization in burn unit secondary to large desquamating lichenoid hypersensitivity reaction which could have been reaction to ? art, cephalosporins, or cocaine) complicated by oi, ckd, dm, hepatitis c, recurrent uti, polysubstance abuse with recent cocaine relapse and history of cocaine/opiate abuse transferred from rehab for recurrent cons bacteremia, c. difficile infection, and acute encephalopathy. her hospital course was complicated by acute toxic-metabolic encephalopathy with impaired airway protection resulting in endotracheal intubation for airway protection with suspected ards, gnr bacteremia likely from skin breakdown, acute oliguric renal failure, and erythroderma necessitating transfer to burn unit for further care. # coagulase negative staph, proteus mirabilis, and escherichia coli bacteremia patient was noted to have two episode of coagulase negative staph bacteremias while at rehab in setting of mid-line and central line placements given underlying skin conditions. she was hemodynamically stable throughout hospitalization. blood cultures were obtained on admission showing also proteus mirabilis and escherichia coli bacteremia as well. sensitivities were obtained from blood cultures as below: proteus mirabilis | escherichia coli | | ampicillin------------ <=2 s =>32 r ampicillin/sulbactam-- <=2 s 16 i cefazolin------------- =>64 r cefepime-------------- <=1 s ceftazidime----------- <=1 s =>64 r ceftriaxone----------- <=1 s =>64 r ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s piperacillin/tazo----- s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s =>16 r id consultation was obtained. the patient was initially on iv vancomycin, and iv aztrenonam ( - ) but switched to meropenem due to clinically worsening and above data. cephalosporins were avoided given concern for lichenoid reaction. an echo did not suggest endocarditis. surveillance cultures on and are no growth to date suggestive of clearance. for drug monitoring, her last vancomycin trough (24.8) was on . per pharmacy, her vancomycin trough on before her next dose scheduled for 8 am on . transitional issues including follow-up of culture data, id consultation at , and continuing aforementioned antibiotics. # desquamating lichenoid hypersensitivity reaction patient recently presented to ed on with severe desquamating rash and transferred to burn unit. rash was determined to desquamating lichenoid hypersensitivity reaction which was treated by stopping art, avoidance of cephalosporins and drugs of abuse such as cocaine. dermatology was consulted on admission and recommended wrapping patient in saran wrap and using vaseline for skin care. no mucosal involvement was noted on admission. she was given copious ivf, and hugger was utilized given insensible losses and impaired thermoregulation. dermatology re-evaluation on revealed worsening mucosal involvement and new erythroderma. this raised concern for progression of her severe drug hypersensitivity eruption. this was felt to be secondary to art, specifically abacavir and lamuvidine, and potentially ceftriaxone to her recent admission to . she is not currently on any related medications. of note, her last attempted art was on resulting in maculo-papular rash. another consideration was paraneoplastic pemphigus given extensive oral involvement and reported history of castleman's disease. the patient's labs are concerning that she is not keeping up with insensible losses, among her other current physiologic needs, likely due to the loss of her barrier protection in her skin. it was recommended by dermatology that she be transferred to the burn unit given areas of skin breakdown, immunocompromised state, and need for aggressive nursing care and management of insensible losses although she does not have 10% bsa of full thickness epidermal necrosis transitional issues include medication list review with discontinuation of unnecessary medications. her only new medications are iv vancomycin and meropenem. she should also have daily cbc with differential (eosinophils 8% --> 16% --> 1%) in addition to daily lfts. biopsy was performed on at by dermatology and should be followed up. it was advised that all areas of exposed skin be covered with mupirocin and xeroform. # c. difficile infection: patient had positive c. difficile stool toxin on at rehab. she was switched from po vancomycin to iv flagyl given lack of ngt initially but then swithced back to po vancomycin 125 mg po q 6 hr. id should determine her final c. difficile course given aforementioned treatment of bacteremia with broad spectrum anti-microbials. # acute metabolic encephalopathy: patient was noted to be delirious recently at rehab in setting of hypoglycemia to 45 with self-discontinuation of her central access line. on admission, she