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: falls major surgical or invasive procedure: emg and muscle biopsy history of present illness: mr. is a 77 year old right handed man with a history of primary autonomic failure resulting in orthostatic hypotension and supine hypertension, who is followed by dr. . he was advised to come to the ed today after he had a fall each night for the past two nights. mr. wife and daughter note that for the past week he has been talking, responding, and walking more slowly than usual. his balance has not been as good. at baseline he has a stooped, shuffling gait, and does not use a cane or walker for stabilization. he takes midodrine for the orthostasis, and has required frequent adjustments in his dosing due to the supine hypertension at night. no major adjustments have been made recently, however. he is also supposed to drink plenty of fluids and take salt tabs, but has not been drinking well for the past couple of weeks, and has not been taking the salt tabs for the past 3 days, due to edema in his legs. for the past two nights he has awoken at 3-4 a.m. to change his depends, and while in the bathroom has fallen over backwards. he notes that he did not feel dizzy or lose consciousness, but simply lost his balance. he has not hit his head, but his back has been sore after the falls. his family reports that when he falls, he does tend to fall backwards. he has not been systemically ill, although he sometimes feels dizzy in the morning, which he describes as lightheaded. he has had no headaches, palpitations, fever, shortness of breath. there have been no ill contacts at home. review of systems: no recent fever, weight loss, cough, rhinorrhea, shortness of breath, chest pain, palpitations, vomiting, diarrhea, or rash. no diplopia, dysarthria, tinnitus, dysphagia, vertigo, weakness, numbness, paresthesias. past medical history: - primary autonomic failure with orthostatic hypotension and supine hypertension, diagnosed after he had a number of syncopal episodes - gerd - urinary frequency - hx pancytopenia in , resolved spontaneously, negative lab w/u, has never had bone marrow bx, followed in past by heme/onc - osa, dx per pt as "mild" after sleep study, did not tolerate cpap - h/o hoarseness/cough, evaluated by ent at osh ?vocal cord dysfunction vs. reflux - chronic low back pain - colon polyps s/p polypectomy 5 years ago, next colonoscopy in . social history: lives with his wife and , daughter also stays there. + tobacco- 5 cig/day x 10 yrs-quit . no etoh x 1 yr, works part-time in mail office at local college. family history: father-colon ca. mother-dm, dementia ?alzheimer's physical exam: t 97.2 hr 59 bp 159/94 -> 193/115 sitting up s/p midodrine rr 12 pulse ox 98% general appearance: thin 77 year old man sitting up in bed in nad heent: nc/at, neck supple with full rom and no paraspinal muscle tenderness cv: regular rate and rhythm without murmurs, rubs or gallops. no carotid bruits. lungs: clear to auscultation bilaterally. abdomen: soft, nontender, nondistended extremities: no clubbing, cyanosis; 2+ non-pitting edema to knees bilaterally mental status: alert and oriented to person, place, and date. speech is hypophonic and very slow, with intact naming, delayed but intact registration, comprehension. repetition somewhat impaired, when asked to repeat "cats dogs" says "cat dog" repeatedly. mildly inattentive. able to recite months of year backwards with 2 errors (left out two months). recalls 0/3 items at 3 minutes. intact calculations. no apraxia. +snout sign, +glabellar tap, - palmomental cranial nerves: pupils are equal, round and reactive to light. visual fields are full to confrontation. extraocular movements are full. there is no nystagmus and no ptosis. facial sensation is intact to light touch. face is symmetric but with somewhat decreased spontaneous mobility and his gaze is slightly intense. hearing is intact to finger rub bilaterally. there is symmetric palate elevation and the tongue protrudes midline. motor system: normal muscle tone, no rigidity. strength is full throughout. there is no pronator drift. +tongue tremor when mouth held open, and +bilateral postural tremor in the hands, but no resting tremor. reflexes: deep tendon reflexes are 2+ and symmetric. plantar responses are flexor bilaterally. no . sensory: sensation is intact to light touch, temperature, position, and pinprick throughout. mildly decreased distal vibration