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: sulfa (sulfonamide antibiotics) / azithromycin / dapsone / spironolactone / tenofovir attending: chief complaint: bradycardia major surgical or invasive procedure: right internal jugular line placement right tunneled line placement history of present illness: mr. is a 61yo male with a past medical history significant for cad s/p cabg in , hiv, hepatitis b and c, who presented to the ed with bradycardia to the 30s. the patient reports that he was in his baseline state of health until about 24 hours prior to admission, when he began to feel sob. he also reports that he had chest pressure for about the day prior to admission, which was relieved with administration of oxygen in the ambulance. the patient reports taht he has been eating a lot of potatoe chips lately. he denies use of heroin and cocaine since mid-. notably, the patient is somnolent and it is difficult to obtain a throrough history although he does answer questions appropriately. he denies cough, fevers, , sore throat, rhinorrhea, headache, ear pain, sick contacts. says that he is able to walk down his hallway and is not able to walk up stairs, limited by shortness of breath. he denies orthopnea. he denies recent travel, no hiking and no tick bites. in the ed, the patient was initially bradycardic to the 30s and initially normotensive, but his pressures then dropped to systolic 70s. bedside ultrasound was performed which showed no pericardial effusion and poor ventricular squeeze. fingerstick was 99. the patient was given atropine 1mg without change. there was concern for beta blocker vs calcium channel blocker overdose and the patient was given glucagon 5mg po with zofran. the patient vomited in response. a cordis was placed in the rij and a dopamine drip was started which increased her hr to 50s and sbp to 100. a cxr revealed bilateral pleural effusions, unable to exclude pna. the patient was started on broad spectrum abx for presumed pna. the patient did receive about 1l of ns. throughout the patient's time in the ed, he was mentating well. labs are notable for creatinine 4.2 (baseline 1.5), troponin 0.03, lactate 3 and potassium 6.1 repeat k is 4.2. on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. he denies recent fevers, or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: - diabetes mellitus - dyslipidemia - hypertension - coronary artery disease s/p cabg with lima to lad, svg to om, s/p rca stent in , re-stented in , positive stress test in - chf, lvef 40-45% in - hiv infection diagnosed in - hepatitis c, genotype 2, not treated. last liver biopsy in showed mild portal and periportal lobular inflammation grade 1 along with increased portal fibrosis with focal septal and bridging fibrosis. - hepatitis b hbsag-, hbsab+, hbcab+ - tuberculosis s/p treatment - anemia of chronic disease - pvd - history of r ocular stroke - status post left arm surgery for necrotizing fasciitis. - status post left hip surgery for abscess. - status post vats for pleural biopsy due to bloody pleural effusion - cytology (-) for malignancy; c/b wound dehiscence - renal insufficiency. cr 1.2-1.5 - hypokalemia. - erectile dysfunction. - lipodystrophy. - nephropathy and neuropathy, secondary to diabetes. - thyroid nodules. social history: mr. is a 35 pack years smoker, stopped smoking in restarted in . history of alcoholism - sober since . no alcohol use since then. ivdu history: quit iv heroin and cocaine, relapsed in and is currently using. married to a woman who is hiv+, has one son. two days per week at a desk job. family history: mother died of heart disease at 32, had scarlet fever. history of depression and alcoholism. father died at 66 of an intestinal gangrene after a rupture and had diabetes, alcoholism and h/o aneurysm. there is no history of cancer. physical exam: admission physical exam: vs: t=95.7 bp=47 hr=103/40 rr=14o2 sat= 100% 2l nc general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa, dry mucous membranes. no xanthalesma. neck: supple with jvp of at jaw line. cardiac: pmi located in 5th intercostal space, midclavicular line. bradycardia, normal s1, s2. diastolic murmer best appreciated at lusb. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. decreased breath sounds at bases. no wheezes abdomen: soft, nt, distended. