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: iodine / crestor / lisinopril attending: chief complaint: new metastatic cancer to spine found on outside mri major surgical or invasive procedure: ortho surgery #1 : 1. l3 bilateral hemilaminectomy. 2. l4 laminectomy for biopsy of neoplasm. 3. open treatment lumbar fracture, posterior. 4. posterolateral fusion l3-l4, l4-l5. 5. posterior spinal instrumentation l3-l5. 6. iliac crest bone graft harvest for fusion augmentation. 7. allograft for fusion augmentation. 8. deep muscle open biopsy. 9. open biopsy deep bone. ortho surgery #2 : 1. l4 corpectomy. 2. l3 partial vertebral body resection for lesion. 3. application of interbody device l3-l5. 4. l3-l4 anterior fusion. 5. l4-l5 anterior fusion. 6. allograft for fusion augmentation. ngt placement x 3 chest tube placement egd with balloon dilation of duodenal stricture picc placement anoscopy history of present illness: 80 yo m with hx mvr bioprosthetic, af on coumadin, 1 month hx of left shoulder and side pain, presents after mri today noted what looked like mets cancer at t1, t2, and t3. he was called by his physician who asked him to come to ed at for specialty evaluation. pt reports being in usoh when he began to have l upper chest pain with coughing about 4 weeks ago. 2 weeks ago noticed left shoulder and scapula pain, as well as left arm/elbow pain. in context of all of this he had recent surgery in for mvr, and had 30 lbs weight loss and early satiety since. he has undergoing several egds which have demonstrated a short duodenal stricture. this has been dilated x 2 and biopsied with results c/w peptic stricture; benign w/o malignancy. eus performed end of by dr. at showed benign stricture. he also had abd ct w/o contrast which showed narrowing of post-bulbar duodenum (stricture as above), with cystic lesion at l4. because of the latter, he underwent bone scan which was negative. mri cervical spine was reportedly performed today in w/o gadolinium and showed thoracic lesions above. however, we do not have report nor images of this. pt denies fevers, abd pain, diarrhea, or night sweats. no problems with urination. he reports colonoscopy 4 months ago at , which was normal. we do not have this report. he reports yearly prostate exam which has been normal. no other localizing complaints. he did have a past basal cell carcinoma which was removed 20 years ago and has not been a problem since. past medical history: esophageal reflux obesity sleep apnea ischemic heart disease - other chronic amnesia/memory disorder back pain hyperlipidemia pulmonary nodule/lesion, solitary macrocytosis without anemia s/p mitral valve replacement atrial fibrillation anticoagulant long-term use past surgical history: pilonidal cyst surgery x 2 , left shoulder, right elbow,right wrist x2; rig* tonsillectomy & adenoidectomy lumbar rhizotomy right shoulder surgery right carpal tunnel surgery both thumb surgery 99 - vasectomy rt shouldr acriomplasty right tennnis elbow surgery left shoulder surgery mitral valve replacement dr - b/w - bovine valve social history: pt is married with 2 children. past pipe smoker, but quit in . three glasses of wine per week. no drug use. family history: father - progressive supranuclear palsy. mother - chf. cancers. physical exam: admission exam: vitals: 96.5, 124/72, 93, 18, 99% ra gen: pleasant, nad. heent: no op erythema or exudate. no scleral icterus. pulm: cta b. heart: rrr. no m/r/g. abd: +bs. ntnd. no hsm. rectal: prostate without clear mass, although there did seem to be some slight irregularity of unclear significance. ext: no c/c/e. discharge exam: vitals: 99.2 122/70 88 22 96% gen: fatigued, no acute distress heent: mmm, anicteric, no lymphadenopathy cv: rrr, 3/6 systolic murmur lungs: clear bilaterally abd: soft, non-tender, non-distend, hyperactive bowel sounds, midline incision well-healing ext: no cce, rash on lower legs c/w tinea back: deep tissue injury to left buttock pertinent results: admission labs: 138 103 14 105 agap=10 --------------- 4.1 29 0.7 ca: 8.9 mg: 2.0 p: 3.7 6.1 > 38.6 < 238 n:64.3 l:27.3 m:4.3 e:3.1 bas:0.9 on discharge: 05:27am blood wbc-7.4 rbc-2.73* hgb-9.1* hct-27.1* mcv-99* mch-33.3* mchc-33.5 rdw-20.6* plt ct-176 03:13am blood pt-15.5* inr(pt)-1.4* 05:27am blood glucose-101* urean-16 creat-0.6 na-140 k-3.7 cl-107 hco3-28 angap-9 07:55am blood alt-7 ast-42* alkphos-134* totbili-0.5 05:31am blood calcium-7.1* phos-3.0 mg-1.8 04:38pm blood freeca-1.21 video swallow evaluation : mr. presented with a moderate oropharyngeal dysphagia as characterized above with penetration of thin liquids, nectar-thick liquids, and ground solid. pt also had trace aspiration of thin and nectar-thick liquids with one episode of significant aspiration with large consecutive sips of thin liquids. pt had a spontaneous throat clear in response to penetration which was moderately effective for clearing the airway, more so with nectar-thick liquids than with thin liquids. recommendations: 1. po diet: nectar-thick liquids, pureed solids. 