sense in feet bilaterally. coordination: no dysmetria with finger to nose. slow but accurate finger tapping bilaterally. gait: shuffling and stooped, but not festinating. tends to retropulse. requires 11 steps to pivot. pertinent results: 03:30pm neuts-81.4* bands-0 lymphs-13.8* monos-4.0 eos-0.3 basos-0.5 03:30pm wbc-3.4* rbc-4.07* hgb-11.8* hct-36.8* mcv-90 mch-29.0 mchc-32.1 rdw-15.3 03:30pm calcium-9.1 phosphate-3.5 magnesium-2.3 03:30pm ck-mb-45* mb indx-13.6* ctropnt-<0.01 03:30pm ck(cpk)-330* 03:30pm estgfr-using this 03:30pm glucose-105 urea n-22* creat-0.6 sodium-140 potassium-4.3 chloride-101 total co2-34* anion gap-9 07:00pm urine blood-neg nitrite-neg protein-neg glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 09:30pm ck-mb-36* mb indx-13.5* 09:30pm ctropnt-<0.01 echo: : normal global and regional biventricular systolic function. mild mitral regurgitation. mildly dilated aortic root. cxr: : polygonal opacity in the lingula could represent scar or atelectasis, or pneumonia. in conjunction with the small right sided pulmonary nodule, a chest ct may be of value. lle doppler: : no evidence of dvt in the left lower extremity ct head: : no acute intracranial hemorrhage. no fracture. ct torso: 1. bilateral lower lobe pneumonia. 2. 2.7 cm gastric wall mass, of uncertain etiology. 3. asbestos-related pleural plaques. 4. wedge compression fracture of l1 vertebral body of uncertain chronicity. l-spine mri : compression deformity, age indeterminate, of the l1 vertebral body, and possibly of t11 and t10 as well. please correlate with the site of the patient's pain. emg: abnormal study. the electrophysiologic findings are most consistent with a mild generalized myopathy without denervating features. there is no electrophysiologic evidence for a generalized polyneuropathy affecting large-diameter nerve fibers (including syndrome) or for a pre- or post- synaptic disorder of neuromuscular junction transmission. incidental note is made of a mild ulnar neuropathy at the left elbow. the reduced activation noted on needle electromyography also suggests that a component of this patient's weakness is due to a central process or poor effort. muscle biopsy: mild, non-specific changes: mild fiber size variation with occasional small, angulated myofibers and round, atrophic myofibers occasional nuclear knots. isolated regenerating myofiber. no significant inflammation. 05:30am blood wbc-4.3 rbc-3.14* hgb-9.4* hct-27.7* mcv-88 mch-30.0 mchc-34.1 rdw-15.3 plt ct-264 05:30am blood plt ct-264 05:30am blood glucose-105 urean-16 creat-0.5 na-139 k-4.6 cl-100 hco3-34* angap-10 05:30am blood calcium-8.7 phos-3.0 mg-1.8 04:45am blood caltibc-267 vitb12-greater th folate-9.4 hapto-70 ferritn-365 trf-205 11:54am blood hapto-88 04:45am blood tsh-6.0* 01:00pm blood free t4-0.92* 11:54am blood cortsol-26.8* 04:45am blood pep-no specifi igg-707 igm-59 05:50am blood hiv ab-negative 04:04am blood type-art po2-85 pco2-51* ph-7.48* caltco2-39* base xs-12 brief hospital course: initial neurology course neuro/autonomic: - : midodrine was continued at the dosage schedule of 7.5 at 0800, 1100, 5mg at 1400 and 2.5mg at 1800. vasopressin was continued and salt tabs were restarted. morning of had orthostatis of 95/65 supine and 82/55 sitting up with symptoms of dizziness. discussed with autonomic fellow who wanted to continue current midodrine doses, continue salt tabs and ivf or 2-3 liters/day with plan to titrate as needed from here. thought that it was likely that the patient had fallen secondary to his orthostasis despite the fact that he was never pre-syncopal or dizzy because patients with autonomic disorders are often asymptomatic of there orthostasis. mri was unimpressive and non-acute. orthostatics checked again later in the day on and were 120/72 (p87) lying, 120/68 (p88) sitting, then machine could not register upon standing, but manually was 86/40 standing (p40). when checked manually while sitting was 98/72 (p82). patient was not symptomatic at any point. still mildly orthostatic but asympomatic and will continue current doses midodrin, salt tabs, fluids and watch. lumbar puncture considered but deferred secondary to low platelet count and poor platelet smear. -hypothermic to 89.9 rectally on admission to floor. was given bair-hugger and corrected to 93.5 over course of 6 hours. could be related to his autonimic dysfunction but not described in his prior history. discussed with autonomic serivice who