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no femoral bruits. large area of scarring, well healed on l entire left forearm including elbow. large well healed scar on left hip. bilateral lower extremity edema +. skin: no stasis dermatitis, ulcers, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ pertinent results: admission labs: 01:15am wbc-5.8# rbc-3.95* hgb-11.9* hct-37.4* mcv-95 mch-30.1 mchc-31.9 rdw-15.4 plt ct-97* 01:15am neuts-59.2 lymphs-29.2 monos-7.4 eos-3.8 baso-0.4 01:15am pt-12.9* ptt-35.8 inr(pt)-1.2* 01:15am plt ct-97* 01:15am glucose-83 urean-35* creat-4.2*# na-134 k-6.1* cl-104 hco3-22 angap-14 05:30am alt-22 ast-39 ld(ldh)-231 ck(cpk)-97 alkphos-125 totbili-1.4 01:15am calcium-8.8 phos-3.4# mg-2.1 05:30am tsh-1.0 pertinent labs: 05:38am lipase-12 01:15am ctropnt-0.03* 05:30am tsh-1.0 10:09am rheufac-57* 05:30am asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 01:19am lactate-3.0* k-4.2 07:42pm lactate-3.3* 12:05pm fibrino-297# 02:00am ld(ldh)-218 totbili-0.4 02:00am hapto-29* 10:09am anca-negative b 10:09am -negative 10:09am rheufac-57* hit pf4 antibody negative echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef 65%). the right ventricular free wall thickness is normal. the right ventricular cavity is dilated with borderline normal free wall function. there is abnormal septal motion/position. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild to moderate (+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. moderate to severe tricuspid regurgitation is seen. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the tricuspid regurgitation appears worse, and the right ventricle is dilated. cxr moderate-to-large loculated right pleural effusion appears increased in size from prior exam. moderate left pleural effusion is unchanged. bibasilar opacities likely represent atelectasis or infection in the appropriate clinical setting. mild pulmonary edema. cxr comparison is made with prior study performed one hour earlier. right ij catheter sheath tip is at the distal/lower right jugular vein. cardiomegaly is stable. moderate right and small-to-moderate left pleural effusions with adjacent bibasilar atelectases are unchanged. mild pulmonary edema is unchanged. multiple surgical clips project over the left cardiac border. several leads and external monitors are noted. kub ileus right ue duplex us no dvt. cxr: pa and lateral views of the chest. a right internal jugular hemodialysis catheter ends in the low svc. sternotomy wires and mediastinal clips are seen. bilateral layering pleural effusions are unchanged. no pneumothorax. moderate cardiomegaly is stable. bibasilar atelectasis. there is decreased interstitial edema and pulmonary vascular congestion. impression: 1. stable bilateral layering pleural effusions. decreased pulmonary edema. 2. no evidence for pneumonia or active or nonactive tuberculosis. discharge labs: 06:31am wbc-5.7 rbc-2.65* hgb-8.2* hct-25.8* mcv-98 mch-31.0 mchc-31.9 rdw-17.7* plt ct-130* 06:31am glucose-198* urean-51* creat-6.4*# na-136 k-3.9 cl-100 hco3-27 angap-13 brief hospital course: 61yo male with past medical history of cad s/p cabg, htn, hld, diabetes, hiv, hepatitis c and b who is presented with bradycardia, bilateral pleural effusions, concern for pna by chest imaging and acute on chronic renal failure. acute care: # bradycardia - the patient initially presented with bradycardia in a junctional rhythm and hypotension. with dopamine, the patient's junctional rhythm converted to sinus bradycardia. all home antihypertensives were discontinued, echo showed ef of 65% which was improved from prior. his hr and pressure increased with dopamine, which he was eventually weaned off. the patient's bradycardia is of unclear etiology. the most likely etiology is the possibility of a toxin which was in the heroin he used 2 days prior to admission. bradycardia resolved spontaneously and patient was able to be started on dose metoprolol. # elevated pulmonary artery pressures, right ventricular dysfunction ?????? question of elevated pa pressures on echo but right heart cath did not show evidence of right heart failure or pulm htn. , anca were negative. # acute on chronic renal failure - patient with chronic renal insufficiency with baseline creatinine of 1.5 likely secondary to poorly controlled hypertension and diabetes. ceatinine on presentation elevated to with muddy casts on urinalysis and no evidence of active sediment. acute renal failure was attributed to atn from hypotension in the setting of poor forward flow. tenofovir was also discontinued given possible cytotoxic nephrogenic effect. medications were renally dosed. nephrology was consulted and although patient initially refused hd, dialysis was eventually initiated due to metabolic abnormalities and uremia. although urine output slowly improved through hospital course, patient remained with marginal gfr and gross fluid overload. a tunneled line was placed with the plan to continue dialysis as an outpatient. hepatitis