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: penicillins / metoprolol attending: chief complaint: dyspnea major surgical or invasive procedure: intubation central line placement history of present illness: hpi: 89 male with pmh sig for parkinson's disease, af, chf (ef 35-40%), hx of aspiration requiring close monitoring during feeding pureed substances, presented to ed with cc of dyspnea. he was in his usual state of health until end of last week. his family noted that he had slightly increased wheezing and sob. the course was intermittent and did not worsen immediately. his respiratory status stablized over the weekand. he continued to do well until this afternoon around 4-5pm. he had increased wheezing and dyspnea. he also had increasing cough as well. he was fed some ice cream and subseuqently developed respiratory distress and cough. his respiratory status settle down a little bit. he then went to the bathroom, where he was found later by his family to have much worsened respiratory status. . the family (including daughters and wife) denied that he had other complaints over the last several days. denies fever, chills, nausea, vomiting, headache, chest pain, exertional dyspnea, abdominal pain, diarrhea or dysuria. . of note, he was admitted in w/ cellulits of left leg ulceration with exposure. his leg film was negative for osteomyelitis. he was seen by plastics, who felt that pt. should have evaluation of vascularity to area of wound. then, he was seen by vascular surgery. vascular surgery recommeded mra to determine feasibility of revascularization procedure. after discussion within family, decided to defer mra. he was treated with vancomycin. his erythema, warmth, and tenderness to palpation improved. on discharge. he was discharged w/ vascular and plastic f/u. he was d/c on w/ 4 more doses of vanco over next 8 days. he finished vancomycin course on . . in pt was given dose of iv metoprolol 5 mg which caused some resultant hypotension. however the hypotension persisted hours after the single dose of metoprolol infusion. he did not respond to ivf challenge and was transferred to on dpamine drip. past medical history: pmhx: 1) parkinson's disease 2) bph 3) large left hernia 4) s/p appy 5) s/p hernia repair 20 yrs ago 6) atrial fib: dx , not on coumadin, rate 80-100 7) h/o chf: tte ef 35-40%, + ar, + mr, 3+ tr, global hypok w/ distal lateral and inferolateral hypokinesis and apical akinesis. 8) fe def anemia 9) hypothyroidism 10) cri: baseline cr 1.5-1.7 social history: pt lives at home with his wife and daughter. is retired construction/ engineer/ realestate man. no etoh, tobaccol, or drugs. did occasionally smoke a pipe but quit greater than 20 years ago. family history: father had dm. mother died of heart disease /rythm problems. she was over 90 at her death. daughter (alive at 47) had hodgkins many years ago. physical exam: vs: temp 95.4 hr 115 bp 117/60 (dop 6) rr27 bipap 5/5 gen: lying in bed in mod distress on non rebreather mask heent: nc/ at, perrl, mmm neck: + jvd to jam, supple, no lad cv: irregularly irregular, ii/vi sm @ lsb chest: diffuse ant ronchi, bibasilar rales abd: soft, nt, +bs ext: l foot with ulcer, visible, no abcess/puss/erythema. 1+ le edema neuro: a/o x 0, withdrwas to pain, opens eyes randomly, moves all 4 extr spontanously pertinent results: portable ap chest x-ray was obtained and compared to the previous film from , and . the ett tube is inserted with its tip projecting 2.6 cm above the carina. the cuff of the ett tube looks to be overinflated with distention of the proximal trachea. the ng tube is in good position. the right subclavian catheter is inserted with its tip projecting over the superior vena cava. the extensive consolidation seen in the right lung as well as in the left lower lobe may represent an overlying pneumonia in addition to a known congestive heart failure. no significant change in the lung opacification is present except for slight improvement of the left lower lung consolidation. impression: 1. status post insertion of the ett tube with overinflation of cuff. these findings were discussed with dr. during dictating the exam. 2. satisfactory position of ng tube and right subclavian catheter. 3. slight improvement of the left lower lobe consolidation. otherwise, no significant changes in comparison to the previous study. . echo measurements: left atrium - long axis dimension: *4.8 cm (nl <= 4.0 cm) left atrium - four chamber length: *5.5 cm (nl <= 5.2 cm) right atrium - four chamber length: *5.9 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 0.9 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 0.9 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: 4.1 cm (nl <= 5.6 cm) aorta - valve level: 3.3 cm (nl <= 3.6 cm) aorta - ascending: *3.5 cm (nl <= 3.4 cm) aortic valve - peak velocity: 1.1 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 1.1 m/sec tr gradient (+ ra = pasp): *>= 31 mm hg (nl <= 25 mm hg) this study was compared to the report of the prior study (images not available) of . left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv wall thickness. normal lv cavity size. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. mild global lv hypokinesis. mildly depressed lvef. right ventricle: markedly dilated rv cavity. . abnormal septal motion/position consistent with rv pressure/volume overload. aorta: normal aortic root diameter. mildly dilated ascending aorta. aortic valve: mildly thickened aortic valve leaflets (3). no as. mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. mild to moderate (+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. moderate to severe tr. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: trivial/physiologic pericardial effusion. general comments: suboptimal image quality - poor echo windows. conclusions: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is mild global left ventricular hypokinesis. overall left ventricular systolic function is mildly depressed (estimated ejection fraction ?45%). the right ventricular cavity is markedly dilated. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is a trivial/physiologic pericardial effusion. compared with the report of the prior study (images unavailable for review) of , no definite segmental wall motion abnormalities were identified in the current study. left ventricular systolic function may now be more rigorous but prior images not available for comparison. right ventricular size and function were not described in the report (depressed rv function was noted in the tee report). . cxr medical condition: 89 year old man s/p doboff tube placement via ng, in ge junction by initial xray, now s/p advancement. reason for this examination: eval placement of dobhoff tube study: ap chest. findings: compared to the prior study from two hours earlier. the dobbhoff tube has been advanced few centimeters, however the tip still remains just at the gastroesophageal junction. nasogastric tube, endotracheal tube, and right-sided central line are in unchanged position. there is bilateral airspace opacities, right greater than left. there is a developing opacity seen along the right lateral chest wall which may represent some loculated fluid. the right side pleural effusion is seen. there is likely an underlying _____ pulmonary edema as well. . 11:00pm glucose-167* urea n-39* creat-1.9* sodium-135 potassium-5.4* chloride-105 total co2-19* anion gap-16 11:00pm calcium-7.8* phosphate-4.4 magnesium-2.0 03:48pm o2 sat-49 03:46pm type-art po2-71* pco2-34* ph-7.39 total co2-21 base xs--3 03:46pm lactate-1.8 10:25am cortisol-108.3* 09:39am cortisol-107.9* 08:48am cortisol-100.4* 07:43am type-art rates-/28 o2-100 po2-55* pco2-33* ph-7.39 total co2-21 base xs--3 aado2-641 req o2-100 intubated-not intuba 06:26am glucose-113* urea n-33* creat-1.9* sodium-139 potassium-5.0 chloride-106 total co2-20* anion gap-18 06:26am ck(cpk)-63 06:26am ck-mb-6 ctropnt-0.05* 06:26am calcium-8.1* phosphate-3.2 magnesium-1.7 06:26am wbc-5.5 rbc-3.30* hgb-9.6* hct-28.6* mcv-87 mch-29.2 mchc-33.6 rdw-19.5* 06:26am neuts-76* bands-15* lymphs-6* monos-2 eos-0 basos-0 atyps-0 metas-1* myelos-0 06:26am hypochrom-2+ anisocyt-1+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-occasional ovalocyt-occasional target-occasional burr-occasional stippled-occasional 06:26am plt smr-normal plt count-294 06:26am pt-13.6* ptt-27.3 inr(pt)-1.2* 12:20am ctropnt-0.02* 12:10am glucose-145* urea n-32* creat-2.0* sodium-141 potassium-5.0 chloride-109* total co2-22 anion gap-15 12:10am lipase-15 12:10am lipase-15 12:10am ck-mb-notdone probnp-* 12:10am albumin-3.0* calcium-8.2* phosphate-3.8 magnesium-2.0 12:10am tsh-4.4* 12:10am wbc-4.6 rbc-3.36* hgb-9.5* hct-29.7* mcv-88 mch-28.4 mchc-32.2 rdw-19.0* 12:10am neuts-85.3* bands-0 lymphs-11.6* monos-2.0 eos-0.8 basos-0.3 12:10am hypochrom-3+ anisocyt-2+ poikilocy-1+ macrocyt-normal microcyt-1+ polychrom-normal ovalocyt-1+ schistocy-1+ elliptocy-1+ 12:10am plt smr-normal plt count-260 12:10am pt-12.7 ptt-23.7 inr(pt)-1.1 12:10am fibrinoge-351# 12:10am urine color-straw appear-clear sp -1.009 12:10am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 12:10am urine rbc-0 wbc-0 bacteria-none yeast-none epi-<1 11:54pm type-art rates-/36 peep-10 o2-100 po2-74* pco2-36 ph-7.37 total co2-22 base xs--3 aado2-619 req o2-99 intubated-not intuba vent-spontaneou 11:54pm glucose-157* lactate-1.9 na+-140 k+-4.8 cl--108 11:54pm freeca-1.13. . clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. reference range: negative. . 