was aaox2 with fluctuating mental status. her mental status continued to worsen - likely a combination of toxic-metabolic and septic encephalopathy given worsening laboratory abnormalities and infection. she was placed in wrist restraints. head ct on did not show acute intracranial process. an lp was considered; however, given the areas of skin breakdown, it was favored that the risk would exceed the benefit at current time although could be considered if mental status does not improve. the patient was intubated in the afternoon on for failure to protect her airway from copious secretions. her discharge ventilator settings are in physical exam section and last abg in laboratory section. she was started on ardsnet ventilation given appearance of cxr. a bronchoscopy was also performed showing no significant respiratory mucosal sloughing or debridement, mo mucosal lesions. the airways are patent with minimal blood-tinged, easily suctionable secretions in the right mainstem and the right upper lobe. there was no endobronchial masses # adrenal insufficiency- patient had iatrogenic cushings disesae due to mucosal clobetasol when re-started on drv/r/abc/3tc and then experienced adrenal insufficiency secondary to withdrawal from clobetasol. she was initially given iv solumedrol given lack of enteral access. she was switched to po prednisone 10 mg ng for "stress dose" steroids given hypoglycemia on presentation and k/hco3 abnormalities that could be suggestive of adrenal issues. she should have her steroids tapered after acute illness. # acute on chronic kidney disease with oliguric renal failure her admission cr was at baseline (~ 2) with rise to ~ 3. her baseline is typically . the patient was given copious ivf including up to 350 cc/hr for insensible losses. she developed oliguric renal failure in the afternoon on . she may require renal replacement therapy if she continues to be oliguric. # hypoglycemia- likely multifactorial in setting of poor po intake and known history of acquired adrenal insufficiency. her blood glucose improved with stress dose steroids and normalized with enteral feedings. # eye infection- patient has bilateral crusting of eyes with some discharge. ophtamology evaluated the patient and was concerned about infection. she was started on multiple eye drops (see medication). culture results were as below: gram stain (final ): reported to and read back by i. demenezes, r.n. on at 1010. no polymorphonuclear leukocytes seen. 3+ (5-10 per 1000x field): gram positive cocci. in pairs. 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (preliminary): staph aureus coag +. heavy growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . escherichia coli. moderate growth. piperacillin/tazobactam sensitivity testing available on request. proteus mirabilis. sparse growth. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | escherichia coli | | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- =>64 r ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s <=1 s levofloxacin---------- =>8 r meropenem------------- <=0.25 s oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=0.5 s =>16 r vancomycin------------ 1 s fungal culture (preliminary): no fungus isolated. she should have continued eye consultation at . # hiv complicated by oi her outpatient provider is . at . her art continues to be on hold given aforementioned hypersensitivity reaction. her famciclovir was changed to acyclovir for therapeutic exchange. # diastolic heart failure/hypertension patient has history of diastolic heart failure and pulmonary hypertension. a tte was performed (see results section). her anti-ischemic/chf regimen was held including isosrbide mononitrate, metoprolol, and hydralazine. there was also a question of drug-induced lupus with hydralazine at rehab, which should not be continued in the future. # depression/anxiety her bupropion andclonazepam were held. #access: left femoral line (), will need to re-site to internal jugular site or obtain picc/peripherals once less agitated/stabilized #precautions: c. diff/mrsa #code: full code # communication: the patient has two hcp a) relationship: mentor and friend phone number: b) relationship: son phone number: # pending studies - multiple blood cultures are pending - pathology specimen was obtained on , pathology pending # transitional issues - as above - sutures in the right thigh from biopsy on can be removed in days medications on admission: home medications: unknown discharge medication from rehab: - arixtra 2.5 mg sc qd - vancomycin 1 gm iv qd - lidocaine patch topically left and right hip - vancomycin 250 mg po q 6 hr - iron sucrose 100 mg iv daily, total of 1 gram - sodium chloride 2 gm po q 8 hr - furosemide 40 mg po qd - protonix 40 mg po qd - magnesium