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: lipitor attending: chief complaint: altered mental status major surgical or invasive procedure: hd tunneled line catheter insertion () and removal. history of present illness: mr. is a 82yom with multiple medical problmes including cad, chf (ef 30-35%), ckd (cr 3.2 on admission to rehab) who was brought to the ed from rehab with sob and confusion. in the ed, he was combative and initially refusing vital signs. initial vitals: 97.8 74 136/53 18 96% 4l np. while in the ed, he calmed but was noted to be delerious. when he fell asleep, o2 sats dropped. he he was temporarily placed on a non-rebreather, but when awoken was easily weaned back to nasal canula. on exam in the ed, crackles were noted in the in right base. in the ed, ua was done and was negative. head ct negative. cxr was notable for new r-sided opacity. no consults were called in the ed. vital prior to transfer: 154/63, p76, rr18, 100% on 3l nc . in her ed call-in, pcp was concerned about uremia. pt has a documented "cognitive impairment," but it is unclear what this entails from the notes in omr. otherwise, the patient had been quite functional at home prior to his admission, after which he went to rehab where he has been since. of note, last admission, poor responsse to 120mg lasix with metolazone 5mg. . on the floor, pt is unable to articulate words and not following commands. . review of systems: unable to obtain past medical history: cad (- cath ' - lad -> stent) htn chf (ef = 30-35% in 2+ mr, 2+ ai, 2+ tr) renal cancer () cri (2.4-2.7) () hyperlipidemia, prostate cancer ()() h/o colitis, cataracts, seasonal allergies, bilateral knee oa, gerd, iron deficiency anemia, cervical and lumbar djd, right testicular atrophy secondary to mumps social history: he lives alone. he is a retired barber. originally from . denies tobacco, recreational drugs, or alcohol excess. per nephew drinks 2 shots of schnapps nightly. family history: father died at 41 of nephritis. mother with aortic stenosis. physical exam: admission physical exam: 154/63, p76, rr18, 100% on 3l nc general: axo x 0, speech difficult to understand, copious bruises noted across body. no fentanyl patch noted. heent: sclera anicteric, mmm, oropharynx clear lungs: limited exam patient positioning and mental status, ctab cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended gu: no foley ext: warm, well perfused, bilateral + edema to the knees. erythema to above the ankle on the left. both ankles are bandaged with kerlix. neuro: unable to engage in coversation, not following comands, no focal deficit, but jerking of the b/l ue . discharge physical exam: vitals: protocol gen: nad aox2 heent: eomi, perrl, oropharynx clear cv: rrr s1/s2 -m/r/g r: minor bibasilar rales, otherwise cta b/l -w/r/ a: +bs soft ntnd -hsm ext: -c/c/e skin: -rash/new lesions, diffuse echymoses over his arms and legs. neuro: aox2-3, follows commands. pertinent results: admission labs: 01:30pm blood wbc-9.7 rbc-4.03* hgb-11.3* hct-34.2* mcv-85 mch-27.9 mchc-32.9 rdw-20.9* plt ct-161 01:30pm blood alt-18 ast-32 ck(cpk)-95 alkphos-84 totbili-1.0 01:30pm blood calcium-8.6 phos-6.2* mg-1.8 06:27am blood vitb12-1567* folate-17.7 06:27am blood tsh-24* 01:30pm blood tsh-13* 06:27am blood free t4-0.57* 07:21am blood hbsag-negative hbsab-negative hbcab-negative 06:20am blood wbc-11.8* rbc-3.81* hgb-10.9* hct-33.0* mcv-87 mch-28.6 mchc-33.0 rdw-20.2* plt ct-121* 06:35am blood wbc-8.4 rbc-3.66* hgb-10.4* hct-31.1* mcv-85 mch-28.6 mchc-33.6 rdw-20.2* plt ct-108* 07:45am blood neuts-87* bands-0 lymphs-4* monos-9 eos-0 baso-0 atyps-0 metas-0 myelos-0 discharge labs: 06:20am blood pt-16.1* ptt-38.0* inr(pt)-1.4* 06:20am blood glucose-100 urean-30* creat-2.5* na-140 k-4.0 cl-98 hco3-28 angap-18 06:35am blood glucose-98 urean-52* creat-3.2* na-137 k-3.9 cl-98 hco3-27 angap-16 06:20am blood glucose-106* urean-36* creat-2.5* na-137 k-3.8 cl-97 hco3-28 angap-16 06:36am blood glucose-112* urean-59* creat-3.1* na-139 k-3.6 cl-97 hco3-30 angap-16 06:20am blood calcium-8.8 phos-3.1 mg-1.9 studies: cxr () limited study due to rotation demonstrates bilateral pleural effusions with bibasilar airspace opacities, worst on the left than the right, possibly due to atelectasis though infection is not excluded. ct head w/o contrast () no acute intracranial process. renal u.s. () 1. stable large left mid-to-lower pole renal mass. 2. mild stable left-sided pelviectasis. 3. unchanged atrophic, slightly echogenic right kidney. liver or gallbladder us () 1. trace perihepatic ascites. 2. doppler assessment of the hepatic portal veins and inferior vena cava (retrohepatic and mid) shows patency and appropriate directionality of flow. no evidence of thrombus. tte () there is a mobile echodensity seen in the left atrium at the base of the mitral leaflet, near the aorto-mitral fibrous continuity. this could be a vegetation or part of the myxomatous mitral valve. a tee would help clarify, if clinically relevant. moderate focal lv systolic dysfunction. dilated and depressed right ventricle. mild to moderate mitral regurgitation. mild to moderate aortic regurgitation. moderate to severe pulmonary artery hypertension. mr head w/o contrast () 1. no evidence of new hemorrhage, edema, masses, mass effect or infarction. study is somewhat limited by motion artifacts. 