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: vicodin attending: chief complaint: odynophagia major surgical or invasive procedure: flex and rigid bronchoscopy x 2 radiation therapy to esophagus lumbar puncture eeg history of present illness: . 58f with a history of metastatic rcc complicated by extensive mediastinal mets requiring placement of bronchial stent who was recently admitted for near syncope where she had a work up including head ct, which was without changes, a cta of the chest which was negative for pe and showed stable masses and an echo which showed mild hypokinesis and an 40-45%. she noted yesterday she had a low grade temp 100.4 that she states went up to 102 so she contact her oncologists dr and dr who told her to come to the hospital if it continued above 100.4. she has also been experiencing a significant amount of throat pain from her esphagitis and was encouraged to use lidocaine/ benedryl for this. she has been unable to swallow and her po intake is down. she has also noted flu like symptoms over the past few days such as myalgias cough with yello sputum, body aches. she just recieved radiation therapy yesterday. she was started on palliative chest xrt () and chemotherapy with sunitinib. in the ed she was tachycardiac on presentation to 123 and improved with fluids. she had a t max of 101.4 for which she was given rectal tylenol. she had nausea and was give 8mg zofran. blood and urine cultures were drawn, she was flu swabbed and she was started on levofloxasin. her wcc was 1.4 and anc 1275. lactate 1.1 past medical history: past oncologic history: the patient was in usoh until winter of when she developed cold symptoms which did not clear with antibiotics. she developed hemoptysis, which was evaluated in with x-rays of the chest. lung mediastinal mass was detected on cxr, which was followed by a ct scan, which confirmed a mass in the mediastinum. scanning also indicated a mass in the left kidney. this was further evaluated with imaging studies of the abdomen, which showed a large left renal mass measuring 15 x 11 cm. lytic lesion was also detected in the right acetabulum. she was further evaluated with mri which showed a left renal mass with no evidence of involvement of the left renal vein. mri scan showed a mass in the vertex of the skull measuring 5 cm in greatest dimension. she underwent a bronchoscopy to evaluate the hemoptysis symptoms and biopsy the lung mass. however, pathology from this study was inconclusive. she underwent a biopsy of the left kidney mass, which showed renal cell carcinoma nuclear grade 1. these slides have been reviewed and showed renal cell carcinoma, clear cell type, and nuclear grade 1. with these findings, she underwent radiation therapy to the right hip and leg receiving 10 treatments at the . following these treatments, she was evaluated by the biologics group and the urology group for definitive treatment of renal cell carcinoma. recommendation was for dendritic cell vaccine therapy. for this therapy, she will require a tumor sample. she is now s/p left debulking nephrectomy . ====================== past medical history: - renal ca metastatic to skull, r hip, lungs, medistiastinum as above - airway compression, s/p y-stent - sciatica ==================== social history: married. occ etoh, 30-40pkyr hx of smoking, no illicits family history: non-contributing oncologic history physical exam: vitals: stable hr 100 bp 121/65 o2 98% 2l t 98.1 general: laying on the bed with discomfort in her neck pt not allowing palpation of neck due to pain cvd tachy lungs: scattered rhonchi all lung fields abdomen soft non distended diffuse tenderness ext wwp back no cva tenderness ln no axillary or femoral ln palpated exam on discharge: 97.6 110/70 100 18 96% ra 590+2260/3750 general: laying on the bed, nad, communicative, a and o x 3 and appropriate - perrla, eomi, clear oropharynx cv- regular rhythm, tachycardic, no m, r, g lungs: left lung has improved breath sounds s/p bronchoscopy, clear on right abdomen soft, non distended, non-tender to palpation, no guarding/rebound, active bs ext wwp no cva tenderness ln no axillary or femoral ln palpated pertinent results: tte: the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses and cavity size are normal. there is severe global left ventricular hypokinesis (lvef = 20 %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. with normal free wall contractility. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. tricuspid regurgitation is present but cannot be quantified. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. . compared with the prior study (images reviewed) of , the lvef has significantly decreased. there is now a small pericardial effusion. . ct abdomen/pelvis 1. distended gallbladder, with no definite ct evidence of cholecystitis. if clinical concern, this can be further evaluated with hida scan. 2. interval free fluid in the abdomen, mostly at the perihepatic and perisplenic distribution and tracking along the right paracolic gutter into the pelvis. bilateral pleural effusions. 3. questionable wall thickenning of the colon at the splenic flexture, could be due to collapsed colon; however this finding can be seen in colitis, if there is clinical concern. 4. stable right acetabular lesion with pathologic fracture at the right inferior acetabulum, unchanged. multiple lesions within the spine consistent with metastatic disease, with possible hemangioma at l1. 