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: penicillins / pollen extracts attending: chief complaint: incidental finding of cystic neuroendocrine neoplasm. major surgical or invasive procedure: : 1. distal pancreatectomy with splenectomy. 2. ligation of intra-abdominal vessel for control of hemorrhage (splenic arterial takeoff). history of present illness: mr. is a 69-year-old gentleman who has pulmonary issues including copd and chronic bronchitis and pulmonary infections. in the workup of one of his recent bouts with this, a ct scan was performed and cuts from this revealed a cystic lesion in the pancreas. this was focused on the tail. he subsequently was worked up with an endoscopic ultrasound and aspiration of this tissue revealed a cystic neuroendocrine neoplasm. the features of this were a size close to 3 cm in diameter along with some enhancing features suggestive of solid tumor growth and malignancy. furthermore, a detailed ct scan the abdomen showed that he had multiple cystic lesions throughout his liver and kidneys; but that there was a suspicious-appearing lesion in the superior pole of the left kidney that might also be a neoplastic problem. was admitted for planned distal pancreatectomy. past medical history: pmhx: pancreatic neuroendocrine tumor, hyperlipidemia, htn, asthma, copd, h/o cva, ha, obesity, hiatal hernia, renal insufficiency, renal cyst, liver cysts. . pshx: eus, appy; umbilical hernia repair . social history: married. family history: non-contributory physical exam: pre-admission examination : his abdomen is soft, nontender, and nondistended with positive bowel sounds. he has a well-healed umbilical hernia scar and appendectomy incision. there is no evidence of recurrent hernia. he is extremely rotund in the abdomen and would be considered obese. there is no evidence of any hernias or masses in his inguinal and genital region. a rectal exam is deferred today. the rest of his physical exam is entirely normal with the exception of coarse expiratory rhonchi bilaterally. . at discharge: avss/afebrile. gen: well appearing male in nad. heent: sclerae anicteric. o-p clear. neck: supple. lungs: cta(b) cor: rrr; nl s1/s2 w/o m/c/r abd: incision with steri-strips c/d/i. bsx4. soft/nt/nd. extrem: no c/c/e neuro: a+ox3. non-focal/grossly intact. pertinent results: on admission: 01:16pm freeca-1.07* 01:16pm hgb-13.5* calchct-41 01:16pm glucose-142* lactate-1.1 na+-141 k+-3.8 cl--106 01:16pm type-art po2-87 pco2-40 ph-7.42 total co2-27 base xs-0 04:31pm freeca-0.99* 04:31pm hgb-11.7* calchct-35 04:31pm glucose-156* lactate-2.0 na+-138 k+-4.5 cl--108 05:32pm freeca-0.87* 05:32pm hgb-11.7* calchct-35 05:32pm glucose-168* lactate-3.1* na+-139 k+-4.9 cl--114* 05:32pm type-art po2-311* pco2-44 ph-7.27* total co2-21 base xs--6 06:28pm freeca-0.97* 06:28pm hgb-13.7* calchct-41 06:28pm glucose-169* lactate-3.0* na+-140 k+-5.5* cl--113* 08:15pm fibrinoge-160 08:15pm pt-15.1* ptt-29.1 inr(pt)-1.3* 08:15pm plt count-152 08:15pm wbc-18.4*# rbc-4.92 hgb-14.4 hct-43.2 mcv-88 mch-29.3 mchc-33.4 rdw-14.9 08:15pm estgfr-using this 08:15pm glucose-204* urea n-17 creat-1.1 sodium-142 potassium-5.8* chloride-114* total co2-22 anion gap-12 08:58pm freeca-1.04* 08:58pm lactate-1.4 10:25pm glucose-253* potassium-4.8 10:38pm freeca-1.38* . prior to discharge: 06:05am blood wbc-30.9* rbc-2.78* hgb-7.9* hct-24.5* mcv-88 mch-28.5 mchc-32.4 rdw-15.1 plt ct-1072* 06:05am blood glucose-132* urean-12 creat-1.1 na-136 k-4.2 cl-100 hco3-25 angap-15 06:05am blood calcium-8.2* phos-3.7 mg-1.9 . imaging: cta abd (pre-admit): 1. 2.6 x 2.4 x 2.7 cm predominantly cystic lesion in the body of the pancreas, with a thin periphery of enhancement, and 1.5 x 1.1 cm nodular area of enhancement along its superior margin. results from recent endoscopic fna biopsy are consistent with a neuroendocrine lesion, which is concordant with the imaging findings. no definite evidence of metastatic disease within the abdomen. 2. multiple bilateral renal cystic lesions, several of which are hyperdense. the majority of these are consistent with renal cysts, and are statistically most likely benign. however, 2.4-cm left upper pole cystic lesion is more mass-like, enhances substantially more from the other lesions, and is suspicious for renal neoplasm. this lesion would be amenable to image-guided biopsy. . cxr: et tube ends at the thoracic inlet, nasogastric tube passes into the upper stomach, right jugular line tip is at the junction of brachiocephalic veins. heart size is normal. mediastinal vasculature is engorged but there is no pulmonary edema. bibasilar atelectasis is severe, worsened since . . chest/abd/pelvic ct: 1. post-surgical changes, status post partial pancreatectomy and splenectomy with small amount of fluid at the pancreatic bed just at the tip of drainage catheter. 