2. small focus of altered signal intensity, unchanged from previous study, likely representing hemorrhagic residuum in right frontal lobe. 3. increasing confluence of flair hyperintensities seen in the periventricular white matter, most likely indicating progression of chronic small vessel infarction. brief hospital course: assessment and plan: 82yo m with ckd, chf (ef 30-35%), and cad who was brought to the ed with ams and hypoxia and admitted to the icu and later transfered to the medical floor and hemodialysis was intiated. # ams: the patient's altered mental status was thought to be possibly due to delirium from an infection or toxic metabolic cause or due to his uremia secondary to worsening chronic renal failure. he was found to have lle cellulitis and rll pna and was started on broad antibiotics for these (initially vanc/zosyn then changed to vanc cefepime). his mental status improved dramatically on the antibiotics. an lp was considered, but not performed as it was thought his pneumonia accounted for the source of infection. it was felt that while his uremia was not the cause of such an acute change in his mental status, it was felt that this was at least contributing to his apparent baseline confusion. his mental status continued to fluctuate between aox1 to aox2-3, with obvious inattention and confusion at times. # acute on chronic renal failure: the patient was found to have a high bun:cr, although his feurea was not consistent with pre-renal. the patient also had recently started on colchicine which was inappropriately dosed for his gfr. he was resuscitated with ivf and his renal function improved somewhat. renal was consulted and recommended hemodialysis be started. his feelings towards dialysis were not fully known and it was determined that he did not have capacity at this time to make the decision. it was felt that by initiating hemodialysis on this admission, the correcting of his uremia may help his mental status to the point where mr. could make his wishes known. his health care proxy consented to begin hemodialysis. the patient underwent hd and tolerated it well. aggressive amounts of fluids were removed. the patient became more alert and awake, indicating that hd was helping with his overall mental status, however he also began to endorse visual hallucinations and paranoid delusions. he was typically only oriented to self, but occasionally also to place. after thorough discussion, it was felt that given the patients multiple complex medical problems continued hemodialysis was not recommended. two family meetings were held with the healthcare proxy to discuss goals of care. ultimately it was decided that mr would be transitioned to hospice care, as his multiple comorbidities and likely untreated renal cell carcinoma would shorten his overall prognosis regardless of hd. # dementia while his functioning prior to this episode was not entirely clear, multiple report indicated that this was a relatively rapid decline in mr. . he was reported as ambulatory and interactive as late as the spring. while it was clear that he was delirious due to his infection and uremia, it also became clearer that his underlying dementia was more significant than was thought. a work up for possible reversible causes of dementia was done, including thyroid studies, syphilis testing, vitamin b12 and folate levels, and a mri of the brain. the only revealing study was an elevated tsh, however he was treated for this during this admission. # pulmonary hypertension as the patient was significantly volume overloaded, and transthoracic echocardiogram was done which revealed pulmonary artery hypertension. the pulmonary service was consulted who said that they felt that this was most likely due to his significant left sided heart disease leading to pulmonary venous hypertension. the recommended volume reduction through hd and diuresis. also, a mobile echodensity was incidentally seen in the left atrium at the base of the mitral leaflet; the echo report felt that this could be a vegetation or part of the myxomatous mitral valve. further work up was deferred due to his concurrent kidney failure and worsening mental status. # renal mass an renal ultrasound was done in order to rule out obstructive causes of kidney failure. it did not show obstruction, however it did show the persistence of a known renal mass that was felt to be increasing in size. in his medical chart, it appears to suggest that mr. knew this was likely a malignancy and did not chose to take action at that time. while it is not known what his cognitive status was at that time, given his multitude of medical problems, further work up of this mass was deferred to see if dialysis might have improved his mental status. # decreasing platelets