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: ativan attending: chief complaint: copd exacerbation, s/p y-stent placement major surgical or invasive procedure: y stent ploaced endotracheal intubation central line placed history of present illness: 54m with h/o severe copd, recurrent tracheobronchomalacia s/p tracheoplasty and revision ( and ) and multiple stent placements, who was admitted from the pacu s/p y-stent placement with suspected copd exacerbation. patient is sedated, so this history was obtained from the ip staff and the patient's wife. has had increasing exertional dyspnea over the last few months. he has had some associated cough, non-productive. he has had no fever or chills. he underwent bronchoscopy on , which showed severe malacia of the cervical as well as intrathoracic trachea and bilateral mainstem bronchi. he was admitted electively today for y-stent placement by ip. his y-stent was placed without complication. he was extubated in the pacu, with subsequent development of bronchospasm resistant to nebulized bronchodilators. his abg showed significant co2 retention and acidemia, and he was reintubated and sedated with propofol. ip then performed flexible bronchoscopy through the ett and the stent was found to be well-seated and without obstruction. he was given solumedrol 125mg iv, levofloxacin 500mg iv, and aggressive combivent mdis. he was transferred to the micu for continued management of copd exacerbation. . currently, he is sedated and unable to answer further questions past medical history: 1. severe copd- pfts with fev1 0.64 (22% pred) and fev1/fvc 40 (54% pred); on 2l home o2 since ; followed by dr. at 2. tracheobronchomalacia- s/p tracheoplasty as above, followed by of interventional pulmonary and of thoracic surgery social history: married, lives with wife in , mass., has a 24yo son. worked as a truck driver. + heavy smoking history, 3 ppd x 30y, quit ~12y ago. no etoh or drug use. family history: f with htn, died of lung cancer. m with htn, died of lung cancer. brother died of brain cancer, two other brothers and a sister are healthy. son is healthy. physical exam: vitals- t 98.6, hr 133, bp 109/76, o2sat 98% on ps 8/peep 10/ fio2 0.40 general- sedated and intubated, significant abdominal breathing heent- ncat, sclerae anicteric, perrl, ett neck- unable to assess jvd body habitus pulm- inspiratory breath sounds clear and equal bilaterally, prolonged expiratory phase with little air movement on expiration, no wheeze auscultated cv- tachycardic but regular, no murmur auscultated abd- +bs, distended and tympanitic extrem- no le edema, dp pulses 2+ b/l pertinent results: labs on admission: abg: po2-267* pco2-78* ph-7.24* total co2-35* base xs-3 glucose-193* urea n-23* creat-1.1 sodium-140 potassium-3.9 chloride-101 total co2-23 calcium-9.2 phosphate-3.7 magnesium-1.9 wbc-17.0* rbc-3.93*# hgb-12.7*# hct-38.6*# plt count-312 - neuts-95.7* bands-0 lymphs-2.5* monos-1.6* eos-0.1 basos-0.2 labs at discharge: wbc-13.0* rbc-2.59* hgb-8.5* hct-25.0* mcv-97 mch-32.7* mchc-33.9 rdw-16.1* plt ct-405 - neuts-86.0* bands-0 lymphs-9.2* monos-2.7 eos-2.0 baso-0 glucose-98 urean-13 creat-0.5 na-138 k-3.8 cl-102 hco3-25 alt-116* ast-42* alkphos-140* amylase-61 totbili-0.3 lipase-87* ammonia-111 --> ammonia is 34* last abg post extubation: po2-64* pco2-34* ph-7.52* caltco2-29 studies on admission: ekg- poor baseline, sinus tachycardia at 129bpm, normal axis, borderline long qt, poor r wave progression, no obvious st/t changes to suggest ischemia . cxr- the endotracheal tube is identified with tip approximately 5 cm above the carina. the cardiomediastinal silhouette is normal in appearance. the left costophrenic angle is not included in this study. blunting of the right costophrenic angle suggests small right pleural effusion. no signs of congestion or opacities to suggest pneumonia. paucity of peripheral vasculature is suggestive of copd. there is a displaced posterior right fourth rib fracture which appears old. . ct chest: 1. interval development of right middle lobe and right lower lobe and minimally left lower lobe tree- in- and reticular interstitial opacities consistent with small airways disease, as may be seen in viral, atypical, or mycobacterial infections. 2. severe emphysema and right upper lobe postsurgical changes. . ruq us: 1: coarsened texture and increased echogenicity of liver likely represents fatty infiltration, however other forms of liver disease and more advanced liver disease, including significant fibrosis/chrosis, cannot be excluded on this study. 