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: nortriptyline / diltiazem attending: chief complaint: spinal stenosis major surgical or invasive procedure: total laminectomy l3-l5 () history of present illness: mr. is an 80yo male with cad s/p mi and ptci, carotid stenosis s/p cea, osa, obesity, hypothyroidism, ckd (baseline cr ~1.7), spinal stenosis s/p total laminectomy l3-l5 on , who is transferred from ortho-spine to micu in setting of altered mental status, fevers to 102, chest pain, and episode of unresponsiveness earlier today. . patient initially admitted to ortho service for elective laminectomy. underwent total laminectomy of l3-l5; fusion l3-l5; instrumentation of l3-l5, autograft, and epidural catheter placement on day of admission. tolerated procedure well, with ~600cc ebl, and 2l ivf administration during procedure. pain initially treated with dialudid pca, and patient had since been transitioned to oral pain meds. his hospital course has been c/b transient hyperkalemia yesterday (k 6.0), which resolved with administration of kayexalate x2. . per reports, patient was at his baseline mental status this morning, but became more confused over the course of the day. also became febrile to 102, and medicine consultation was requested. given concern for ams secondary to narcotic pain med administration, patient received narcan x2 with good response. he received 40mg po oxycodone yesterday; today had received dilaudid 0.5mg iv x2. mental status was still slightly altered per his family, who were present at time of medicine consult interview. at that time, rr was about 12, and patient was unable to keep his eyes open for more than 10 seconds at a time. was still responsive to commands. abg revealed 7.38/46/85/28 on 3l nc, and of note patient has required supplemental o2 since the or. . patient then developed substernal cp, non-radiating, with associated sob and nausea per his report. as an ekg was being obtained, he was unresponsive for 10 seconds (per nursing), then aroused, somewhat confused with sbp ~110. telemetry showed that he switched into afib approximately at this time with rate around 100. ekg confirmed afib, but there was no evidence of ischemic changes. asa 325mg ordered (d/w ortho-spine). cardiac enyzmes sent: trop 0.05, ck 888, mb flat. given fever to 102, blood and urine cultures also sent, and ua returned suggestive of uti. cxr not concerning for pna. . ortho spine attending requested transfer to medicine overnight for management of delirium, fevers, chest pain. decision was made to transfer patient to micu given recent onset and acuity of these issues. . on arrival to micu, patient no longer reports cp. still reports sob, though cannot characterize the nature of his dyspnea. no orthopnea. reports back pain at surgical site, as well as suprapubic pain. had nausea earlier with cp, which has since resolved. no emesis. cp was substernal, non-radiating, and not associated with any diaphoresis. past medical history: -colon ca, s/p r hemicolectomy' -spinal stenosis -cad s/p stents '. no active cardiac sx. -previous mi -carotid stenosis s/p l cea -hld -htn -osa (non-compliant with cpap) -gout -dm -hypothyroidism -obesity -divertulosis -gerd -ckd bl cr 1.7 -l cea' social history: married, lives with wife. former , quit 40 years ago. rare etoh use. no illicits. family history: non-contributory physical exam: vitals: t:98.1 bp:116/53 p:85 r:14 o2:96% general: alert, orientedx3, no acute distress appears in pain. heent: pinpoint pupil reactive to light neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: irregular rhythm, nno rubs, gallops abdomen: soft, non tender to palpation , non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly back: dressing intact, no drainage gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: i. labs a. admission 03:56pm blood hgb-11.8* hct-32.8* 05:45am blood glucose-132* urean-32* creat-1.8* na-136 k-6.0* cl-102 hco3-26 angap-14 b. misc 03:36pm blood alt-15 ast-49* ld(ldh)-234 ck(cpk)-888* alkphos-63 totbili-0.5 01:20pm blood probnp-1136* 04:50am blood ck-mb-6 ctropnt-0.05* 09:21pm blood ck-mb-5 ctropnt-0.05* 03:36pm blood ck-mb-5 ctropnt-0.05* 05:45am blood calcium-8.3* mg-1.8 01:20pm blood caltibc-194* ferritn-665* trf-149* 04:50am blood vitb12-1022* 04:50am blood tsh-3.6 06:01pm blood type-art temp-38.9 po2-85 pco2-46* ph-7.38 caltco2-28 base xs-0 intubat-not intuba 06:01pm blood lactate-1.0 03:53pm urine color-yellow appear-cloudy sp -1.012 03:53pm urine blood-lg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-tr 03:53pm urine rbc-27* wbc-20* bacteri-few yeast-none epi-<1 03:53pm urine castgr-27* casthy-4* 03:53pm urine amorphx-occ 03:53pm urine eos-negative 11:02am urine hours-random urean-137 creat-17 na-90 k-10 cl-101 11:02am urine osmolal-256 