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: patient recorded as having no known allergies to drugs attending: chief complaint: chills, hypoxic episode, fever major surgical or invasive procedure: none history of present illness: 57 yo m with h/o metastatic prostate cancer presents after episode of chills and acute sob. patient was dx with prostate cancer 5 yrs ago on routine screening. he had recurrence about 1 year ago, now with known liver and bone met's. of note, he started an estrogen based chemotherapy (estramustine) on wed. of last week with concurrent coumadin for possible hypercoagulable state. . patient had been at baseline prior to 1 day pta when he describes first feeling very cold and then developing severe sob after walking to bathroom. he attempted to get into bed, but legs gave out and he fell onto floor. no loc. denies chest pain, fever, leg pain, n/v/d. + leg swelling few weeks ago, but none recently. denies any cough or hemoptysis. he has had nosebleeds with clots when he blows his nose. also had hemorrhoidal bleeding 1 month ago and was admitted for endoscopy. . called ems and was noted to be hypoxic to 80s on ra, tachy to 150s initially. ems gave him 40mg iv lasix en route for ? flash pulmonary edema as he was on lasix at home. . in the ed, initial vs:97, 153, 112/68, 100% nrb. shortly thereafter spiked to 104 . noted to have a lactate to 4.2. initial cxr was unimpressive, cta was a suboptimal study but no large central pe. recieved levofloxacin/zosyn, 1.5l ns, zofran x1 and one unit of platelets. noted to have guaiac positive red stool in ed and one episode of hemoptysis. groin central line was placed. given obstructive pattern on lfts, got non-con ct abd with no obvious obstruction, only a multinodular liver. . transferred to icu, transfused 2 units prbc given low hct, hct went up 2 points only and has remained stable. on interview in the micu, patient endorses sharp r subcostal pain this am, but states that it occurs when he misses his neurontin and it has not recurred since. he currently denies any sob or cp, is comfortable on room air. past medical history: hypertension gout right shoulder fracture, history of chlamydia and gonorrhea prostate ca with mets to bone, liver and spine, status post prostatectomy with lupron injection umbilical hernia status post arthroscopy of the knee. hemorrhoidectomy, with hx of anal fissures recent lower gib with negative and egd depression/anxiety social history: lives with wife, has children and step-children. had twice weekly vna. no tobacco or etoh. family history: sister with ca physical exam: gen: obese, nad heent: mmm, jvp not visible due to body habitus cv: tachy, no m/r/g pulm: ctab ab: positive bs, nt/nd, no hsm ext: 1+ non-pitting pedal edema to shins neuro: cn ii-xii intact (q/o l facial droop but resolves with smiling), strength 5/5 throughout, sensation intact, reflexes 1+ throughout. pertinent results: cbc: 8.5 7.6 >---< 31 25.9 neuts-71* bands-9* lymphs-7* monos-4 eos-0 basos-0 atyps-2* metas-3* myelos-3* promyelo-1* nuc rbcs-23* hypochrom-2+ anisocyt-2+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-occasional spherocyt-occasional ovalocyt-occasional schistocy-occasional teardrop-occasional . chem: 138 | 106 | 21 / 141 4.6 | 16 | 0.8 \ albumin-2.8* calcium-9.1 phosphate-2.7 magnesium-2.0 . coags: pt-21.4* ptt-30.3 inr(pt)-2.0* . lfts: alt(sgpt)-74* ast(sgot)-261* ld(ldh)-4440* ck(cpk)-447* alk phos-1129* tot bili-5.1* lipase-64* . tox screen: serum: asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg urine: bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg . ce: 09:20pm ctropnt-0.03*, ck-mb-3 . fibrinogen 873 retic count 2.0 ferritin > haptoglobin 169 trf 148 tibc 192 . psa 223.8 . abg: type-art temp-37.6 rates-/21 o2-15 po2-234* pco2-25* ph-7.46* total co2-18* base xs--3 intubated-not intuba comments-green top . ua urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-tr rbc-0-2 wbc-0-2 bacteria-mod yeast-none epi-0-2 . micro: urine cx- neg . blood cx: : 1 bottle growing mssa repeat daily blood cx neg . urine legionella neg influenza swab neg . ecg: probable sinus tachycardia. st-t wave changes are non-specific. . imaging: portable cxr: 1. low lung volumes which accentuate the bronchovascular markings. 2. widened mediastinum, which could in part be due to low lung volumes and ap technique. however, if clinical concern for acute aortic syndrome, recommend chest cta for further evaluation. 3. hilar prominence may be due to vascular engorgement. 4. subtle opacities in both lung fields may be due to edema, infection and/or metastases. 5. bilateral, right greater than left pleural thickening versus less likely effusions. chest cta : 1. suboptimal evaluation for pulmonary embolus, as above, although no large, central embolus identified. 2. extensive osseous metastatic disease due to prostate cancer. 3. central interstitial thickening in upper lobes may be due to pulmonary edema, but given fever, also consider infectious source. due to history of malignancy, malignant component is also possible. recommend follow-up to resolution. . cta chest 1. no evidence of central pulmonary embolism or aortic dissection, but limited study due to timing of contrast and motion. 