2: biliary sludge. . ct head: small hypodensities of the left internal capsule and external capsule which likely represent chronic lacunar infarcts. minimal amount of small vessel chronic infarction elsewhere, as noted above. further evaluation with mri could be obtained to assess for acute infarcts, which may be difficult to detect with ct. . cxr: dobbhoff tube passes below the diaphragm and is out of view. interval development of small left pleural effusion and left basal atelectasis. brief hospital course: mr. is a 54yo man with severe copd (fev1 0.64) and tracheobronchomalacia, who was initially admitted to the micu on with respiratory failure after tracheal y-stent placement. . # respiratory failure requiring prolonged intubation: after the y stent was placed the patient had significant bronchospasm on exam in the pacu, believed to be due to severe copd exacerbation. repeat bronchoscopy at that time showed the y stent was in good position. cxr was not remarkable for any new changes. the patient was intubated and sent to the icu. repeat bronchoscopy revealed purulent sputum consistent with tracheobronchitis. the patient was started on vancomycin and zosyn treatment. the patient was extubated, but quickly failed this largely due to anxiety, tachycardia, hypertension and tachypnea, and was quickly re-intubated. the paln was to optimize his other hemodynamic parameters prior to re-attempting extubation. he was aggressively diuresed with lasix and responded well. his blood pressure and heart rate were controlled with beta blockade, verapamil and ace inhibitors. he continued antibiotic therapy but worsening of secretions prevented extubation for some time. his anxiety was eventually controlled with standing clonazepam as well as prn haldol. the patient was difficult to awaken from sedation and took several days to become responsive. this was in the setting of elevated liver function tests and elevated ammonia. he was started on lactulose tid and zosyn was stopped on as it can cause transaminitis and his course was nearly completed. ct head was unremarkable and after 2-3 days the patient awakened off sedation and became responsive to questions. he was extubated to bipap on and was quickly weaned to oxygen by nasal cannula without problem. his goal o2 saturation is approximately 90-92% given the severity of his copd and he was able to maintain this on nasal cannula. he was treated with nebulizers as well as guafenesin liquid standing. ideally he should be on mucinex tabs 1200mg po bid, however this cannot be crushed so we substituted with mucinex. he was given aggressive chest pt and used a mechanical in-exsufflator three times daily, which should be continued at rehab. he was initially on high dose iv steroids, but is currently in the course of a prednisone taper. his current dose is 30mg po daily and he should continue this for 4 more days, then decrease to 20mg po daily for 5 days, then decrease to 10mg po daily for 5 days, then off. he should be maintained on his current singulair dose as well as standing and prn nebulizer treatments. he should be continued on guaifenesin standing, however when he passes swallow evaluation and can swallow pills this should be changed to mucinex tabs 1200mg po bid as this is ideal for his stenting but cannot be crushed. on the evening prior to discharge the patient had an episode of desaturation that responded well to clonazepam as well as suctioning. again, anxiety has been a recurrent problem for his respiratory status. should he develop desaturation or respiratory distress consider using clonazepam or haldol as well as suctioning. . # tracheobronchomalacia: the patient has developed recurrent tracheobronchomalacia after tracheoplasty, a typically curative procedure. now with y-stent in place, stable position after extubation. he should continue with chest pt as well as guaifenesin (goal to change to mucinex when can swallow pills) and the mechanical in-exsufflator as above. he should follow up with eihter dr. or dr. in interventional pulmonary in approximately 2-3 weeks. an appointment can be made by calling . . #extreme weakness: after extubation and being off sedation the patient was found to have profound but nonfocal weakness which is likely deconditioning. head ct was normal. he was seen by both physical therapy and occupational therapy in-house who recommended continued services at rehab. in order to optimize nutrition, ng tube was left in place and the patient continued tube feeds. . # transaminitis: the patient had a mysterious elevation of his lfts, with alt peaking at 166 and ast at 104. his amylase/lipase peaked at 662/192 respectively. ruq us showed possible fatty infiltration of the liver with some biliary sludge but no stones or biliary dilatation. we stopped zosyn on as this can cause transaminitis. lfts have been decreasing since that time. . # hypertension: this was well controlled with lisinopril, verapamil and metoprolol and were titrated as tolerated. . # fen: the patient initially required free water boluses for hypernatremia, however this quickly resolved so no further need for free water boluses. tube feeds were kept at goal throughout his stay and given via ng tube. the patient failed a swallow study on , thus requiring continued tube feeds despite extubation. as his nutritional status is tenuous, tube feeds should be continued until the patient has improvement in weakness, at which time swallow study should be repeated prior to advancing to po diet. . # prophylaxis: the patient was kept on heparin subcutaneously as well as proton pump inhibitor throughout his stay. he was kept on a bowel regimen as well. . # access: the patient had a left internal jugular central line as well as an arterial line during his stay. the were discontinued prior to discharge. . # code status: full code . # communication: the health care proxy is his wife ( (cell), ( (home). she was very involved throughout his stay, here visiting at his bedside daily. . # dispo: the patient is discharged to a rehab facility today. he has been stable from a respiratory perspective and should continue nebs, guaifenesin, singulair, frequent chest pt, use of in-exsufflator, and oxygen by nasal cannula (currently 4l) for goal o2 saturation of about 90%. he should have a follow up appointment made in our interventional pulmonary department as above in the next 2-3 weeks. he should continue to work with pt and ot for his profound weakness. his tube feeds should continue until weakness improves and he can pass a swallow study (failed on ). after passing swallow study his guaifenesin liquid should be changed to standing mucinex tabs 1200mg po bid which is ideal for his stenting but cannot be crushed. medications on admission: serevent 50mcg 1 puff combivent mdi prn theophylline 100mg prednisone 20mg qd metoprolol 25mg qd paroxetine 60mg qd clonazepam 0.5mg tid naproxen 375mg mucinex 600mg prilosec 20mg qd oxycontin 20mg oxycodone 5mg tid lidoderm patch discharge medications: 1. paroxetine hcl 20 mg tablet : three (3) tablet po daily (daily). 2. metoprolol tartrate 25 mg tablet : one (1) tablet po tid (3 times a day). 3. lactulose 10 g/15 ml syrup : thirty (30) ml po tid (3 times a day). 4. miconazole nitrate 2 % powder : one (1) appl topical tid (3 times a day) as needed. 5. clonazepam 0.5 mg tablet : one (1) tablet po tid (3 times a day). 6. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr (). 7. potassium & sodium phosphates mg packet : two (2) packet po bid (2 times a day). 8. lisinopril 5 mg tablet : one (1) tablet po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection tid (3 times a day). 10. aspirin 325 mg tablet : one (1) tablet po daily (daily). 11. polyvinyl alcohol 1.4 % drops : 1-2 drops ophthalmic prn (as needed). 12. mineral oil-hydrophil petrolat ointment : one (1) appl topical tid (3 times a day) as needed. 13. docusate sodium 50 mg/5 ml liquid : ten (10) ml po bid (2 times a day). 14. haloperidol lactate 5 mg/ml solution : 2.5 mg injection q4h (every 4 hours) as needed for anxiety: may give iv, im or sc. 15. verapamil 80 mg tablet : two (2) tablet po q8h (every 8 hours). 16. montelukast 10 mg tablet : one (1) tablet po daily (daily). 17. ipratropium bromide 0.02 % solution : one (1) nebulization inhalation q4h (every 4 hours). 18. ipratropium bromide 0.02 % solution : one (1) nebulization inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 19. albuterol sulfate 0.083 % solution : one (1) nebulization inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 20. guaifenesin 100 mg/5 ml syrup : ten (10) ml po qid (4 times a day): please change ot mucinex 1200mg po bid when pt can swallow pills (mucinex cannot be crushed). 21. insulin please give insulin q6h as directed by slide scale. 22. prednisone 10 mg tablet : three (3) tablet po daily (daily) for 14 days: please take 30mg po daily for 4 days, then decrease to 20mg po daily for 5 days, then decrease to 10mg po daily for 5 days, then stop. discharge disposition: extended care facility: discharge diagnosis: copd exacerbation tracheomalacia ventilator associated pneumonia tracheobronchitis transaminitis hypertension discharge condition: stable blood pressure, oxygenating with sat 90-95% on 4l nc, afebrile, profound weakness but able to move arms bilaterally. discharge instructions: please take all medications as directed. please be sure to continue chest pt, pt/ot, and use of the mechanical in-exsufflator three times daily. please continue tube feeds and medications though ng tube until patient has improved weakness and passes a swallow evaluation (failed swallow eval ). please continue o2 by nasal cannula (current 4l) for goal saturation of 90-92%. . when patient is able to swallow pills please change from standing guaifenesin liquid to mucinex tabs 1200mg po bid as this is more ideal for his stent but cannot be crushed. . please call for an appointment with either dr. or dr. in our interventional pulmonary department in the next 2-3 weeks at . . if you have chest pain, fever, increased difficulty oxygenating, please call your physician or come to the emergency room. followup instructions: please call for an appointment with either dr. or dr. in our interventional pulmonary department in the next 2-3 weeks at . procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube fiber-optic bronchoscopy fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances non-invasive mechanical ventilation other intubation of respiratory tract closed [endoscopic] biopsy of bronchus diagnoses: pneumonia, organism unspecified unspecified essential hypertension long-term (current) use of steroids acute respiratory failure encephalopathy, unspecified hyperosmolality and/or hypernatremia other malaise and fatigue flatulence, eructation, and gas pain other diseases of trachea and bronchus nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] abnormal involuntary movements panic disorder without agoraphobia obstructive chronic bronchitis with acute bronchitis 

Answer: The patient is high likely exposed to