2. bilateral lower lobe consolidations may represent aspiration,pneumonia, or atelectasis. 3. apparent air in the nondependent portion of the cecum and proximal ascending colon is unlikely to represent pneumatosis and likely represents air mixed with fecal material. there is no portal venous air or free peritoneal air to suggest ischemia. 4. dilated loops of small bowel with no definite transition point most likely representing paralytic ileus. clinical correlation and follow-up is suggested. 5. bilateral renal lesions, with the largest measuring 2.4 cm in the left upper pole which is suspicious for renal neoplasm due to soft tissue attenuation. 6. multiple liver hypodensities, likely cysts. 7. small hiatal hernia. . chest/abd/pelvic ct: 1. multifocal bilateral lung consolidations compatible with pneumonia. this has worsened in the interval. 2. partial pancreatectomy and splenectomy changes with inflammatory changes and fluid in the surgical bed. the drain appears to be in appropriate position. no discrete or drainable fluid collection is identified on this limited non-contrast study. 3. interval worsening small-bowel dilatation with bowel wall thickening. these findings are concerning for developing partial small-bowel obstruction, with a transition to normal caliber near the surgical site. no pneumoperitoneum or portal venous air is demonstrated. 4. multiple hepatic cysts. 5. bilateral renal lesions, some of them dense, which may represent complicated cyst versus underlying mass lesion. the need for further evaluation with ultrasound should be determined on a clinical basis. 6. diverticulosis with no signs of acute diverticulitis. . echo: image quality is very limited. the left atrium is elongated. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef 70%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. there are focal calcifications in the aortic arch. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is no pericardial effusion. impression: suboptimal image quality. this is a nondiagnostic study - no obvious intracardiac shunt seen during color flow imaging and air buibble contrast injection, but cannot be excluded with certainty on the basis of this study . cxr: bibasilar opacities most consistent with atelectasis although underlying infiltrate cannot be excluded. . pathology: specimen submitted: distal pancreas, middle pancreas, spleen: diagnosis: i. middle pancreas (a-b): benign pancreatic tissue. ii. distal pancreas, distal pancreatectomy (c-h): well differentiated neuroendocrine tumor, see synoptic report. iii. spleen (i-j): spleen with congestion; no malignancy identified. pancreas (endocrine): resection synopsis macroscopic specimen type: partial resection, pancreatic tail. tumor site: pancreatic tail. tumor focality: unifocal. tumor configuration: circumscribed: cystic and nodular, partially encapsulated. tumor size greatest dimension: 2.5 cm. additional dimensions: 2.3 cm x 1.9 cm. other organs/tissues received: spleen. microscopic functionality type: pancreatic endocrine tumor, secretory status unknown. extent of invasion primary tumor: tumor limited to pancreas. regional lymph nodes: pn0: no regional lymph node metastasis. lymph nodes number examined: 2. number involved: 0. distant metastasis: pmx: cannot be assessed. margins: uninvolved by tumor: distance from closest margin: 15 mm, microscopically . specified margin: pancreatic parenchymal margin. lymphovascular invasion: present. perineural invasion: absent. mitotic activity: absent. additional pathologic findings: none identified. comments: the tumor has been characterized previously by immunohistochemistry (specimen s09-; positive for ae1/ae3, cam5.2, synaptophysin, and chromogranin). the tumor has a mitotic index of 0-1/50 hpf. the tumor invades into adjacent pancreatic parenchyma but does not invade peripancreatic soft tissue. clinical: pancreatic mass. gross: the specimen is received fresh in three containers, all labeled with the patient's name, ", ", and the medical record number. part 1 is additionally labeled "middle pancreas." it consists of an unoriented segment of pancreas with attached blood clot measuring overall 5 x 3.1 x 2.1 cm. the pancreatic parenchymal margins are inked in yellow and the outside surface of the pancreas is inked blue. the specimen is serially sectioned to reveal soft tan yellow lobulated cut surfaces with no obvious lesions noted. the specimen