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: no known allergies / adverse drug reactions attending: chief complaint: weakness, shortness of breath major surgical or invasive procedure: none (note: patient had right sided chest tube removed that had been placed at outside hospital) history of present illness: in summary, mr. is a 74 year old male with past medical history significant for copd on home o2, htn, paroxysmal atrial fibrillation, (not on coumadin; compliance issues), diastolic chf, and oa who presented initially to osh at on with worse shortness of breath from baseline, poor po intake. notable leukocytosis to 22k range and concern for underlying pna. additional imaging with chest ct revealed loculated right pleural effusion with pleural thickening suggestive of an empyema as well as smaller left sided effusion. zosyn was initiated on and chest tube was placed at osh with failure to obtain any pleural fluid. outside hospital labs were significant for leukocytosis 22.2 (: 10.7); hct 43; na: 135; co2: 32.7; creatinine 1.7 (prior 0.9); u tox negative. . he was transferred to sicu for additional thoracics evaluation for potential vats/pigtail placement vs. decortication but thoracics team did not feel imaging or clinical picture suggestive of true empyema and feels this is a chronic effusion that does not need to be drained. sicu vitals on arrival to on were: hr 93, bp 107/55, rr 24 and o2 sat 97% 3l. thoracic service had chest tube removed , this morning. per sicu team, patient's leukocytosis felt to be secondary to possible pna vs. uti given that recent urine studies growing coag negative staph. patient was started on vanco/zosyn at which was continued here over past day. . in addition, at osh patient went into afib with rvr to 120s and was managed on a combination of digoxin and diltiazem gtt prior to transitioning back to oral beta blocker therapy with fair resolution and hr control (hrs 70-80s). . also developed arf over last week as his creatinine on admission to was 0.8 on and now up to low 2 range. he had exposure to contrast for ct imaging studies and he was also given lasix for question of chf exacerbation at osh which may have been contributing factors. lasix held here since admission. . lower extremity doppler done here after transfer for mild le edema and picked up a right le dvt with thrombus within the right superficial femoral vein and within the right popliteal vein. at time of transfer now patient has yet to be started on anticoagulation for dvt. . lastly, patient also complained of some vague abdominal pains and per reports he had question of obstruction at osh so kub performed with with nonspecific bowel gas pattern. here in sicu patient has had healthy bowel sounds but mild llq tenderness. no bm since transferred at 10pm last night, no nausea, no vomiting. of note, history of diverticulosis. . at time of transfer to general medicine service on patient appeared to be in no apparent distress but seems confused which is near typical baseline per family. vitals signs at time of transfer: t98.3, bp 110/67, hr 89, rr 16 and 02 saturation 97% 3l. . review of systems: patient unable to cooperate so ros limited. denies fever, chills, night sweats, recent weight loss or gain. denies headaches. past medical history: past medical/surgical history: -asthma -hypertension -copd on home oxygen -history of atrial fibrillation -osteoarthritis -seborrheic dermatitis -diverticulosis -rt inguinal hernia -cataract surgery social history: social history: patient states he was living with his son prior to recent hospitalization. smoking hx of 1ppd x 30 years (quit age 50). distant etoh use and per prior omr notes also history of heroin abuse in the past but quit >20 years ago. confused at baseline per family. . family history: non contributory physical exam: physical exam at transfer to medicine: vitals: t98.3, bp 110/67, hr 89, rr 16 and 02 saturation 97% 3l. general: alert and oriented x2, mildly agitated, no acute distress heent: sclera anicteric, mmm, perrl, + arcus senilis, oropharynx clear neck: supple, jvp not elevated, no lad lungs: bilateral basilar crackles (right >left). no wheezes. no dullness to percussion. prior ct site appears c/d/i with no bleeding, covered with dressing. cv: irregular rhythm noted, normal s1 + s2, no murmurs, rubs, gallops or clicks noted abdomen: soft and obese, ventral hernia (mild), mild ttp over left abdomen but no rebound, non-distended, bowel sounds present, no guarding, no organomegaly ext: warm and increased erythema below mid calf bilaterally, 2+ pulses, + edema over