5. status post left nephrectomy with no definite evidence of recurrence at the surgical bed. . eeg : this is a normal video eeg study. interictal background activity was normal. there were no epileptiform discharges or electrographic seizures. compared to recording from 24 hours prior, this study contains fewer electrographic seizures . eeg this is an abnormal portable eeg due to continuous generalized rhythmic spike and slow wave activity at a frequency of 2.5 hz for the first half of this record consistent with non-convulsive status epilepticus. eeg markedly improved after administration of i.v. ativan with resolution of non-convulsive status and only brief short bursts of generalized spike slow wave discharges in the latter half of the study. no focal lateralizing features were noted. an irregularly irregular rhythm was seen on cardiac monitor. based on these findings, we would recommend long-term monitoring for this patient . mr head: compared to the previous mri from , the soft tissue component associated with the vertex frontal bone calvarial lesion has markedly decreased in size likely reflecting interval treatment. the bony component appears relatively stable. this may represent treated neoplasm in bone. . left frontal scalp lesion is unchanged compared to the most recent study. . there is no evidence for intracranial metastatic disease. . there is diffuse pachymeningeal enhancement, which may be related to prior radiation/lp or infectious/inflammatory sequela. appearance is not suggestive of dural mets. there is a tiny 5- mm left frontal subdural focal thickening or collection which does not cause mass effect. . cxr (post-bronch): atelectasis in the left base has minimally improved. cardiomediastinal contours are unchanged. patient has known mediastinal and hilar lymphadenopathy and right rib metastatic lesion. there is no evident pneumothorax or enlarging pleural effusion. the left hemidiaphragm is elevated. stent is seen in the left main bronchus . cxr: complete white out of the left hemithorax and shifting of the cardiomediastinum towards the left is unchanged due to collapse of the left lung. assessment of the left pleural effusion is limited. the right lung is grossly clear. destructive lesion in the lateral aspect of right mid rib is again noted. . labs on discharge: wbc rbc hgb hct mcv mch mchc rdw plt ct 1.6* 2.90* 8.5* 24.6* 85 29.2 34.3 21.3* 200 . neuts bands lymphs monos eos baso atyps metas myelos 68 2 14* 14* 0 0 0 2* 0 . pt 11.5 ptt 26.4 inr 1.0 . glucose urean creat na k cl hco3 angap 108* 17 0.6 136 4.4 101 25 14 . alt ast alkphos totbili 11 15 78 0.2 . calcium phos mg 8.7 3.4 2.2 brief hospital course: 58 year old female with metastatic renal cell carcinoma to skull, mediastinum, lungs, s/p y stent placement presented with an episode of fever, nausea and worsening dysphagia/odynophagia. . # fever/odynophagia/dysphagia- initial differential diagnosis of this constellation of symptoms included esophagitis from radiation, thrush, or mucositis. flu swab was negative. the patient was initially given levofloxacin in the ed, but this was discontinued. the patient also received supportive care, including magic mouthwash, sucralfate, ppi, h2 blocker, morphine, and reglan. fluconazole was given for oral/esophageal candidiasis. . # renal cell carcinoma- patient recently completed course of radiation therapy to skull and espophagus. sutent had been started and was initially continued upon admission with good response. sutent was then discontinued in the setting of developing pancytopenia, which improved following cessation of the drug. . # mental status- the patient had an episode of altered mental status on that was attribued to hyponatremia. she required a brief course in the icu, received ivf and hypertonic saline with improvment in both her mental status and hyponatremia (thought to be due to mild hypovolemia and siadh). the patient was hypotensive thought to be due to hypovolemia, which improved with ivf. an echocardiogram was obtained, and her lvef was depressed at 20%. the patient did not have any other signs or symptoms of chf, and was started on metoprolol and lisinopril. her depressed ef was non-ischemic in etiology and was thought to be due to either radiation or sutent. . the patient then developed second episode of ams on - patient was non-verbal/non-communicative, not somlonent. an lp was performed, which showed a normal opening pressure, with no evidence of infection. the patient received empiric ceftriaxone, vancomycin, and acyclovir which were all discontinued after cultures were negative. an eeg on showed that the patient was in non-convulsive status epilepticus. she was loaded with ativen and fosphenytoin with near-immediate improvement in her mental status. she again required a brief stay in the icu to monitor her airway after receiving anti-epileptic therapy. her airway was never compromised. she initially received phenytoin, but developed a leukopenia thought to be secondary to phenytoin. she is now being bridged to keppra and doing well. she will continue taking phenytoin 100 mg tid for six days. she will continue taking keppra 500 mg for three days, then keppra 750 mg for three days, then keppra 1000 mg ongoing. . # bronchial stents- the patient underwent a flex bronchoscopy on which showed increasing tumor burden in the left main stem bronchus. post-bronchoscopy, the patient was noted to have decreased breath sounds on the left, and a chest film showed a white out of her left lung. the patient never dveloped an oxygen requirement. a scheduled rigid bronchoscopy on was performed which showed an occluded left main stem with granulation tissue, dilation was performed and a stent was replaced in the left main stem with good