is represented as follows: a = sections of the parenchymal margin, b = representative sections of pancreas. part 2 is additionally labeled "distal pancreas." it consists of a distal pancreatectomy specimen measuring 4.5 x 3.5 x 2.7 cm with attached peripancreatic adipose tissue measuring 5 x 1.6 x 1.1 cm. the parenchymal resection margin is inked yellow and the outer surface of the pancreas is blue inked and the specimen is sliced horizontally to reveal a solid-cystic mass measuring 2.5 x 2.3 x 1.9 cm, located 2 cm away from the parenchymal resection margin at its closest approach. the cyst is filled with a clear serous fluid and contains a focally solid area measuring 2 x 1.2 x 0.2 cm. the specimen is represented as follows: c = sections through the parenchymal resection margin, d = section of the mass in relation to the normal pancreas and the parenchymal resection margin, e-g = additional representative sections of mass, h = sections of the peripancreatic fat containing possible lymph nodes. part 3 is additionally labeled "spleen." it consists of a splenectomy specimen with attached adipose tissue measuring overall 14.5 x 12.8 x 3.5 cm and weighing 311 grams. the spleen is serially sliced to reveal maroon brown cut surfaces with no gross lesions identified. the specimen is represented as follows: i = sections of hilar fat containing possible lymph nodes, j = sections of spleen. . microbiology: urine urine culture: no growth to date - prelim. blood culture: no growth to date - prelim. blood culture: no growth to date - prelim. blood culture:no growth to date - prelim. catheter tip: no growth. blood culture: no growth to date - prelim. blood culture:no growth. blood culture: no growth. blood culture: no growth. urine urine culture:no growth. blood culture:no growth. sputum gram stain-final; respiratory culture-final {yeast} stool clostridium difficile toxin a & b test: positive for clostridium difficile - final. blood culture: no growth. urine urine culture:no growth. blood culture: no growth. mrsa screen mrsa: negative. urine urine culture:no growth. blood culture: no growth. blood culture: no growth. urine urine culture: no growth. mrsa screen mrsa screen: negative. brief hospital course: the patient was admitted to the general surgical service on for for planned distal pancreatectomy. on that date, the patient underwent distal pancreatectomy with splenectomy, which was complicated by major intraoperative hemorrhage requiring additional ligation of intra-abdominal vessel for control of hemorrhage (splenic arterial takeoff). during the surgery, the patient required the administration of 7000 ml of crystalloid, 1000ml of 5% albumin, two units of ffp, and 9 units of packed red blood cells. he remained hemodynamically stable throughout the procedure(reader referred to the operative notes for details). after the surgery, the patient was admitted to the ticu, where he arrived npo with an ng tube, intubated on mechanical ventilation and neomycin infusion, on iv fluids, with a foley catheter and two jp drain in place, and a dilaudid/bupivacaine epidural for pain control. . while in the ticu, he was treated for hyperkalemia with a return of his potassium to a baseline of 3.8-4.6. on pod#1, the patient was successfully extubated. serial hematocrits remained stable. he remained hemodynamically stable, and was transferred to the inpatient floor later that day. . post-operative pain was initially well controlled with the epidural, which was converted to just a dilaudid pca on pod#4. when tolerating a diet, the pca was discontinued, and the patient started on oral pain medications with continued good effect. the ng tube was discontinued, and the patient started on clears on pod#5. his diet was progressively advanced as tolerated to fulls by pod#6. the foley catheter discontinued in the afternoon of pod#4, six hours after the epidural was discontinued. as he was unable to void, the foley was replaced, and he was started on flomax. post-splenectomy immunizations consisting of the pneumovax, meningicoccal, and haemophilus b vaccines were given on pod#5. at this point, the patient was being prepared for discharge in the next 1-2 days. . on pod#8, the patient went into atrial fibrillation, which could not be converted on the floor with metoprolol and lasix. the patient was emergently transferred to the ticu for further evalaution and care. he was intubated, placed on a neomycin drip, and treated for hyperkalemia. he was able to be extubated the next day. when hemodynamically stable, he was returned to 9 on , at which point the ng tube was out, he was npo except