rle, no clubbing, cyanosis access: 22g piv and groin/femoral cvl in place pertinent results: admission labs: 09:20pm glucose-151* urea n-25* creat-2.1* sodium-134 potassium-3.9 chloride-89* total co2-33* anion gap-16 09:20pm alt(sgpt)-15 ast(sgot)-18 alk phos-85 tot bili-1.8* 09:20pm calcium-8.3* phosphate-3.4 magnesium-1.9 09:20pm wbc-18.9* rbc-4.88 hgb-14.9 hct-44.0 mcv-90 mch-30.5 mchc-33.8 rdw-15.0, plt count-336 09:20pm pt-15.6* ptt-38.9* inr(pt)-1.4* . interval significant labs: tsh 2.2 inr 2.3 vanco trough 34.7 . discharge labs: glucose-85 urea n-7 creat-0.9 sodium-136 potassium-3.4 chloride-96 total co2-33* anion calcium-7.6 phosphate-2.4 magnesium-1.7 wbc-8.5 hct-36.9 (stable x2 days) plt count-380 inr 5.1 vanco trough 19.8 . urine studies: 09:20pm urine color-yellow appear-hazy sp -1.033 09:20pm urine blood-lg nitrite-neg protein-75 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 09:20pm urine rbc-0-2 wbc-0-2 bacteria-mod yeast-none epi- . imaging: . cxr: the examination is compared to . in the interval, the patient has received a right-sided picc line. the tip of the line projects over the lower svc. there is no evidence of complications, notably no pneumothorax. otherwise, the radiograph is unchanged. cxr - findings: as compared to the previous radiograph, the right-sided chest tube has been removed. minimal right pleural thickening, minimal left pleural effusion. no evidence of pneumothorax. . cxr - findings: small lung volumes. borderline size of the cardiac silhouette, small left pleural effusion, small platelike right atelectasis. on the right, the patient has a chest tube. the sidehole of the tube is outside the pleural cavity and projects over the soft tissues. there is no evidence of pneumothorax. . rle ultrasound: thrombus within the right superficial femoral vein, with total occlusion seen in the mid portion and partial occlusion seen in the proximal portion. the distal portion is patent. patent right common femoral vein, which contains a catheter. small isolated nonocclusive thrombus within the right popliteal vein. non-compressible thrombus demonstrated in at least one right deep calf vein. no dvt detected within the left lower extremity. the left peroneal veins were not assessed as the patient refused further evaluation. 6. 3.0 x 2.1 x 2.7 cm right groin hematoma, without internal flow. . outside hospital images: : chest ct: mdct of the chest was done with intravenous infusion of 100 cc omnipaque 300. sagittal and coronal reformatted images were obtained. there is a moderate posterior right pleural effusion. suggestion of thickening and enhancement of the surrounding pleural surfaces. there is minimal swelling of the overlying soft tissue as well. there is a minimal posterior left pleural effusion. there is anterior pericardial thickening or a small loculated anterior pericardial effusion. streaky pulmonary parenchymal densities bilaterally, consistent with subsegmental atelectasis and/or scarring. there is scattered atherosclerotic calcification. the heart and mediastinal structures are otherwise unremarkable. no lymphadenopathy is identified. there is no significant chest wall abnormality. impression: posterior right pleural effusion. evidence for surrounding pleural thickening and enhancement suggests the possibility of empyema; very small posterior left pleural effusion. minimal pericardial thickening or loculated pericardial effusion. . tte osh: ejection fraction is 55%. he has mild aortic stenosis, normal tricuspid valve, normal pulmonary valve, no pulmonary hypertension. overall findings of his echocardiogram similar to one from . . osh: rle ultrasound: noncompressibility of the right superficial femoral to popliteal vein but with normal color flow on doppler studies. augmentation studies of these segments were not performed. findings are suggestive of chronic dvt. no dvt was seen in the other leg, the left lower extremity . cardiac: ekg on : afib with rvr in low 100s range . microbiology: blood cx - pending urine cx - no growth . osh urine studies --> urine tox was positive for opiates, positive for trace blood, trace ketones, no white blood count. micro urine: coag-negative staph, 25-50, organisms per ml. blood culture is negative. brief hospital course: in summary, mr. is a 74 year old male with longstanding copd on home o2, dchf, atrial fibrillation, admission for pna/dyspnea now s/p chest tube placement (then removal) for questionable empyema who continues to recuperate on iv antibiotics without any additional thoracic procedures. please see below for more detailed hospitalization