4:10 pm blood culture **final report ** aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. brief hospital course: 89 yo m pmh of parkinson's, af not on coumadin, chf presents with 1 week of progressive sob in addition to an acute episode of aspiration in respiratory distress and acute or chronic renal failure, his hospital course is discussed by problem: . 1. chf: initially, the patient had a cxr consistent with pulmonary edema, secondary to chf, a known lvef of 40% and bnp of 10,000. he was carefully diuresed in the acute setting, but his hypotension, as described below, made it a difficult balance. an echocardiogram indicated right heart failure, and he required pressors for blood pressure control. he was eventually weaned off the pressors, and successfully diuresed with iv lasix, which were eventually changed to oral. upon transfer to the medicine floor, he was initially continued on the lasix regimen, with a fluid goal of negative 500 cc to even balance on a daily basis. after his foley was removed, however, it was more difficult to measure strict is/os as the patient was incontinent of urine. he had one episode of hypotension with his systolic pressure dropping to the 80's. it improved and stabilized with a gentle fluid bolus, and the lasix was held for the remainder of his hospitalization. his lung exam did not demonstrate new rales or crackles, and his oxygen requirements remained stable. therefore, the lasix was discontinued and may be restarted as an outpatient depending on the patient's fluid balance once he is on a regular schedule with his tube feeds. in addition, it was felt that with a depressed ejection fraction, the patient would likely benefit from an ace inhibitor. however, this was not initiated given his history of hypotension, but may be considered in the future. . 2. hypotension: the patient was hypotensive and pressor dependent while in the . it was felt that this was most likely multifactorial. the patient had been in a-fib with a rate of 110's, leading to decreased filling time. in addition, the patient may have been septic given the pulmonary process on cxr, hypothermia, and sputum/cough. he was administered broad spectrum antibiotics and treated with an approximately two week course of antibiotics for likely aspiration pneumonia. he was initially started on a dopamine drip at maximum doses, but given poor urine output, he was changed to levophed; and then secondary to tachycardia it was changed to neo-synephrine for blood pressure stabilization. upon transfer to the medicine floor, his blood pressure remained stable other than one episode of hypotension that responded to a gentle fluid bolus. . 3. resp distress: this was thought to be due to chf with resp pneumonitis/ pna. he was initially on a nonrebreather, alternated with bipap. as the patient respiratory status continued to decline, discussions were made the family regarding goals of care, and his hcp decided intubation was in the goals of care. he was intubated and later successfully extubated on . he completed an approximately two week course of antibiotics for pneumonia, although there was likely a component of chemical pneumonitis from aspiration as well. . 4. afib: the patient was found to be in atrial fibrillation with hr into 100's. given that he had become hypotensive in the ed after receiving nodal agents and had a history of sinus arrest on metoprolol, nodal agents were avoided. his tachycardia resolved with treatment of underlying factors (sepsis/ chf). on transfer to the medicine floor, he was in sinus rhythm at a normal rate by ekg. it was decided not to put the patient on anticoagulation given his fall risk. . 5. anemia: the patient had a history of iron deficiency anemia, and also had recent blood loss from elbow after falling. his hematocrit was monitored, and remained stable throughout his admission, was 30 at the time of discharge. he did not have any guaiac positive stools while on the medicine floor. . 6. arf: this was thought to be secondary to a decreased intravascular volume and poor forward flow due to chf. with diuresis and subsequent fluid mobilization resulting in increased intravascular volume, the patient's acute renal failure resolved, and his creatinine normalized to .9. he maintained a good urine output, and upon transfer to the floor his foley was successfully removed. . 7. chronic rle ulcer: the patient was initially treated with iv vanco given his history of mrsa. he was evaluated by wound care nursing, with recommendations followed. in addition, the patient was seen by the plastics service. they recommended resection of the , but the family was against any type of surgical intervention. the patient has also been seen by vascular as an outpatient, but the family refused to have an mra of the leg. upon transfer to the floor, the patient was seen by both the plastic service and wound care nursing, and the family was provided the number to dr. clinic for follow-up within one-two weeks as an outpatient. . 