effect and significant improvement in her chest film. the patient has scheduled follow up with her outpatient pulmonologist on . . # prophy: mobilization (patient will need continued physical therapy, ppi, bowel regimen) nutrition: the patient was tolerating some po intake at discharge, and was also receiving ppn. please cont transition to full regular diet access: piv code: full medications on admission: docusate sodium 100 mg capsule po bid folic acid 1 mg tablet po daily senna 8.6 mg tablet sig: one tablet po bid morphine 30 mg tablet sustained release i tab po q12 hydromorphone 2 mg tablet sig: 1-2 tablets po q3h tessalon perle 100 mg capsule sig: one capsule po tid prn levalbuterol hcl 0.63 mg/3 ml 1 neb q4 hours prn ipratropium bromide 0.02 % solution one (1) neb q6h prn lactulose(30) ml po q8h as needed for constipation. reglan 10 mg one (1) tablet po every 6-8 hours prn nausea ferrous sulfate 325 mgone (1) tablet po once a day. ativan discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 4. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 3 days. 5. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day) for 6 days. 6. levetiracetam 750 mg tablet sig: one (1) tablet po twice a day for 3 days. 7. levetiracetam 1,000 mg tablet sig: one (1) tablet po twice a day. 8. maalox 200-200-20 mg/5 ml suspension sig: 15-30 mls po every six (6) hours as needed for pain with swallowing. 9. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 10. lidocaine hcl 2 % solution sig: twenty (20) ml mucous membrane tid (3 times a day) as needed for pain. 11. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed for constipation. 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 13. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 15. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 16. lorazepam 0.5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for anxiety/seizure. 17. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 18. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) gm po daily (daily) as needed for constipation. 19. acetylcysteine 20 % (200 mg/ml) solution sig: one (1) neb miscellaneous tid prn () as needed for wheezing/cough. 20. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 21. guaifenesin ac 10-100 mg/5 ml syrup sig: ml po four times a day as needed for cough. 22. mucinex 1,200 mg tab, multiphasic release 12 hr sig: one (1) tab, multiphasic release 12 hr po twice a day. discharge disposition: extended care facility: - - discharge diagnosis: primary diagnosis: renal cell cancer with mediastinal/bronchial metastases secondary diagnoses: systolic chf sciatica chronic sinusitis benign breast cyst c-section seasonal allergies discharge condition: stable and improved discharge instructions: you were admitted to the hospital with difficulty swallowing and fever. you finished radiation to your esophagus, and your discomfort was thought to be due to a possible infection in your esophagus or from the radiation itself. you then developed some confusion, which was thought to be due to a low sodium level. you improved somewhat after your sodium was increased and you received ivf. however, you developed increased confusion and an inability to speak, which was due to a seizure. this improved dramatically after you received treatment for your seizure. you will need to continue taking a medication to prevent future seizures. you also had an ultrasound of your heart which showed decreased function (ef of 20%), but luckily you did not have symptoms from this. you also had 2 bronchoscopies to help clean out your airways. you will need rehabilitation. . medications: most of your medications have changed. please see the list provided to your rehabilitation center. - you will be transitioned from phenytoin to keppra as indicated on your medication list and on the discharge summary. . please call your doctor or return to the er if you have increasing pain, confusion, fevers/chills, nausea/vomiting, diarrhea, chest pain or other concerns. followup instructions: you should call the neurology clinic ( for an appoinment in the next 2-4 weeks. , md phone: date/time: 2:00 , md phone: date/time: 2:00 , md phone: date/time: 10:00 procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified spinal tap incision of lung parenteral infusion of concentrated nutritional substances fiber-optic bronchoscopy other intubation of respiratory tract endoscopic excision or destruction of lesion or tissue of bronchus bronchial dilation diagnoses: pneumonia, organism unspecified other iatrogenic hypotension unspecified pleural effusion congestive heart failure, unspecified unspecified septicemia severe sepsis atrial fibrillation malignant neoplasm of kidney, except pelvis candidiasis of mouth pulmonary collapse poisoning by benzodiazepine-based tranquilizers accidental poisoning by benzodiazepine-based tranquilizers alkalosis septic shock grand mal status antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use secondary malignant neoplasm of lung encephalopathy, unspecified hypovolemia phlebitis and thrombophlebitis of superficial veins of upper extremities other and unspecified infection due to central venous catheter acute on chronic systolic heart failure other disorders of neurohypophysis secondary malignant neoplasm of bone and bone marrow secondary malignant neoplasm of mediastinum radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure other esophagitis candidal esophagitis hydantoin derivatives causing adverse effects in therapeutic use other specified aplastic anemias 

Answer: The patient is high likely exposed to