summary: . #shortness of breath /effusions, healthcare associated pna: mr. has longstanding copd at baseline and requires home o2 2.5l nasal cannula. he arrived to osh with notable dyspnea worse from typical baseline. this was initially attributed to possible diastolic chf exacerbation in setting of poorly controlled atrial fibrillation. he was given generous amounts of iv lasix at but continued to have some worse shortness of breath. cxr showed bilateral effusions. however, review of older images shows these are chronic, fairly stable effusions and seem a less likely cause for acute worsened dyspnea. given elevated wbc to peak 22k, recent malaise, poor po intake and shortness of breath there was clinical suspicion for underlying pna with worse local inflammatory/irritation and copd flare up as patient with very poor pulmonary reserve. the differential also includes possible underlying malignancy given his declining state x months, prominent smoking history and and note of pleural thickening on recent ct chest. in terms of chf, recent bnp in 1000s range, h/o mainly diastolic chf with ef 55% on tte just days ago. after concern for possible underlying complicated loculated effusion with ct chest questioning empyema, patient underwent right sided chest tube placement at outside hospital but no pleural fluid able to be collected. he was then transferred to surgical icu service with urgent thoracic surgery consult. thoracic surgery team felt patient had very minimal effusions on imaging and did not feel ct chest imaging constituted a true empyema picture. thus, thoracic surgery felt a repeat attempt at thoracentesis or any other invasive procedures like ir guided pigtail drain placement or vats/decortication would only be of minimal or no benefit given very small amount of pleural fluid which was felt to be chronic as patient has had similar fluid at lung bases in previous imaging. chest tube was removed in sicu and patient transferred to medical service where he was continued on plan for 8 days continued broad coverage for hospital acquired pna with iv vancomycin and zosyn. blood cultures with no growth. also continued patient on prn nebulizers, advair inhaler, spiriva, chest physical therapy routine and he was eventually weaned down to usual home 2l o2 nasal cannula. at time of discharge he had no fevers, wbcs in normal range, and no complaints of cough or shortness of breath. . #leukocytosis: trend with initial rise from admission and then resolved after 2-3 days of being on iv vancomycin/zosyn therapy. wbc trend 10-> 22-> 19-->10--> 8 prior to discharge. remained afebrile after his transfer to medicine service on . most probable source was underlying pna. although there was some initial concern for uti as his urine grew out coag negative staphylococcus (25-50 only) at osh. however, a repeat urinalysis and urine culture collected showed no significant evidence for any uti. moreover, patient had no complaints of dysuria, urgency, or frequency. he had some mild tenderness over his abdominal midline and left side but he stated this was chronic and due to history of ventral hernia. he had no concerning abdominal cramps, nausea or emesis prior to discharge. he did have a few loose stools which were felt to be a side effect of his antibiotics. as above, plan is to continue broad iv abx with zosyn/vancomycin for hap up until for full 8 day course. . #right le dvt: mild edema was noted on the right lower extremity. imaging with ultrasound demonstrated a mixed picture of possible mixture of both some newer/older thrombi. patient very immobile at baseline which increases his risk. he was started on weight based iv heparin gtt with close ptt monitoring and started on daily oral coumadin with plan for at least 3 months of therapy. his heparin was stopped on when his inr rose to 2.3 (on 4mg of coumadin) on the evening of he got 2mg of coumadin. his inr the morning of discharge was 5.1 (goal inr ) and his coumadin is being held. his inr should be followed daily and coumadin restarted at 1 mg once his inr is <3. he will need 3 months of coumadin treatment for his dvt. he should discuss with his pcp whether he needs to stay on coumadin longer for his a fib. he has no significant gi bleeding in past but he is a slight fall risk at this time which makes longer term anticoagulation decision making more challenging as risks/benefits need to be discussed further. . #atrial fibrillation: currently rate controlled with hrs 80s-low 100s range. at home had been on po diltiazem regimen and needed placement on dilt drip, digoxin, and additional metoprolol while at . he was transitioned to once daily toprol xl 150 mg the morning of discharge. ******he did have one episode of emesis and a single dose of metoprolol tartrate 25mg was given as it is unclear whether he vomited his am dose.