b surface antigen was negative (core antibody positive, viral load in was undetectable) and chest x-ray showed no evidence of active tuberculosis (hx of tuberculosis s/p treatment). # hiv: vl in is 61 with cd4 count of 205, repeat vl during hospitalization was 56. due to renal function, haart regimen was held at time of presentation, and he was started on a drug holiday. management of his haart regimen will be difficult given his resistance and his renal failure. atovaquone ppx was initiated given low cd4 count. patient will follow up with outpatient physician, . , to discuss possible haart regimens. # thrombocytopenia: baseline platelet count is 100, trended down to 48 during hospitalization. heparin was discontinued and evaluation for ttp, dic and hit were negative. acute decrease in platelet count was felt to be secondary to acute illness. platelet count improved spontaneously and heparin was reinitiated. at time of discharge, platlet count had improved to baseline of 120s. # diabetes: hga1c was 7.9% in . home regimen: 70/30 40u subq qam and 30 u subq qpm. given new onset renal failure, insulin dose was reduced by and gradually titrated to achieve euglycemia. at time of discharge, patient was taking 70/30 30u qam and 20u qpm. if patient remains hyperglycemic, he was instructed to increase dose by 2u and call endocrinologist at . # loose stools ?????? while patient was on broad spectrum abx (see below), patient was noted to have copious loose stools. cdiff toxins was negative and change in bowel movements was attibuted to antibiotic associated diarrhea. bowel regimen was held and patient developed relative constipation with kub consistent with ileus. ileus was managed conservatively with uptitrated bowel regimen, and by time of discharge, bowel movements had returned to normal. # (?) pneumonia - on presentation, patient complained of dyspnea with cxr consistent with pulmonary edema. pneumonia could not be excluded. given initial presentation with hypotension, patient was empirically covered with broad spectrum antibiotics of vanc/ zosyn. as clinical status improved, all antibiotics were discontinued. respiratory status improved with initiation of dialysis and fluid removal. chronic care: # polysubstance abuse: admitted to recent heroine use last on , denies recent cocaine use. urine tox screen positive for opiates. patient was seen by social work and counseled on drug cessation # cad s/p cabg in . as above, there was no evidence of ischemia per ekgs or repeat echo. patient had reportedly not been taking his aspirin at home. # htn: the patient has a history of hypertension but was hypotensive during his hospital stay. metoprolol, felodipine, valsartan, lisinopril, spironolactone were discontinued. pressure stablized with sbp 110-130s and patient was able to be re-initiated on metoprolol xl 50mg. # hyperlipidemia: lipids well controlled in 6/. continued pravastatin. # neuropathic pain: continue amitriptyline 10mg tablet qhs prn pain. # hepatitis c: chronic, stable, untreated. lfts remained normal throughout stay, inr is elevated and albumin is low. issues of transitions in care: code status: full code (confirmed) comm: (wife) pending studies at time of discharge: none issues to address at follow up: 1. acute on chronic renal failure: - continue outpatient hemodialysis - monitor urine output and kidney function with goal to discontinue hd once atn has resolved 2. hiv: - follow up with outpatient provider to discuss reinitiation of harrt - cont atovaquone for ppx 3. diabetes: - uptitrate insulin to maintain euglycemia 4. htn: goal bp < 140 - discontinue lisinopril, valsartan, spironolactone, felodipine - reduce metoprolol to 50mg daily medications on admission: amitriptyline - 10 mg tablet - 1 (one) tablet(s) by mouth at bedtime as needed for neuropathy pain darunavir - 400 mg tablet - 2 tablet(s) by mouth daily take with ritonavir. this is in place of atazanavir and kaletra emtricitabine-tenofovir - 200 mg-300 mg tablet - 1 tablet(s) by mouth daily felodipine - 2.5 mg tablet extended release 24 hr - 1 tablet(s) by mouth daily lisinopril - 20 mg tablet - 1 tablet(s) by mouth once a day metoprolol succinate - 100 mg tablet extended release 24 hr - 1 tablet(s) by mouth once daily pravastatin - 40 mg tablet - 1 tablet(s) by mouth once a day ritonavir - 100 mg tablet - 1 tablet(s) by mouth daily spironolactone - 25 mg tablet - 1 tablet(s) by mouth once a day - no substitution torsemide - 20 mg tablet - 1 tablet(s) by mouth daily valsartan - 160 mg tablet - 1 (one) tablet(s) by mouth twice a day insulin nph & regular human - 100 unit/ml (70-30) suspension - 40 units sq qam, 30 units qpm the following medications are on the patient's medication list but he is not taking them: ergocalciferol (vitamin d2) - 50,000 unit capsule - 1 capsule(s) by mouth every other week aspirin - 325 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day sildenafil - 25 mg tablet - 1 tablet(s) by mouth daily as needed nitroglycerin - 0.4 mg tablet, sublingual - one tab sublingually as needed for chest pain, every five minutes for a total of three tabs. call your doctor or go to the emergency room for severe chest pain potassium chloride - (dose adjustment - no new rx) - 20 meq tablet, er particles/crystals - 2 tab(s) by mouth once a day discharge medications: 1. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 2. amitriptyline 10 mg tablet sig: one (1) tablet po qhs prn () as needed for pain. 3. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*0* 4. atovaquone 750 mg/5 ml suspension sig: ten (10) ml po daily (daily). disp:*1 bottle* refills:*2* 5. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*0* 6. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. insulin nph & regular human 100 unit/ml (70-30) insulin pen sig: see below subcutaneous twice a day: 30 units in the morning; 20 units in the evening. disp:*5 pens* refills:*2* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: primary diagnosis: acute on chronic renal failure bradycardia hypotension secondary diagnosis: hiv hepatitis c diabetes mellitus hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , you were admitted to for very slow heart rate and low pressure. you were admitted to the icu because you required a medication to support your heart. your kidneys began to decline and you were advised to initiate dialysis. you were not able to take your haart medications for hiv because of your poor renal function. you were also treated for a pneumonia. it is unclear what caused all of these symptoms but it may be related to your drug use. it is of the utmost importance that you do not continue to use drugs. it is also very important that you quit smoking cigarettes. unfortunately your kidney function did not recover significantly during your hospital course to allow you to come off of dialysis. you had to have a catheter placed to receive dialysis as an outpatient. however, the kidney doctors think that your kidney function may still improve over the upcoming months. please note the following changes to your medications: stop your haart medications: darunavir, emtricitabine- tenofovir, ritonavir stop lisinopril stop felodipine stop valsartan stop torsemide stop spironolactone decrease your metoprolol succinate to 50mg daily decrease your insulin to 30units in the morning and 20units in the evening decrease your aspirin to 81mg daily start nephrocaps daily start atovaquone daily you may take senna and colace as needed for constipation only take the medications that are listed on your discharge paperwork please be sure to follow up with your physicians. weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: please go to your initial dialysis session: friday, at 5:15pm at department: when: monday at 3:00 pm with: , md building: sc clinical ctr south campus: east best parking: garage department: when: wednesday at 12:00 pm with: building: sc clinical ctr campus: east best parking: garage department: cardiac services when: tuesday at 10:00 am with: , m.d. building: sc clinical ctr campus: east best parking: garage procedure: hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis pulmonary artery wedge monitoring central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified hyperpotassemia thrombocytopenia, unspecified anemia of other chronic disease tobacco use disorder acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified acute on chronic diastolic heart failure aortocoronary bypass status diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes cocaine abuse, unspecified other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) other specified cardiac dysrhythmias hypotension, unspecified long-term (current) use of insulin paralytic ileus other ascites personal history of noncompliance with medical treatment, presenting hazards to health accidental poisoning by heroin chronic viral hepatitis b without mention of hepatic coma without mention of hepatitis delta opioid abuse, unspecified diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled asymptomatic human immunodeficiency virus [hiv] infection status poisoning by heroin personal history of alcoholism tricuspid valve disorders, specified as nonrheumatic personal history of tuberculosis impotence of organic origin 

Answer: The patient is high likely exposed to