felt that this could be part of the autonomic dysregulation but also suggested sepsis or other systemic cause as an etiology. lactate and ammonia levels returned within normal. cardiovasc: ckmbi was elevated x 3 but troponins negative x 3. echo had ef 55% and mild mitral regurg and mild aortic root dilation. resp: co2 retention with abg co2 55 and hc03 35. lactate .9. likely chronic. no history of copd but does have history of opbstructive sleep apnea with cpap intolerance. pna seen in left lower lobe lingula on cxr and also associated nodule. started levaquin. id later recommended d/cing as patient not symptomatic and has known history of pulmonary scarring followed by pulmonologist at osh. given his history of asbestos exposure and smoking, ct with contrast ordered which showed a pneumonia, asbestos related plaques, and a 2.7 gastric wall mass. gi: tolerated diet well. when ct chest performed, incidentally found a gastric calcification and nodule suspicious for gist tumor. biopsy of this showed that it was nonneoplastic. has mildly elevated lfts alt>ast with no known source, which has essentially resolved. endo: regular insulin sliding scale for prophyaxis. tsh and free t4 borderline but satisfactory. he was started on levothyroxine for treatment. heme: pancytopenic on admission and worsened on repeat labs in am. consulted heme. recommended sepsis work up, ebv titer, hiv, ppd, parvovirus, cmv, coags, cortisol, cortistim, lactate, spep, tsh, fe studies, folate, repeat blood cultures, hit, ca/mg/phos, ldh, b-glucan and galactomanin. urine study: add mmp22 (urinary ca marker) tte and maybe tee for vegetations. ct chest. ivf and follow uop. ppd. possible lp. had transiently elevated ptt of 84 on am labs with inr of 1.2. heparin d/c'd and coags as well as dic panel re-ordered stat. second set showed ptt corrected to 45 and normal fibrinogen/haptoglobin and d-dimer around 1000. discussed with heme who was not impressed and thought was possibly a down stream draw from heparin flush as it corrected so quickly without treatment. work up for pancytopneia negative at day 3 and pancytopenia beginning to spontaneously resolved. currently still pancytopenic but not terribly far off from his baseline. if everything resolves, will still need to follow up with dr in 2 weeks as op for possible further work up including marrow. id: consulted given the hypothermia and concern for sepsis. they were not at all concerned for sepsis as his pressures have been stable and now at baseline temperature, also had normal lactate level. recommended cancelling aspergillosis and fungal infection work up, and was not too concerned about lyme or parvovirus. did not think that there was any significant sign of infection in the patient and that current work up in addition to cmv igm reasonable. did not think that tuberculosis precautions needed and thought that ppd placement not imperative but could be done and should only be done >48 hours after the cortistim test completed (would interfere). will not pursue tee as likelihood of endocarditis very low and no positive blood cultures as of yet. all id work up negative at day 3 and id has signed off. notify id if any cultures/antibodies return positive. id did not feel strongly for/against lp and agreed with holding off given the poor coags. micu course: the patient was admitted to the micu for respiratory distress attributed to aspiration pna +/- mucus plugging. the patient arrived intubated and was started on vanc and zosyn for a 10 day course. the following issues were addressed during his micu course: . # hypoxic and hypercarbic respiratory failure/failue to extubate: the respiratory failure was thought to be secondary to an aspiration pna +/- mucous plugging. the patient was intubated and treated with vanc and zosyn for ten days. he was extubated on , was apneic, and subsequently emergently reintubated. the cause of his apnea was unclear. his niffs were very low, making a myopathy a possible cause. hypothyroidism was also on the differential given his elevated tsh. an emg suggested a myopathic process but a muscle biopsy was non-diagnostic. the patient's hypothyroidism was treated with synthroid and diamox was used to lower his bicarb. the patient's hco3 fell and his niffs improved with time. his sputum grew out gnrs. he was eventually extubated successfully. he was placed on nocturnal bipap for hypoventilation during sleep. of note, his repeat sputum cultures continued