8. id- upon transfer to the medicine floor, the patient remained afebrile, without a leukocytosis. blood cultures were negative and was found to be c-diff negative on three separate occasions. he was maintained on contact precautions for history of mrsa bacteremia (). his central line was carefully monitored on the floor, without any evidence of infection. it was removed on the day of discharge. . 9. asymmetric lower extremity edema: the patient was found to have increased edema of the right lower extremity when compared to the left. he was ruled out for a dvt, no evidence of infection or cellulitis. it was thought that this may be dependency related from lying on r side. this was carefully monitored, the patient was repositioned frequently, and continued to work with pt to increase mobility as much as possible. . 10. mental status/parkinson's disease: he was restarted on his home medications. speech therapy worked with the patient on multiple occasions, and pt/ot followed the patient as well. the family will follow-up with dr. as instructed on an outpatient basis, as he does not do inpatient consults when he is not on service. given that there were no acute neurological issues, it was felt that a consult was not necessary. after he failed a speech and swallow eval, a discussion was had with the family regarding access to nutrition and the aspiration risks. a dobhoff tube was placed under ir and the patient was started on tube feeds. dr. and the gi service discussed peg tube placement with the family, and a peg tube was eventually placed. nutrition service followed for tube feeding recommendations, and the patient was started on a 14 hour cycling (overnight) schedule. the family underwent education/instruction regarding peg tube care and use, and home vna services were arranged. . the patient will follow-up with his pcp, , and plastics as instructed. medications on admission: 1. carbidopa-levodopa 25-100 mg po tid 2. finasteride 5 mg po qd 3. terazosin 5 mg po qhs 4. levothyroxine 25 mcg po qd 5. lansoprazole 30 mg po qd 6. colace 100 mg po bid 7. aspirin 81 mg tablet po qd 8. brimonidine 0.15 % drops ou 9. multivitamin po qd 10. zinc sulfate 220 mg po qd 11. entacapone 200 mg po tid prn parkinson's 12. silver sulfadiazine 1 % cream tid discharge medications: 1. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. levothyroxine 25 mcg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*2* 4. brimonidine 0.15 % drops sig: one (1) drop ophthalmic (2 times a day). disp:*qs * refills:*2* 5. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 6. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed. disp:*qs * refills:*0* 7. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). disp:*qs ml(s)* refills:*2* 8. pramipexole 1 mg tablet sig: three (3) tablet po tid (3 times a day) as needed for parkinson. disp:*90 tablet(s)* refills:*0* 9. entacapone 200 mg tablet sig: one (1) tablet po tid () as needed for parkinsons. disp:*30 tablet(s)* refills:*0* 10. carbidopa-levodopa 25-100 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*2* 11. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). disp:*qs mg* refills:*2* 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. disp:*60 capsule(s)* refills:*0* 13. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. disp:*30 tablet(s)* refills:*0* 14. probalance liquid sig: as instructed po at bedtime: 100cc/ hr to be cycled 14 hours overnight. disp:*qs * refills:*2* discharge disposition: home with service facility: discharge diagnosis: sepsis secondary to aspiration pneumonia congestive heart failure parkinson's disease left lower extremity ulcer paroxysmal atrial fibrillation discharge condition: good discharge instructions: weigh yourself every morning, md if weight > 3 lbs. . please continue to take all of your medications as instructed. call your doctor or return to the hospital if you develop fevers/ chills/ chest pain, or difficulty breathing. followup instructions: provider: , .d. phone: date/time: 12:30 . please call and speak with to schedule an appointment with dr. (surgery) within two weeks to have his wound evaluated. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances non-invasive mechanical ventilation percutaneous [endoscopic] gastrostomy [peg] transfusion of packed cells transfusion of packed cells diagnoses: anemia, unspecified congestive heart failure, unspecified acute kidney failure, unspecified unspecified septicemia hyposmolality and/or hyponatremia severe sepsis unspecified acquired hypothyroidism atrial fibrillation systolic heart failure, unspecified ulcer of other part of foot paralysis agitans acute respiratory failure hypotension, unspecified pneumonitis due to inhalation of food or vomitus 

Answer: The patient is high likely exposed to