oxide 400 mg po bid - nitroglycerin prn - ambien prn - loratadine 10 mg po qd - zinc sulfate 220 mg po qd - famciclovir 500 mg po qd - prednisone 5 mg po qd - multivitamin po qd - ergocalciferol 50,000 units po bid - folic acid 1 mg po qd - petroleum topically daily - isosorbide mononitrate 30 mg po qd - mupirocin topically daily - metoprolol tartrate 12.5 mg po bid - hydralazine 100 mg po tid - ascorbic acid 500 mg po bid - diphenhydramine/lidocaine/antacid 10 ml tid - bupropion 150 mg po bid - clobetasol one topically - trazodone 100 mg po qhs - hydroxyzine 25 mg po qhs - ophthalmic lubricant ophthalmically qhs - oxycodone prn - diphenhydramine prn - clonazepam prn - albuterol sulfate prn - acetaminophen prn discharge medications: 1. acyclovir 400 mg po q12h 2. aquaphor ointment 1 appl tp tid 3. artificial tears 1-2 drop both eyes q2h dry eyes 4. artificial tears preserv. free 1-2 drop both eyes q2h 5. diphenhydramine 25 mg iv q6hr hold if too sedated 6. famotidine 20 mg po q24h 7. fentanyl citrate 25-100 mcg/hr iv drip infusion allow : yes : 50 mcg mr x2 q1h prn 8. fexofenadine 120 mg po bid 9. hydromorphone (dilaudid) 0.5-2 mg iv q2h:prn pain 10. meropenem 500 mg iv q12h d1 = chagned from aztreonam 11. metoprolol tartrate 12.5 mg po bid hold for sbp<100 or hr<60 12. midazolam 0.5-2 mg/hr iv drip titrate to rass -3 moderate sedation movement/eye opening to voice (no eye contact) allow : yes : 1 mg mr x2 q1h prn patient must have adequate airway support prior to administration of dose. 13. moxifloxacin *nf* 0.5 % ou qid reason for ordering: per eye consult wait 5 minutes between drops 14. moxifloxacin *nf* 0.5 % ou qid reason for ordering: per eye consult wait 5 minutes between drops 15. polyethylene glycol 17 g po daily:prn constipation 16. prednisolone acetate 1% ophth. susp. 1 drop both eyes qid 17. prednisone 10 mg po bid stress dose (not home dose) 18. senna 1 tab po bid:prn cosntipation 19. vancomycin 1000 mg iv q48h start: in pm 20. vancomycin oral liquid 125 mg po q6h d1 = 21. zinc sulfate 220 mg po daily discharge disposition: extended care facility: - discharge diagnosis: desquamating hypersensitivity skin reaction respiratory failure renal failure gram negative rod bacteremia coag negative staph bacteremia hiv discharge condition: mental status: confused - always. level of consciousness: lethargic and not arousable. activity status: bedbound. discharge instructions: dear ms. , you were admitted to the after you were found to have a blood stream infection when you were at rehab. while you were here you were seen by the dermatologist and infectious disease specialists and eye specailists. you were treated with iv antibiotics for your blood stream infection and had management of your skin problems. became more confused and unable to protect your airway so you were intubated (breathing tube) on and were found to have evidence of inflammation in your lungs. your kidneys stopped making as much urine and it was felt that you would benefit from specialized care in a burn unit so are being transferred to burn unit. trnasitional issues: -management of respiratory function- patient is intubated and being ventilated based on a ards protocol given cxr findings -biopsys were performed on -results pending at pathology lab -sutures will need to be removed -renal function needs to be monitored closely as decreased urine output despite attempts at aggressive fluid hydration -management of skin reaction- biopsy was taken on and is pending at pathology at the time of transfer -repeat tte was transferred followup instructions: department: when: wednesday at 9:40 am with: , md building: sc clinical ctr campus: east best parking: garage department: west clinic when: thursday at 11:00 am with: , md building: de building ( complex) campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube other bronchoscopy diagnoses: acidosis hyperpotassemia thrombocytopenia, unspecified congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified depressive disorder, not elsewhere classified cocaine abuse, unspecified human immunodeficiency virus [hiv] disease chronic kidney disease, unspecified anxiety state, unspecified acute respiratory failure bacteremia antiviral drugs causing adverse effects in therapeutic use iron deficiency anemia, unspecified metabolic encephalopathy glucocorticoid deficiency staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus enlargement of lymph nodes proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site chronic diastolic heart failure insomnia, unspecified cushing's syndrome other and unspecified escherichia coli [e. coli] other specified erythematous conditions hypoglycemia, unspecified purulent endophthalmitis, unspecified prurigo 

Answer: The patient is high likely exposed to