c. discharge 06:10am blood wbc-5.1 rbc-3.23* hgb-9.7* hct-28.1* mcv-87 mch-29.9 mchc-34.5 rdw-13.4 plt ct-183 06:10am blood glucose-96 urean-35* creat-1.6* na-140 k-4.2 cl-100 hco3-31 angap-13 06:10am blood ck(cpk)-137 06:10am blood calcium-8.5 phos-2.9 mg-1.9 ii. microbiology mrsa screen mrsa screen-final inpatient blood culture blood culture, routine-pending inpatient urine urine culture-final inpatient iii. radiology a. study: six intraoperative radiographs of the lumbar spine . comparison: none. indication: lumbar fusion in or. findings and impression: surgical instruments are seen posterior to the l4 level. multilevel degenerative changes. status post l3-l5 posterior spinal decompression and fusion. the hardware appears intact. please see operative report for further details. b. v/q scan () impression: low likelihood ration for recent pulmonary embolism. c. leni () impression: no dvt in both lower extremities. iv. pathology pathology report tissue: disc l3 l4. study date of v. cardiology a. cardiology report ecg study date of 3:29:16 pm sinus rhythm. left anterior fascicular block. poor r wave progression in the anterior leads. compared to the previous tracing of no significant diagnostic change. intervals axes rate pr qrs qt/qtc p qrs t 81 178 104 332/368 39 -29 81 b. echo () the left atrium is mildly dilated. no left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality with improved visualization with definity contrast. normal biventricular cavity sizes with preserved global and regional biventricular systolic function. no valvular pathology or pathologic flow identified. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. #### pending studies: blood culture, pathology report (disc l3 l4) brief hospital course: 80-year-old male with cad s/p mi and s/p stents, osa, obesity, ckd (baseline cr 1.7), spinal stenosis admitted for total laminectomy l3-l5 on without complication that was transferred from ortho-spine to micu for management of altered mental status secondary to excessive narcotic usage, isolated fever with negative cultures perhaps representing resolved aspiration pneumonitis, and chest pain temporally linked to new onset short duration post-operative atrial fibrillation. secondary issues during hospitalization were hyperkalemia treated with kayexalate, acute on chronic renal failure secondary to intrinsic etiology that resolved with supportive fluids, and acute on chronic congestive heart failure secondary to injudicious usage of fluids in the peri-operative period with subsequent diuresis. major issues at discharge are continuing diuresis with po lasix, addressing deconditioning with physical therapy regimen, and supporting nutritional status. #. status post total laminectomy l3-l5 () patient has diagnosis of spinal stenosis and was admitted for total laminectomy of l3-l5. patient initially had high level pain after operation with acute pain service consultation who recommended epidural bupivicaine and dilaudid pca. he was then transitioned to high dose oxycodone by the orthopedics service, resulting in an episode of unresponsiveness as described below. after transfer to the micu, he was placed on standing tylenol, oxycodone 5 mg po q 4 hr prn pain, gabapentin. he may require ongoing pain regimen titration as an outpatient. he will follow-up with dr. on monday . he will need daily dressing changes for his lower back incision. #acute on chronic diastolic heart failure (last ef > 55 %) likely related to fluid overload post-operatively and subsequent onset of transient atrial fibrillation. echo showed preserved ejection fraction. he was diuresed with 40mg iv lasix boluses. subsequently, lung crackles and elevated jvp resolved and o2 requirement also resolved. he was not discharged on home beta blocker secondary to bradycardia to the 50's. he was discharged on lasix 40 mg po qd for another 2 days (last dose on ) to further achieve euvolemia. his oxygen requirement has gone from 4 l to room air with pox in the mid-90s and ability to lie relatively flat. # acute metabolic encephalopathy patient had episode of unresponsiveness on likely secondary to increased narcotic usage. narcan 0.6 mg was administered with resultant reversal of somnolence. he remained confused and was transferred to the micu for further monitoring. his mental status cleared in about a day, and he was aaox3 with some issues suggestive of mild cognitive impairement (e.g. trouble saying days of week backwards). reversible causes of dementia including b12/tsh within normal limits. his narcotic regimen was reduced (see pain control regimen below). #. atrial fibrillation. after the above episode of unresponsiveness, he developed atrial fibrillation approximately 3 hours later of short duration (< 4 hours) likely secondary to increased adrenergic