2. po meds crushed with applesauce. 3. 1:1 supervision to maintain strict aspiration precautions 4. small sips, one sip at a time. 5. tid oral care. 6. agree with keeping ng tube in place until pt demonstrates sufficient po intake. 7. we will f/u later this week to evaluate for further upgrades. brief hospital course: in summary (please see below for more details): 80 yo m with hx mvr bioprosthetic, af on coumadin, 1 month hx of left shoulder and side pain, presents after mri noted what looked like mets cancer at t1, t2, and t3. biopsy of the spine identified multiple myeloma as the cause of the lytic lesions. his hospital course has included: - posterior lumbar fusions on - anterior lumbar fusion - ileus and gastric outlet obstruction, requiring dilation - acalculous cholecystitis and infectious pericholecystic fluid - c difficile diarrhea - right sided exudative pleural effusion s/p chest tube and removal - health care associate pneumonia (treated with vanc/cefe/flagyl) - sacral decubitus ulcer on discharge, his condition has significantly improved. his active problem list now includes: - multiple myeloma: untreated, will likely start chemo soon - nutrition: tolerating pureed and nectar diet, advance as tolerated - duodenal stricture: tolerating diet, gi will followup if having difficulty with po - afib: in nsr during hospitalization, holding warfarin given comorbidities - sacral decub: needs wound care - physical therapy . . hospital course: #) multiple myeloma: pt presented initially with concern for metastatic disease seen on outside mri. he was found to have a pathologic l4 fracture in need of stabilization and his multiple myeloma was diagnosed via tissue pathology from posterior spine stabilization on . heme/onc and rad/onc were aware of patient but put further treatment or evaluation for multiple myeloma on hold until more acute hospital issues are resolved (see below). from the beginning family expressed desire to pursue treatment of myeloma once patient able. given his improved medical status, he was transferred to rehab with followup by the oncology there to consider therapy with decadron and velcade. the family also opted for dr. as their oncologist, and he can be reached at . will need pamidronate q4wks (1st dose was ). . #) pathologic spine fracture: pt had lumbar instability due to l4 lytic lesion found incidentally on initial mri. pt had no symptoms at time of this discovery. pt underwent l3-l4 bilateral hemilaminectomy with posterolateral fusion of l3-l5 with iliac crest bone graft harvest for fursion augmentation. due to extent of metastatic destruction, also needed second surgery for anterior spine stabilization. on patient went to or and underwent anterior fusion of l3-l5. he was transferred to the micu post-op then called out to the floor. on the floor he was helped out of bed to chair without use of the brace. . #) gastric outlet obstruction/ileus: post operative ileus was present from date of initial spine stabilization surgery. pt also had known benign duodenal stricture dilated x 4 at osh (/ - see atrius records) in /. he became acutely obstructed on with axr showing severe dilation of his stomach. an ngt placement yielded 1l bilious fluid. ercp took to egd later that day and performed another balloon dilation of stricture. afterward pt had some improvement but over the next 10 days twice become more distended and had ngts placed twice with some bilious output from the ngt and abdominal relief each time. possible that the 2nd two events were due to total bowel distension and ileus to narcotics, cdiff, immobility, and limited diet as much as a problem with the duodenal stricture as they were not completely relieved with ngt placement and abdominal imaging showed