to grow out gnr and a recent cxr showed a possible consolidation in the rll in the setting of improving respiratory function and overall clinical picture. the patient had been afebrile for >1wk with a stable and low wbc ct. given he had no clinical signs of pna, he was not treated with antibiotics. the patient was supported with chest pt, nebs, incentive spirometry with good effect. because he continued to hypoventilate and have hypercarbia on abg, he was started on nocturnal bipap of . patient was transferred to the neurology service on . he was continued on his noctural bipap. he has been afebrile, stable vital signs, and white count of 4.3. recent cxr on shows improved of original opacities. we have obtained an esr and ua/ucx prior to discharge to ensure that he is free of any infection. current autonomic neurology recommendations: continue aggressive hydration with at least 2l of fluid per day and salt tablets to a goal of 10gm of salt per day. orthostatic blood pressures should be checked. continue midodrine. the patient is likely deconditioned which will worsen hypotension. bp should be taken prior to pt, and if <100 mmhg, midodrine can be increased (by 2.5-5mg increments) to tolerate pt (goal sbp >100mm hg). he should avoid being supine for several hours after midodrine is given, thus it should not be given after 4pm. if there is supine htn (190's-200's), the head of the bed should be elevated to 45 degrees. continue ddavp. pending labs: anti , ro, la, upep, ssa, ssb medications on admission: midodrine 7.5 mg in the am, 7.5 mg in mid-am, 5 mg at 2 p.m., and 2.5 mg around p.m. (about 4 hours before he goes to sleep); desmopressin inhaler; salt tabs 1g, up to 10 per day (family titrates) discharge medications: 1. midodrine 5 mg tablet sig: one (1) tablet po prn as needed for if sbp <100 prior to physical therapy: please check blood pressure prior to physical therapy and administer if sbp <100. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. midodrine 2.5 mg tablet sig: three (3) tablet po qam (once a day (in the morning)). 5. midodrine 2.5 mg tablet sig: three (3) tablet po at 11 am (). 6. midodrine 2.5 mg tablet sig: one (1) tablet po at 6 pm (). 7. sodium chloride 1 g tablet sig: one (1) tablet po tid (3 times a day). 8. desmopressin 10 mcg/spray aerosol, spray sig: one (1) spray nasal hs (at bedtime). 9. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 11. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 12. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 13. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 14. albuterol sulfate 0.083 % solution sig: one (1) inhalation q3-4h (every 3 to 4 hours) as needed. 15. midodrine 5 mg tablet sig: one (1) tablet po at 2 pm (). 16. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. discharge disposition: extended care facility: hospital - discharge diagnosis: autonomic failure, s/p respiratory failure, pneumonia s/p antibiotics, pancytopenia and coagulopathy - resolved, 2.7 cm gastric wall mass - biopsy nonneoplastic. discharge condition: good discharge instructions: please take your medications as directed and attend your follow up appointments. followup instructions: please follow up with dr. (hematology) on at 11am. the clinic is located on 9. the clinic's phone number is (. please have your sutures removed around , 7-10 days after your muscle biopsy was performed. follow up with dr. and dr. of autonomic neurology on at 3pm. the clinic is located on 8. the clinic's phone number is (. procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances non-invasive mechanical ventilation esophagogastroduodenoscopy [egd] with closed biopsy open biopsy of soft tissue transfusion of platelets diagnoses: obstructive sleep apnea (adult)(pediatric) unspecified essential hypertension unspecified acquired hypothyroidism abnormality of gait acute respiratory failure urinary frequency pneumonitis due to inhalation of food or vomitus other and unspecified coagulation defects foreign body accidentally entering other orifice atrophic gastritis, without mention of hemorrhage orthostatic hypotension foreign body in main bronchus history of fall inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation myopathy, unspecified unspecified disorder of autonomic nervous system other disorders of the pituitary and other syndromes of diencephalohypophyseal origin foreign body in stomach 

Answer: The patient is high likely exposed to