2. new peripancreatic fat stranding. clinical correlation for acute pancreatitis is recommended. 3. pulmonary edema vs atypical pneumonia, slightly improved. multiple pulmonary nodular opacities are incompletely evaluated on the background of ground-glass opacity and a followup chest ct after the acute pulmonary process resolves is recommended on an outpatient. 4. 1.6-cm mediastinal lymph node, which may also be reassessed at the time of follow up ct. 5. stable extensive osseous metastasis. . echo the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef 60-70%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated at the sinus level. the ascending aorta is moderately dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 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. . ct ab/pelv 1. no evidence of colitis or acute abdominal process. 2. cirrhosis. 3. left base small effusion/atelectasis. upper lobe interstitial changes; see chest ct. 4. extensive osseous prostate metastases; e.g. vertebral body destruction. . ruq u/s: innumerable echogenic masses throughout the liver without biliary ductal dilatation. this is an unusual pattern for metastatic prostate cancer, and if appropriate, biopsy can be considered. . lenis no deep venous thrombosis identified in the lower extremities bilaterally. of note, the right common femoral vein was not interrogated due to overlying dressing. . head ct 1. no evidence of hemorrhage, edema or mass effect. 2. no acute fractures are identified. 3. soft tissue swelling is noted over the left parieto-occipital region. . . . discharge labs: lfts: . coags: . vancomycin trough : 18.5 brief hospital course: 57 yo m with metastatic prostate cancer (bone, liver mets) presents with episode of hypoxia and tachycardia, fever after starting estrogen-based therapy. . #. hypoxia/tachycardia/fever: patient's initial presentation with acute dyspnea, hypoxia and tachycardia concerning for pe, especially in setting of pro-coagulable state on estrogen-chemotherapy. patient had been started on coumadin days prior, and also inr was 2/0 on presentation, it may have been subtherapeutic when his decompensation began. patient underwent cta which was non-diagnostic due to respiration artifact and poor contrast timing. there was no e/o rv strain on ekg or tte. lenis were negative for dvt. patient was admitted to micu, where he was treated empirically for pe with heparin gtt. infection was also on the differential given high fever to 104 after presentation to the ed and ct chest showed upper lobe infiltrates. patient was started on broad spectrum antibiotics (vancomycin, cefepime, levaquin) to cover for healthcare associated pna, since his last hospital admission was less than 1 month prior. he was ruled out for flu. legionella antigen was negative. in the micu, patient improved on this treatment regimen, and he had stable 02 sat on room air. . patient will need repeat chest ct once infection resolves ( weeks) to rule out underlying malignancy. . patient was transferred to medical floor after stabilization. heme-onc was consulted and recommended repeat cta to rule out pe, since this diagnosis would be a contraindication for estramustine therapy. patient's primary oncologist, dr. , was also contact and remained involved in our treatment plan. repeat cta showed no pe. heparin gtt was stopped and patient was restarted on home dose coumadin. however, inr became supratherapeutic, likely because of interaction with levaquin, and coumadin was held, vitamin k given. dr. plan is to start patient on therapeutic dose lovenox when he reinitiates estramustine (likely after 10 days antibiotics). patient was placed on prophylactic dose lovenox once inr normalized. . patient had one positive blood cx, with mssa, and all repeat blood cx were negative. he will therefore be treated with a hap course (10 days of vancomycin and cefepime, 5 days of levaquin) with 4 additional days of vancomycin for bacteremia (14 days total). picc was placed. patient remained afebrile after receiving initial abx on hd# 1. . #. anemia: admission hct 25.9 from prior 28. had h/o lgib 1 month ago with neg . guiaic positive in ed and started on iv ppi. had intermittent hemorrhoidal bleeding and epistaxis/hemoptysis anticoagulation and thrombocytopenia. no evidence of significant gi bleeding. received 3 total units prbc and hct remained stable. no e/o hemolysis. likely baseline anemia due to bone marrow replacement by cancer, with minimal acute bleeding. . #. hypotension: patient was hypotensive in ed, but stabilized with antibiotics and fluids. he remained normotensive and stable, lactate trended down. patient received stress dose steroids for since he was on a chronic dexamethasone regimen at home. after hd#2, his home dose of dexamethason 1 mg tid was resumed. . #. thrombocytopenia: most likely etiology is bone marrow replacement by malignancy in addition to past xrt/chemo. patient was transfused platelets for count <50 and minor bleeding. . #. prostate