persistently dilated bowel loops. after his anterior fusion, abdomen remained distended possibly from gastric obstruction/post-operative ileus/narcotic use. kub showed no signs of sbo. on pod4 he had 2bms and he was started on clears for diet. on the , he was tolerating clear diet, moving bowels reguarly. however there was concern for aspiration pneumonia and patient was transferred to micu for respiratory distress. he was started on tpn in the micu, and then transitioned to tube feeds. he was transferred back to the floor and tpn was discontinued. he continued on continuous tube feeds until his mental status was improved, and then underwent another video swallow eval. recommendations from speech/swallow were to start him on a pureed and nectar diet. he tolerated this well without further abdominal distention, and the ng tube and tube feeds were discontinued. he was discharged to rehab on the pureed diet, which he was tolerating well. . #) cdiff infection: pt started developing leukocytosis with low grade temps on . was having very little stool but it was liquid and cdiff toxin sent on came back positive on . pt had already been started on metronidazole on (along with ctx) for emperic coverage of gallbladder. initially wbc and exam improved with this therapy but when wbc worsened again po vanco was added to metronidazole on . bowel distension slowly improved with this treatment and abdominal pain slowly resolved. however, continued to have persistently dilated bowel loops as noted above. since pt was started on cefepime/vanco for hap coverage when transfered to the icu initially and completed a 8 day course of this therapy, decision was made to extend po vanco/iv metronidazole coverage to end . po vanco was restarted because of the high likelihood of recurrence. he continued prophylactic po vanco coverage until . . #) poor respiratory status: this was not present on hospital admission and cxr on had no effusion but picc confirmation cxr on showed large unilateral (right) effusion which had developed in the 3 day interval. pt had worsening of breathing status a day or two before this was observed as well as discomfort in r side which presumably was due to effusion although initially had been attributed to either cdiff or choleystitis as both were being evaluated at that time. pt was doing okay on 2-3l nc but fluid was not responding well to lasix when on the evening of he became acutely tachypnic and was transfered to the icu where he was briefly on bipap and ct surgery placed a chest tube with >1l of output. fluid studies boarderline exudate vs transudate and cultures pending. abx were broadened to cefepime and vancomycin at time of unit transfer. pt now with stabilized respiratory status and has largely resolved effusion on f/u cxrs. chest tube removed today and pt doing well enough to call out to floor on . after arrival to the floor, stayed comfortable on ra-2l nc with only minimal reaccumulation of r pleural effusion noted on f/u cxrs. completed 8 day course of cefepime/iv vancomycin as noted above for presumed hospital acquired pneumonia and wbc which had spiked up on day of hospital transfer trended down to the normal range with these treatments. pt returned to the or on and remained intubated post-op. he was extubated on . since transfer to the on 06/31, he has remained tachypneic, with rr rising upto 50. he was also tachycardic with hr up to 120. ekg was unchanged from previous, abg shows alkolosis, multiple cxrs and mri with contrast () showed only stable atelectasis and stable right-sided pleural effusion, with no evidence of pneumonia or pe. started therapeutic heparin to treat presumptive pe on ; he was not fluid overloaded and did not improve w/ lasix. given aspiration risk, pleural effusion and previous hcap, restarted iv vancomycin and cefipime on for 1 week. he was transferred out of the micu on and continued to be tachypnic to high 20s, but respiratory status was otherwise stable. his respiratory status continued to improve and he was discharged with a rr ~20 on room air with a normal oxygen saturation. . #) question of cholecystitis: during time when pt initially developed leukocytosis, low grade temps, and abd distension, concern developed about possible gallbladder process. abdominal ct had showed gb enlargement but picture muddied by fluid around gallbladder from small amount of ascites due to low