the patient was noted to have a decreasing platelet count from 161k to 105k. the diagnosis of heparin induced thrombocytopenia was considered. heparin dependant antibodies were negative. # hypernatremia: the patient was found to be hypernatremic on admission. this was likely a result of his ams rather than the etiology. the patient was replete with free water and his sodium levels improved. # depression: the patient's antidepressants were held in the setting of altered mental status. # hypothyroidism: the patient was continued on his home levothyroxine, the dose of which was increased # cad: the patient was continued on his home medications. ___________________________________________ . goals of care: a meeting was held with the health care proxy to discuss what mr. would have wanted going forward. hemodialysis was initiated to see if resolving the patient's uremia may have helped his mental status improve to the point that he would be able to fully express his wishes. this was not the case however, and while it did help the patient to be more awake and alert, he continued to lack capacity to make medical decisions. the futility in continuing with hemodialysis was discussed in light of his multiple organ dysfunction - dementia, esrd, severe pulmonary hypertension, and likely malignancy. it was decided to discontinue hemodialysis and mr. code status was made dnr/dni. goals of care were discussed a second time with the hcp, and the decision was confirmed to transition to hospice care. medications on admission: per last d/c summary 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. citalopram 10 mg tablet sig: one (1) tablet po once a day. 4. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 5. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 6. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a day). 7. balsalazide 750 mg capsule sig: three (3) capsule po twice a day. 8. fluticasone 50 mcg/actuation spray, suspension sig: two (2) sprays nasal once a day. . list from rehab: asa 81 balsalazide 750mg 3 tablets seoquel 50mg qhs acetaminophen 325 2 tablets q6 hours prn bisacodyl 10mg suppository fleet enema 1 daily prn mom 30ml daily prn citalopram 20mg daily fluticasone 1 spray per nostril daily furosamide 80mg metolazone 2.5mg 30 mins before lasix metop succinate 50mg daily mvi niferex-150 cap daily omeprazole 20mg daily colcrys 0.6mg po tid () levothyroxine 37.5mcg qam (recent increase from 25mg on ) renvela 800mg 1 tab tid keflex 250mg tab tid x 7 days (start ) fentanyl 12.5mcg patch (started ) . discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 3. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 4. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 5. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 6. acetaminophen 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain: do not exceed 8 tablets daily. 7. milk of magnesia 400 mg/5 ml suspension sig: thirty (30) ml po once a day as needed for constipation. 8. multivitamin tablet sig: one (1) tablet po once a day. 9. renvela 800 mg tablet sig: one (1) tablet po three times a day: please take with meals. 10. haloperidol lactate 5 mg/ml solution sig: one (1) 0.25mg injection (2 times a day) as needed for agitation/anxiety. 11. haloperidol 0.5 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for agitation. 12. furosemide 80 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: senior healthcare of discharge diagnosis: primary diagnosis: end stage renal disease secondary diagnoses: pneumonia cellulitis (left lower extremity) demenita delirium discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking care of you during your hospitalization. you were admitted because you were having difficulty breathing and you were confused. when you arrived, we found that you had pneumonia in your lungs as well as an infection in the skin of your legs. you were treated with antibiotics. we also found that your kidneys were no longer functioning well enough. you continued to be confused and very tired and we felt that this may have been due to your kidneys not functioning. we started you on temporary dialysis, however we do not recommend continued dialysis. followup instructions: none procedure: hemodialysis venous catheterization for renal dialysis diagnoses: pneumonia, organism unspecified end stage renal disease renal dialysis status esophageal reflux congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism personal history of malignant neoplasm of prostate other persistent mental disorders due to conditions classified elsewhere systolic heart failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia cellulitis and abscess of leg, except foot unspecified disorder of kidney and ureter primary pulmonary hypertension pressure ulcer, lower back iron deficiency anemia, unspecified encephalopathy, unspecified hyperosmolality and/or hypernatremia osteoarthrosis, localized, not specified whether primary or secondary, lower leg pressure ulcer, unstageable 

Answer: The patient is high likely exposed to