********* his metoprolol dose will likely need to be further uptitrated for tighter hr control. he had a chads score of 3 and a concomitant diagnosis of rle dvt and is on coumadin (currently with supratherapeutic inr as above). his worsing a fib could have been due to hypovolemia volume shifts vs. infection as outlined above. he was ruled out for acute cardiac syndromes with biomarkers at osh. digoxin was stopped early on in his admission and no additional diltiazem was used as he did very well on metoprolol po tid which was transitioned to toprol xl as above . #arf: baseline is near 0.9-1.0 range and peaked up to cr 2.1 range on . his creatinine was 0.9 on the day pf discharge. causes include recent contrast exposure with ct studies, pre-renal causes in setting of osh lasix dosing. feurea <35% and urine electrolyte profile favored pre-renal causes. renal dysfunction from antibiotics/ain was also considered but he only had a very scant amount of eosinophils in urine making this less probable. vancomycin was renally dosed and troughs monitored. his vanco trough was 34.7 on and 19.8 on . his vancomycin dosing was decreased to 1 gram q24 hrs and a dose was given the morning of . gentle ivfs given to patient and his lasix was held for several days and his creatinine improved back to his baseline. . #hypertension, benign: well controlled and normotensive during hospital course. continued on beta blocker as above with no need to add other agents. his home diltiazem was discontinued. . #copd, chronic: at baseline on home oxygen at 2.5l by time of discharge. currently has o2 saturations in the mid 90s range and has no complaints of worse wheeze or shortness of breath. his cough has now resolved. as above, continued home advair and tiatropium inhaler medications, gave nebulizers prn, chest physical therapy and treated pna with broad antibiotics. . #chronic diastolic chf: history of noted diastolic chf. recent notes with last tte ef%55, mild aortic stenosis, normal tricuspid valve, normal pulmonary valve, no pulmonary hypertension. tte findings similar to that from . initially appears intravascularly hypovolemic to euvolemic on exam with no jvp despite mild overloaded picture on cxr. very minimal le edema (r>l ; dvt rle). continued patient on strict i/o checks, na restriction diet. held lasix briefly while arf resolved and restarted home lasix 20mg daily (restarted on ). . # code status: full code; confirmed with patient . #. hcp is daughter cell: , home medications on admission: . medications at home : -albuterol inh prn -advair 200/50 -diltiazem 120 -spiriva 18mcg daily inh -lasix 20 mg daily . medications at transfer from sicu: -potassium chloride iv sliding scale -piperacillin-tazobactam 2.25 g iv q6h -digoxin 0.125 mg po/ng every other day -oxycodone (immediate release) 5 mg po/ng q6h:prn pain -magnesium sulfate iv sliding scale -vancomycin 1000 mg iv q 12h -metoprolol tartrate 50 mg po/ng tid -metoprolol tartrate 2.5 mg iv q6h:prn tachycardia -tiotropium bromide 1 cap ih daily -fluticasone-salmeterol diskus (250/50) 1 inh ih -heparin 5000 unit sc tid -aspirin 325 mg po/ng daily -ondansetron 4 mg iv q8h:prn nausea -bisacodyl 10 mg po daily -mirtazapine 15 mg po/ng hs . allergies: nkda . discharge medications: 1. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 2. oxycodone 5 mg tablet sig: 0.5 tablet po every eight (8) hours as needed for pain, arthralgias for 1 weeks: hold for sedation or rr<12 and re-eval if still needs in 2 wks. tablet(s) 3. piperacillin-tazobactam 2.25 gram recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 2 days: to end on . 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. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: inhalation as needed as needed for shortness of breath or wheezing. 7. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 8. vancomycin vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 24 hrs. got dose morning of (prior has supratherapuetic level). next dose due 10 am on . last dose due . 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. metoprolol succinate 50 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po once a day. 11. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 12. 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. 13. 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. 14. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 15. senna 8.6 mg tablet sig: one (1) tablet po twice a day as needed for constipation. 16. inr, potaasium, calcium, mag, phos check daily. inr 5.1 on . goal until on stable regimen after antibiotics are completed. 17. warfarin 1 mg tablet sig: one (1) tablet po once a day for 3 months: please start once inr <3, was 5.1 at discharge and then monitor daily given pt on antibiotics. goal inr . re-evaluate if pt should continue after 3 months for his a fib. currently on for both dvt and a fib. 18. zofran 4 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. discharge disposition: extended care facility: - discharge diagnosis: primary: -pneumonia -atrial fibrillation -right lower extremity deep vein thrombosis -acute renal failure discharge condition: mental status: oriented to self, knew he was at hospital but not which one, knew date and month but not year. does not appear confused. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. hcp is daughter cell: , home: discharge instructions: it was a pleasure taking care of you here at . you were admitted to outside hospital with shortness of breath, poor appetite, and fatigue. you were then transferred from after imaging of your chest with plain x-rays and chest ct revealed concern for possible complicated pneumonia and worse pleural effusions or fluid on the lungs. you had a chest tube at outside hospital to attempt to drain this fluid but because it was a very small amount it was unable to be successfully drained. . you were sent to for additional management of a suspected complicated pneumonia and for further evaluation with the thoracic surgical team. the thoracic surgery specialists did not feel you needed any further procedures or surgeries. your pneumonia was managed with iv antibiotics, increased supplemental oxygen and nebulizer treatments to help with shortness of breath. you had no additional fevers and your breathing was back to your usual baseline on 2.5l oxygen via nasal cannula by time of discharge. please continue the remainder of your antibiotics as prescribed while your pneumonia continues to resolve. you will need a repeat chest x-ray with your pcp, . in about 4-6 weeks time. . you also had recurrence of your known abnormal heart rhythm called atrial fibrillation. your rapid heart rate was eventually controlled on higher doses of metoprolol which should be continued as an outpatient. the medical team diagnosed you with acute kidney injury as well which was attributed to dehydration and effects from a diuretic medication (for your diastolic congestive heart failure treatment) called lasix. after getting gentle iv fluids and holding your lasix for several days your kidney function returned to . . after notice of right lower extremity swelling you had an ultrasound study which revealed a blood clot in your leg called a deep vein thrombosis (dvt). therefore you were started on blood thinning medications called heparin (iv given) and coumadin. you will need to continue your outpatient coumadin therapy for at least 3 months, perhaps longer. total length of therapy needs to be discussed with dr. , your pcp. . please see below for all of your outpatient follow-up appointment instructions. . medication changes/instructions: the following new medications were started: 1. coumadin daily therapy for your right lower leg blood clot and atrial fibrillation (prevents strokes). inr level needs lab monitoring closely on this medicine (inr goal ) 2. toprol xl 150mg daily for heart rate control 3. iv vancomycin and iv zosyn until . 4. oxycodone 2.5mg q8hrs as needed for low back pain 5. bisacodyl, senna, and colace as needed for constipation 6. mirtazepine 15mg before bed for appetite stimulation and improved mood effects 7. aspirin 325mg daily 8. zofran 4mg as needed for nausea the following medications were discontinued: -diltiazem the following medications were continued at their previous dose: 1. lasix 20mg po daily 2. albuterol inhaler as needed for shortness of breath or wheeze 3. advair inhaler twice a day 4. spiriva inhaler daily followup instructions: please make a follow-up appointment with dr. at # after you are discharged from rehab procedure: central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified congestive heart failure, unspecified chronic airway obstruction, not elsewhere classified atrial fibrillation acute venous embolism and thrombosis of deep vessels of proximal lower extremity chronic diastolic heart failure deaf, nonspeaking, not elsewhere classifiable 

Answer: The patient is high likely exposed to