medications, on iv fluids, the foley was still in place, and the patient still on the dilaudid/bupivacaine epidural for pain control. while on the floor, his diet had been advanced to fulls, the epidural was discontinued, and the patient started on a dilaudid pca, and jp amylase levels were sent. . on , the patient again experienced atrial fibrillation, which could not be converted on the floor. he was cardioverted. he was transfered back to the ticu, started on a diltiazem drip, which was converted to an amiodarone drip due to hypotension. cycled cardiac enzymes were unremarkable. chest ct revealed findings consistent with aspiration pneumonia, for which patient was started on iv vancomycin and cefepime. abdominal/pelvic ct revealed apparent air in the nondependent portion of the cecum and proximal ascending colon is unlikely to represent pneumatosis and likely represents air mixed with fecal material. there is no portal venous air or free peritoneal air to suggest ischemia. dilated loops of small bowel with no definite transition point most likely representing paralytic ileus. he developed acute renal failure with a creatinine of 2.4, which responded well to iv fluid boluses x2 with inproved urine output. ngt was placed, and immediately 1l bilious fluid was suctioned. following the removal of fluid, his sao2 improved to low 90s, his nausea resolved, and his abdominal pain decreased to a . he required subsequent fluid boluses foe a fena of 0.1. repeat chest/abdominal/pelvic ct on demonstrated multifocal bilateral lung consolidations compatible with pneumonia, which had worsened in the interval. interval worsening small-bowel dilatation with bowel wall thickening concerning for developing partial small-bowel obstruction, with a transition to normal caliber near the surgical site was also noted. also, the patient had been experiencing multiple loose stools. c.diff was returned positive, and the patient was started on po vancomycin and flagyl in addition to iv vancomycin and cefepime. the patient was started on tpn. . on , the patient was again returned to 9 in stable condition. he was npo with an ng tube, on iv fluids and tpn, continued on iv vancomycin, flagyl, and cefepime as well as po vancomycin, a foley was in place, and he received acetaminophen for pain control. home medications were re-introduced after the ng tube was discontinued, and the patient started on sips. he experienced a transient low grade temperature on , and he was again cultured, but then defervesced. wbc did remain in the 24-30 range after splenectomy, but the wbc was stable. diet was advanced to low sodium/heart healthy regular diet by . tpn was discontinued on . foley was discontinued the morning of ; the patient was subsequently able to void without problem. had been removed, and steri-strips applied. incision remained clean and intact. by discharge, the aspiration pneumonia was treated, and there was four days remaining of treatment for c.diff. . during this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. physcial and occupational therapy were consulted. the patient received subcutaneous heparin and venodyne boots were used during this stay. the patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. he received glucose monitoring and insulin administration teaching. labwork was routinely followed; electrolytes were repleted when indicated. . at the time of discharge, the patient was doing well, afebrile with stable vital signs. the patient was tolerating his diet, ambulating with assistance, voiding without assistance, and pain was well controlled. he was discharged to an extended care facility for rehabilitation and nursing care. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po every hours as needed for fever or pain. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 4. flonase 50 mcg/actuation spray, suspension sig: sprays in each nostril nasal once a day as needed for allergy symptoms. 5. zocor 20 mg tablet sig: one (1) tablet po once a day. 6. buspirone 5 mg tablet sig: 1.5 tablets po qam and 1 tablet po (by mouth) qpm. 7. reglan 5 mg tablet sig: one (1) tablet po bid 8. multivitamin tablet sig: one (1) tablet po once a day. 9. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po once a day. 10. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 11. singulair 10 mg tablet sig: one (1) tablet po once a day. 12. proair hfa 90 mcg/actuation hfa aerosol inhaler sig: puffs inhalation four times a day as needed for shortness of breath or wheezing. discharge medications: 1. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po every hours as needed for fever or pain. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. disp:*60 capsule, delayed release(e.c.)(s)* refills:*11* 4. flonase 50 mcg/actuation spray, suspension sig: sprays in each nostril nasal once a day as needed for allergy symptoms. 5. zocor 20 mg tablet sig: one (1) tablet po once a day. 6. buspirone 5 mg tablet sig: 1.5 tablets po qam and 1 tablet po (by mouth) qpm. 7. reglan 10 mg tablet sig: one (1) tablet po qid with meals and at bedtime. disp:*120 tablet(s)* refills:*0* 8. multivitamin tablet sig: one (1) tablet po once a day. 9. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po once a day. 10. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 11. singulair 10 mg tablet sig: one (1) tablet po once a day. 12. proair hfa 90 mcg/actuation hfa aerosol inhaler sig: puffs inhalation four times a day as needed for shortness of breath or wheezing. 13. one touch ultra test strip sig: one (1) strips in four times a day. disp:*100 strips* refills:*2* 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 15. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 16. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 17. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation: hold for loose stools. 18. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 19. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 20. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po q6h (every 6 hours). 21. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 22. metoclopramide 10 mg tablet sig: 0.5 tablet po bid (2 times a day): give 30 minutes before breakfast and dinner . 23. insulin regular human 100 unit/ml solution sig: 4-12 units injection as directed per regular insulin sliding scale. 24. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 4 days: completion date: . 25. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: five hundred (500) mg intravenous every eight (8) hours for 4 days: completion date: . discharge disposition: extended care facility: health care center discharge diagnosis: 1. neuroendocrine cystic tumor of the tail of pancreas. 2. cystic lesion of the left kidney. 3. intraoperative hemorrhage. 4. acute on chronic renal failure 5. atrial fibrillation 6. bilateral aspiration pneumonia 7. clostridium difficile discharge condition: mental status:clear and coherent level of consciousness:alert and interactive activity status:ambulatory - independent discharge instructions: please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. avoid driving or operating heavy machinery while taking pain medications. please follow-up with your surgeon and primary care provider (pcp) as advised. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. *if you have , they will be removed at your follow-up appointment. *if you have steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. followup instructions: provider: , md phone: date/time: 9:45. location: 3, . . please call ( to arrange a follow-up appointment with dr. (pcp) in weeks. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances insertion of endotracheal tube other electric countershock of heart prophylactic administration of vaccine against other diseases prophylactic administration of vaccine against other diseases other surgical occlusion of vessels, abdominal arteries total splenectomy distal pancreatectomy insertion of catheter into spinal canal for infusion of therapeutic or palliative substances systemic to pulmonary artery shunt prophylactic vaccination against influenza diagnoses: pneumonia, organism unspecified hyperpotassemia other iatrogenic hypotension acute kidney failure, unspecified cardiac complications, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation accidental puncture or laceration during a procedure, not elsewhere classified chronic kidney disease, unspecified diaphragmatic hernia without mention of obstruction or gangrene other and unspecified hyperlipidemia pneumonitis due to inhalation of food or vomitus long-term (current) use of insulin intestinal infection due to clostridium difficile paralytic ileus need for prophylactic vaccination and inoculation against other specified disease personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits headache obesity, unspecified obstructive chronic bronchitis without exacerbation other specified disorders of liver accidental cut, puncture, perforation or hemorrhage during surgical operation edema neoplasm of uncertain behavior of kidney and ureter secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified malignant carcinoid tumor of other sites 

Answer: The patient is high likely exposed to