state with negative cardiac biomarkers and associated symptom of chest pain. telemetry showed no further episodes. tsh was within normal limits. thromboembolic etiology ruled out as above. we did not iniate anti-coagulation given recent high risk spinal operation and the transient nature of the afib. certainly, if pt has recurrence of atrial fibrillation, anticoagulation would need to be reconsidered given chads of 4. aspirin was restarted. #. fever: patient noted to have isolated fever to 102 on (pod # 3). he was initially treated for uti given urinalysis, but it was subsequently discontinued given negative urine culture. cxr did not indicate pneumonia, surgical wound not infected. isolated fever may have been measurement error or transient pneumonitis given timing relative to unresponsive event. he remained afebrile afterwards. # acute on chronic renal failure (ckd baseline cr 1.7) patient had pyuria with granular casts on urinalysis with negative nitrate, trace leuks, rbc 27, wbc 20 with few bacteria, negative urine culture, negative urine eosinophils in addition to large amount of granular casts. he may have developed atn/ain with contribution of poor forward flow from acute on chronic diastolic heart failure given response to diuresis. his creatinine trended upward from 1.8 to 2.2 () with return to cr 1.8 at discharge. he should have a follow-up ua on outpatient basis to ensure resolution of microscopic hematuria likely secondary to foley trauma. # hyperkalemia patient noted to have admission serum k of 6 ranging between 5.2 and 5.8 before onset of acute on chronic renal failure described above. he was given kayexylate x 2 with decreased to k 5.2. medicine was consulted regarding management of hyperkalemia with impression that renal function was stable, no medication exposures to increase k, no ekg changes with overall unclear etiology but perhaps related to underlying chronic kidney disease. atrius record review indicates that this has been a chronic issue. recommendation was to eat low potassium diet, avoidance of acei, potassium sparing diuretics, nsaids. potassium on discharge was 4.4 likely in setting of diuresis. he is advised to follow-up with both his primary care doctor t after discharge from rehab for potassium recheck. # abdominal discomfort with constipation patient had not had bowel movement for several days and complained of mild abdominal discomfort more suprapubic in nature. kub showed no specific findings including illeus. lack of bowel likely secondary to constipation, narotics and poor po intake. he was discharged on an aggressive regimen including colace, senna, miralax, lactulose, and bisacodyl. #. cad s/p mi with stent: no active issues. continued asa, atenolol, simvastatin, isosorbide mononitrate (er) 60 mg po daily. #. hyperlipidemia: continued statin. #. hypertension: patient was normotensive during hospitalization. his atenolol was held secondary to bradycardia. given his renal function, metoprolol should be considered if further beta blockade is desired in future. #. osa: patient non-compliant with cpap at home. he was started on cpap during hospitalization given desaturations while sleeping. settings were autoset cpap, autoset range 5-20, o2 flow rate 4 l/min, medium facemask with pox 100 % with no witnessed apnea or obstruction episodes. # gout: continued on allopurinol 100mg daily. # anemia admission hgb 11.8 with drop to 9.7 and stable. iron studies suggesting anemia of chronic disease . advise outpatient re-check of hgb/hct and age appropriate cancer screening #. dm: patient reports diet-controlled diabetes. #. hypothyroidism: continue levothyroxine 25mcg daily. # nutrition albumin of 3 suggesting some component of poor nutrition. he should continue on boost supplement with meals. # thrombocytopenia patient has had thrombocytopenia (120s-140s) since . advise outpatient work-up if not already performed. # prophylaxis: patient should continue on sc heparin tid until ambulating on consistent basis # communication: patient, wife (), hter () # code: full (discussed with patient) # transition of care - optimization of pain regimen as patient begins to mobilize. caution is to be exercised as patient did become unresponsive with high-dose narcotics. - daily dressing changes for surgical site on lower back pain - follow-up with dr. for further management - continue diuresis with lasix 40 mg po qd. please check chem 10 panel to assess stability of cr, k, mg after diuresis on - check hgb/hct outpatient to assess stability - renal dosing of all medications - outpatient follow-up urinalysis to assess for resolution of microscopic hematuria - continue aggressive anti-constipation regimen - re-assessment of cardiac regimen for cad as atenolol discontinued secondary to bradycardia. given renal