ca: patient has prostate cancer with met's to liver, bone. dr. was contact and agreed with holding estramutine during acute illness and infection. our heme/onc was also consulted. psa was 223. home dexamethasone was continued. patient had signs of worsening widespread disease, including worsening lfts elevation, tachycardia, and decreased alertness. . #. transaminitis: lfts increased likely met's, although there were no hepatitis serologies in our system so these were repeated. results pending at transfer. . #. lower extremity edema: patient developed le edema on hd# 2, likely due to high dose steroids and fluid resusitation. patient was continued on home dose lasix and tapered to home dose dexamethasone. patient had no evidence of chf on tte, and patient appeared otherwise euvolemic. . #. tachycardia: patient remained tachycardic 100-120s despite adequate hydration and no other signs of uncontrolled infection. tachycardia was attributed to underlying malignancy, since heart rate seemed to increase with increase in lft's, indicative of worsening disease. telemetry and ekgs showed sinus tachycardia. he also had one episode atrial tachycardia vs. avnrt on , which lasted <3 seconds and was asymptomatic and did not recur so was not treated. . #. depression/anxiety: patient became extremely fatigued and remained largely inactive. his alertness level seemed to decrease in days prior to discharge. unclear if this was due to worsening underlying illness vs. depression. con't wellbutrin and clonazepam . *patient was transferred to per request of family, with his primary oncologist dr. as the accepting physician. medications on admission: celebrex 200mg colace 100mg coumadin 3mg po daily clonazepam 0.5mg po bid dexamethasone 1mg tid estramustine 140mg tid fentanyl patch 75mcg/hr q72, last changed hydromorphone 4mg po bid prn lasix 20mg po as needed daily neurontin 400mg po tid omeprazole 20mg po bid senna 2 tabs wellbutrin 100mg tid lupron 22.5 q3mon, last taxotere 20mg, last infustion zometa 4mg, last shot discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. fentanyl 75 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 5. hydromorphone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 6. gabapentin 400 mg capsule sig: one (1) capsule po tid (3 times a day). 7. clonazepam 0.5 mg tablet sig: one (1) tablet po bid (2 times a day). 8. bupropion hcl 100 mg tablet sig: one (1) tablet po tid (3 times a day). 9. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. 10. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily). 11. dexamethasone 2 mg tablet sig: 0.5 tablet po q8h (every 8 hours). 12. celecoxib 200 mg capsule sig: one (1) capsule po bid (2 times a day). 13. enoxaparin 40 mg/0.4 ml syringe sig: one (1) subcutaneous daily (daily). 14. cefepime 2 gram recon soln sig: two (2) g injection q12h (every 12 hours) for 2 days: end date . 15. vancomycin 500 mg recon soln sig: 1250 (1250) g intravenous q 12h (every 12 hours) for 6 days: end date . 16. lasix 20 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care discharge diagnosis: primary: healthcare associated pneumonia prostate cancer . secondary: thrombocytopenia (low platelets) 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: it was a pleasure taking care of you. you were admitted for difficulty breathing and fevers. you were found to have pneumonia. you underwent tests for blood clots, and you did not have a blood clot. you were treated with intravenous antibiotics and a picc line was placed so you can continue these antibiotics at rehab. your coumadin was stopped at the recommendation of dr. , and you will start a different bloodthinner (lovenox) when you restart your estramustine chemotherapy. you received blood and platelet transfusions since you had small amounts of bleeding. . there following changes were made to your medications: - you should have infusions of vancomycin and cefepime through the picc line. - you should take lasix every other day until you are evaluated by a doctor. followup instructions: dr. will see you at . procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnoses: pneumonia, organism unspecified acidosis thrombocytopenia, unspecified abnormal coagulation profile malignant neoplasm of liver, secondary unspecified pleural effusion unspecified essential hypertension cirrhosis of liver without mention of alcohol acute posthemorrhagic anemia gout, unspecified personal history of malignant neoplasm of prostate pulmonary collapse dysthymic disorder other specified cardiac dysrhythmias hypotension, unspecified alkalosis bacteremia methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site retention of urine, unspecified personal history of venous thrombosis and embolism hypoxemia gross hematuria hypovolemia other and unspecified coagulation defects other specified antibiotics causing adverse effects in therapeutic use secondary malignant neoplasm of bone and bone marrow epistaxis anemia in neoplastic disease neoplasm related pain (acute) (chronic) unspecified hemorrhoids with other complication edema 

Answer: The patient is high likely exposed to