albumin. gallbladder u/s was non-diagnostic so hida scan was obtained. this showed evidence of acute cholecystitis with caveat that some question if could be falsely positive in setting of npo status. due to concerns for risk of perc cholecystostomy tube recommended by surgical service, decision was made to initially treat with iv abx and pt had some improvement. development of r pleural effusion raised concern again for gb process and resulting sympathetic effusion in right lung. however, pt improved again with drainage of pleural effusion and empiric treatment for hospital acquired pneumonia and gi consulting service agreed that less likely pt had cholecystitis in current setting although pt continued to remain at very high risk for acalculous cholecystitis due to his overall level of poor health. . #) delirium: pt was intermittently delirious for 4-5 days after initial ortho/spine surgery. this largely resolved in the following 10 days with pt only requiring a couple of doses of haldol (which had only limited effect). pt again started to become somewhat confused on am of which was attributed to multifactorial delerium in an elderly, very sick patient who had been in the hospital for almost 4 weeks. family actually thought patient looked better than he had the entire hospitalization that day but the next day delirium seemed further worsened and that night patient again required icu transfer due to 2 blood containing bowel movements and a small hct drop. in the micu patient had visual hallucinations and required restraints because started pulling at lines. on pod2 after anterior spinal fusion pt became slightly agitated. on transfer to the , delirium continued to wax and wane. on discharge, he is alert and oriented to name, sometimes to date, sometimes to location. . #) gi bleed: although patient had multiple above gi issues, no gi bleeding had been noted during first 3 weeks of hospitalization. pt had history of bleeding hemorrhoids and was on omeprazole for gerd/gi prophylaxis considering his level of sickness. on the afternoon of , pt was reported to have a blood bowel movement while working with physical therapy. on physician exam of the stool, it was brown with some blood streaking and patient had notable hemorrhoid protruding externally on physical exam. in light of stool appearance with very little total blood, hemorrhoid, and pt report of past bleeding hemorrhoids, this bleed was attributed to hemorrhoidal source. however, later that evening pt had a large maroon bowel movement in the setting of low grade new tachycardia and mild respiratory distress. stat hct showed drop from 28.7 to 24.5 which was slightly outside the range of lab error and in the setting of this and other clinic changes (hr and rr), pt was transferred to the micu and iv ppi initiated. of note, this occurred in setting of patient being advanced from liquids to regular diet in the last 24hrs. in the micu, pt was transfused 1u prbc. anoscopy performed by gi. no lesion was visualized. sigmoidoscopy was performed on which suggested bleeding was likely an internal hemmorhoid. hct were stable afterwards. there was concern on a subsequent micu admission for bleeding given a downtrending h/h. upper endoscopy by gi demonstrated a non-bleeding duodenal ulcer. on discharge, h/h was stable. he was converted to pantoprazole 40 po at discharge. . #) atrial fibrillation: pt had history of atrial fibrillation for which he had been on warfarin. this was stopped on admission due to need for spinal surgery and relatively low day to day risk of embolic stroke compared to high risk of spinal bleeding on therapeutic anticoagulation. also has prosthetic mitral valve but it since it was a tissue valve, it did not need anticoagulation. pt was actually sinus most of admission and midly tachycardic when was febrile/developing infection. on low dose metoprolol as an outpatient which was held for the concern of gi bleed. warfarin was held on discharge given multiple comorbidities and relatively low embolic risk. this was discussed with the pcp at discharge. his metoprolol was not re-started during the hospitalization but should be restarted at rehab and was included in his medication list. . # nutrition status: mr. was intermittently on tpn, tube feeds, and diets throughout his hospitalization. most recently he was transitioned from tpn to tube feeds. a video swallow eval recommended