function, metoprolol should be considered if beta-blocker re-started. in addition, avoidance of acei/ should be considered given issues with hyperkalemia - continue cpap at rehab. given non-compliance at home, advise sleep study to optimize cpap - continue nutritional supplementation - advise outpatient work-up for thrombocytopenia if not already performed. - continuation of heparin sc tid until ambulating consistently. medications on admission: levothyroxine sodium 25 mcg po/ng daily simvastatin 20 mg po/ng daily isosorbide mononitrate (extended release) 60 mg po daily gabapentin 300 mg po/ng qid atenolol 25 mg po/ng daily allopurinol 100 mg po/ng daily folic acid 1 mg po/ng daily aspirin 81 mg po q24hrs vitamin d 500 unit po/ng daily vit b12 1000 discharge medications: 1. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 2. simvastatin 20 mg tablet sig: one (1) tablet po once a day. 3. isosorbide mononitrate 60 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 4. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 5. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 6. folic acid 1 mg tablet sig: one (1) tablet po once a day. 7. aspirin 81 mg tablet sig: one (1) tablet po once a day. 8. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 9. vitamin b-12 1,000 mcg tablet sig: one (1) tablet po once a day. 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime). 12. multivitamin tablet sig: one (1) tablet po daily (daily). 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 14. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 15. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 16. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 17. polyethylene glycol 3350 17 gram/dose powder sig: seventeen (17) gram po daily (daily) as needed for constipation. 18. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed for constipation. 19. furosemide 40 mg tablet sig: one (1) tablet po once a day for 2 days: last dose on . discharge disposition: extended care facility: healthcare centre discharge diagnosis: primary: spinal stenosis status post total laminectomy l3-l5, acute metabolic encephalopathy, post-operative atrial fibrillation, acute on chronic diastolic heart failure (ef > 55 %), anemia of chronic disease, acute on chronic renal failure, mild malnutrition secondary: hypertension, obstructive sleep apnea, diabetes type 2, hypothyroidism, thrombocytopenia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital for a spinal surgery and had a total l3-l5 laminectomy. you received a large amount of pain medications that made you very drowsy with resultant transfer to the intensive care unit for further monitoring. you also had chest discomfort related to an abnormal heart rhythm (atrial fibrillation) with blood tests and ecg not suggestive of heart attack. you will be discharged to rehab to regain strength. the facility will also continue to help address pain as you began to exercise again. medication changes: start furosemide 40 mg by mouth daily for 2 days (last dose on ) start tylenol 1000 mg by mouth three times daily for pain start oxycodone 5 mg by mouth every four hours as needed for pain start bisacodyl per rectum as needed for constipation start miralax for constipation start senna for constipation start docusate for constipation start lactulose for constipation as needed start multivitamin for nutrition start heparin until you begin walking on a consistent basis change gabapentin from 300 mg three times daily to twice daily stop atenolol please do not take any nsaids for pain. followup instructions: please follow-up with your primary care doctor and kidney doctor within 1-2 weeks after you are discharged from rehab. your rehab can make these appointments for you. department: orthostatics name: , location: address: , bldg. rm 239, , phone: appointment: monday 11:00am, monday 11:30am, thursday 1:30pm procedure: lumbar and lumbosacral fusion of the posterior column, posterior technique insertion of catheter into spinal canal for infusion of therapeutic or palliative substances systemic to pulmonary artery shunt fusion or refusion of 2-3 vertebrae diagnoses: hyperpotassemia thrombocytopenia, unspecified obstructive sleep apnea (adult)(pediatric) coronary atherosclerosis of native coronary artery urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism cardiac complications, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation acute on chronic diastolic heart failure percutaneous transluminal coronary angioplasty status chronic kidney disease, stage iii (moderate) old myocardial infarction personal history of malignant neoplasm of large intestine iron deficiency anemia, unspecified metabolic encephalopathy lumbosacral spondylosis without myelopathy 

Answer: The patient is high likely exposed to