nectars and pureed food. he tolerated this diet well over the last 24 to 48 hours. his tube feeds were stopped and his ng tube was removed prior to discharge. . # adrenal insufficiency there was a question of adrenal insufficiency raised while the patient was hypotensive in the micu. he was started on steroids with relief of his hypotension. he was then tapered down from the stress dose to a maintenance dose of 10mg am and 5mg pm of hydrocortisone. on he underwent a cortisol stim test, and his cortisol level at 1hr and 15min was 17.8. it was felt that this was nearly a normal response and that his steroids could be tapered. it was likely that the poor adrenal response was related to his signficantly troubled hospital stay. he received 10mg hydrocortisone in the hospital prior to discharge, and then will receive 5mg hydrocortisone at rehab and then will stop. . medications on admission: simvastatin 20 qd xalatan 0.005% 1 drop each eye daily warfarin 5 mg sun/mon/wed/fri; 2.5 mg tue/thurs/sat omeprazole 40 mg metoprolol 25 qd mvi citracal + d. tylenol oxycodone 5 mg prn baclofen 10 prn erythromycin eye ointment tid (for 7 days for eye infection). discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 4. clotrimazole 1 % cream sig: one (1) appl topical (2 times a day). 5. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 6. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 7. hydrocortisone 5 mg tablet sig: one (1) tablet po once a day for 1 doses: finishing steroid taper, give one dose friday morning, then discontinue. 8. pantoprazole 40 mg iv q12h 9. acetaminophen 500 mg tablet sig: 1-2 tablets po three times a day as needed for pain. 10. zyprexa 2.5 mg tablet sig: 1-2 tablets po at bedtime as needed for insomnia or agitation. 11. zoledronic acid 4 mg/5 ml solution sig: one (1) dose intravenous once a month: last dose . discharge disposition: extended care facility: hospital- discharge diagnosis: multiple myeloma discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: mr. , you were originally admitted almost two months ago with back pain, and spinal surgery revealed this was called by multiple myeloma lesions. your hospital stay has since been prolonged by multiple complications including many transfers to the micu. you are being transferred to a rehabilitation hospital for further therapy. followup instructions: ---follow-up with pcp . ( after rehab. ---hem/onc at will follow multiple myeloma. can contact dr. at to coordinate care ---follow-up with gi after rehab regarding duodenal stricture procedure: parenteral infusion of concentrated nutritional substances other endoscopy of small intestine enteral infusion of concentrated nutritional substances thoracentesis other incision of pleura other excision of joint, other specified sites flexible sigmoidoscopy open biopsy of soft tissue lumbar and lumbosacral fusion of the posterior column, posterior technique repair of vertebral fracture lumbar and lumbosacral fusion of the anterior column, anterior technique anoscopy dilation of intestine insertion of interbody spinal fusion device fusion or refusion of 2-3 vertebrae fusion or refusion of 2-3 vertebrae insertion of recombinant bone morphogenetic protein diagnoses: pneumonia, organism unspecified obstructive sleep apnea (adult)(pediatric) coronary atherosclerosis of native coronary artery esophageal reflux toxic encephalopathy acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) unspecified protein-calorie malnutrition atrial fibrillation other and unspecified hyperlipidemia loss of weight alkalosis intestinal infection due to clostridium difficile long-term (current) use of anticoagulants paralytic ileus pressure ulcer, lower back multiple myeloma, without mention of having achieved remission other ascites obesity, unspecified heart valve replaced by transplant hyperosmolality and/or hypernatremia internal hemorrhoids with other complication external hemorrhoids with other complication neoplasm related pain (acute) (chronic) myelopathy in other diseases classified elsewhere pathologic fracture of vertebrae other sedatives and hypnotics causing adverse effects in therapeutic use cauda equina syndrome with neurogenic bladder pressure ulcer, stage iii cholecystitis, unspecified other obstruction of duodenum other specified forms of effusion, except tuberculous 

Answer: The patient is high likely exposed to