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: aspirin attending: chief complaint: shortness of breath major surgical or invasive procedure: picc line placement, and removal history of present illness: pcp: , (apg) chief complaint: sob ms. is an 89f with history of copd on home o2 2lnc, pulmonary hypertension, renal insufficiency and carotid insufficiency who presented with acute onset sob and was admitted to the micu with hypercarbic respiratory distress. patient recently admitted for similar symptoms earlier this month, was discharged from rehab 1 week ago. the patient reports she was doing well until the day of admission, when she noticed acute onset sob at 10:30 pm. prior to that, she was using her oxygen continuously, taking her inhalers as scheduled, and walking around her house/doing daily tasks without any difficulty breathing. ros pertinent for a chronic cough without sputum production. ne fevers or chills. in the ed, patient's vital signs were stable, but was noted to be lethargic with poor air movment on pulmonary exam, both of which improved with nebulizers, solumedrol, and azithromycin/cftx. abg with evidence of co2 retention. ekg with lbbb, lvh similar to prior (ste noted on ekg in ambulance, but not present on arrival to the ed). cxr with possible rll infiltrate. during the patient's icu course, she was noted to be sob with limited air movement. she was started on continuous albuterol inhalers and intermittent bipap. she was started on levo/flagyl for presumed aspiration pna vs cap and had a picc line placed. she was also started on steroids (prednisone 60 mg po daily) for presumed copd exacerbation. this morning she had an episode of l sided ssc 'pain' that radiated to her right arm associated with some diaphoresis but no loc, nausea, or vomiting. has not experienced this pain before. ekg with reportedly no changes. her cp resolved completely with 0.3 mg sl nitroglycerin and did not return during the remainder of the admission. noted to be having improved air movement during icu stay, and was weaned from continuous to q3h ipratroprium and q6h albuterol nebs, and transitioned to oral prednisone prior to being called out to the floor. on the floor, patient states that her sob is greatly improved and denies any further episodes of chest pain. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denied palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. pt admits to some difficulty swallowing and sometimes is concerned that food goes down her windpipe, and states she needs new dentures b/c her current ones are ill-fitting. past medical history: hypertension moderate/severe pulmonary hypertension (pa pressures 66 + ra last echo) copd (on home oxygen therapy) carotid stenosis chronic renal insufficiency (baseline 1.1-1.6) social history: social history: lives with granddaughter and family; has vna at home. employment: previously housekeeper in hotels eg . tobacco: 15-60yo 1 ppd, 45 pack years. quit 40 years ago alcohol: none recently (years). family history: mother had smoking-associated lung disease. son died of liver cancer. daughter died of domestic homicide. physical exam: on transfer from the icu to the medicine floor: vs: 98.0 118/60 102 20 92% on 2 l nc gen: elderly aa f aox3, nad heent: perrla. mmm. + 15 cm jvd sitting at 90'. neck supple. cv: pmi palpable at 5/6th ic space. rrr s1/s2 heard. + sm at llsb. pulm: +inspiratory and expiratory wheezes. slightly decreased air movement in all lung fields. abd: soft, nt, +bs. no g/rt. neg hsm. neg sign. extremities: mild pitting edema. dps, pts 2+. neuro/psych: cns ii-xii intact. interacting appropriately and moving all extremities. on discharge: afebrile sbp 120s-140s hr 70s gen: patient breathing comfortably in no distress cv: regular, s1s2. pulm: no rales, no wheezes, no rhonchi (resolved during the admission) extremities: no pitting edema bilaterally pertinent results: significant for wbc of 17.3, hct of 32.0, cre of 1.3, ck trop-t of 0.01, 0.02 abg 7.4/40/76*/26 lactate 4.0->3.3 microbiology: urine legionella antigen - negative. mrsa screen - negative. imaging: ekg - - sinus tachycardia, + lvh, +lbbb, no new ischemic changes compared to previous. cxr - - cardiac silhouette is normal in size. mediastinal contours are notable for a tortuous aorta as well as aortic calcification. there is no pneumothorax. left pleural effusion and atelectasis are resolved. there is a new small right pleural effusion with overlying atelectasis. cxr - - cardiomediastinal contours are unchanged from , . cardiac size is normal. the aorta is tortuous. right picc tip remains in the right subclavian vein. bibasilar opacities, left greater than right, are stable due to a combination of pleural effusion and atelectasis. there are no new lung abnormalities. tte: - the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is hyperdynamic (ef>75%). there is no ventricular septal defect. the right ventricular cavity is mildly dilated with normal free wall contractility. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve is not well seen. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , no major change. pulmonary hypertension without clear cor pulmonale or intracardiac shunt. brief hospital course: a/p: 89 yo f with copd on 2 l home o2, pulmonary hypertension, ckd who presents with acute onset dyspnea likely c/w hcap requiring icu admission with continuous nebs and nippv, subsequently transferred to the medicine flow. #. shortness of breath: patient initially admitted to the micu with hypercarbic respiratory distress requiring continuous inhalers, nippv (bipap) and iv steroids. likely had a copd exacerbation, triggered by a pna (initially ?aspiration vs hcap, but ultimately most likely hcap given recent hospitalization and rehab stay). initially treated with vanc/cefepime/cipro for hcap, briefly switched to levofloxacin and flagyl for aspiration pna in the micu, subsequently switched to vanc/cipro for hcap once on the general floor. she completed a 7d course of vanc and had 1 add'l day of cipro on discharge. urine legionella antigen negative. patient low probability for pe per well's criteria. pt without evidence of acs on ekg and with several sets of negative cardiac enzymes. nebs were weaned on the floor to albuterol q4h prn and ipratroprium q3h standing, which she tolerated well. by , she was back to her baseline oxygen requirement of 2l nc with minimal shortness of breath. her home inhalers, spiriva and advair, were held during this admission. we began a long prednisone taper starting on (40mg x 3 days) and will continue with 20 mg qd x 3 days starting , then 10mg x 3 days starting . we asked for palliative care's recommendations regarding symptom management and assistance with preventing re-hospitalization. they recommended trying a small dose of liquid morphine 30 mins before activity to see if this might decrease shortness of breath (as trial for home). we encouraged ambulation with walker and assistance, which she was eager to do. # chest pain: pt with episode of cp on morning of , resolved with sl nitro. pt with multiple risk factors including htn, ckd, and previous smoking history. no known history of diabetes with normal hga1c in . enzymes were cycled, troponin of 0.05 was felt to be demand ischemia in the setting of increased work of breathing, no concerning changes on ekg. hba1c of 6.4%. lipid panel: hdl of 67, ldl 83, tg 104. a distinct episode epigastric pain on the morning of was gas/constipation and was relieved with milk of magnesia, tums, and a bm. ekg during this episode revealed no changes. # tachycardia: pt with hr to 102 on the floor, was 90s-100s in the micu. (pulse is usually 70s-80s as an outpatient). likely in the setting of pt's respiratory distress, standing albuterol nebs and holding patient's beta-blocker. heart rate was ultimately in the 70-80s by discharge on home meds. #. acute on chronic renal failure: patient initially with acute on chronic renal failure on admission (cre 1.5, baseline 1.2). with known stage iii ckd. improved with ivfs in the micu, cre back to baseline 1.3 on the floor throughout the rest of her admission. # anemia: pt with 8 pt hct drop in the icu (baseline 40, down to 33), stable on repeat check; likely dilutional due to ivfs and in the setting of phlebotomy. stable around 36-37 throughout the rest of her stay with one drop from 41.5 to 36.8, though the single 41.5 value was felt to be due to volume contraction. stool guaiac x1 was negative. no other concerns for bleeding. #. htn: pt hypertensive in the icu, normotensive on the floor. the patient was restarted on her home medications, and had only mild elevated bps in the setting of the prednisone taper (120s-140s today). # leukocytosis: likely in the setting of steroids. wbc starting to trend down by the time of discharge. #. pulmonary htn: continuous o2 supplementation via nc. to follow-up with her outpt pulmonologist, dr. , on to discuss starting cilastazol. the team emailed with dr during the admission. medications on admission: home medications: atenolol 50 mg cilostazol 100 mg qday advair 100/50 1 puff daily nifedipine er 60 mg qday spiriva 18 mcg daily calcium medications on transfer: heparin 5000 unit sc tid docusate sodium 100 mg po bid senna 1 tab po/ng :prn constipation nifedipine cr 60 mg po daily albuterol 0.083% neb soln 1 neb ih q6h sob/wheezing insulin sc (per insulin flowsheet) olanzapine (disintegrating tablet) 2.5 mg po tid:prn agitation acetaminophen (liquid) 650 mg po/ng q6h:prn pain/headache prednisone 60 mg po/ng daily duration: 5 days metronidazole (flagyl) 500 mg iv q8h famotidine 20 mg iv q24h ipratropium bromide neb 1 neb ih q3h levofloxacin 750 mg iv q48h trazodone 25 mg po/ng hs:prn insomnia discharge medications: 1. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion. 2. prednisone 20 mg tablet sig: two (2) tablet po daily (daily) for 1 days: taper instructions: please give 40mg on ; 20mg on , ; 10mg on , . 3. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 1 days: please administer final dose on . 4. atenolol 50 mg tablet sig: one (1) tablet po bid (2 times a day). 5. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 6. cilostazol 100 mg tablet sig: one (1) tablet po once a day. 7. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) inhalation once a day. 8. advair diskus 100-50 mcg/dose disk with device sig: one (1) puff inhalation once a day. 9. morphine 10 mg/5 ml solution sig: 2.5mg mg po every eight (8) hours as needed for shortness of breath: take 30 minutes prior to walking to help with breathing. 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: primary diagnosis hypercarbic respiratory distress copd exacerbation health-care acquired pneumonia acute on chronic renal failure secondary diagnosis chronic obstructive pulmonary disease pulmonary hypertension chronic renal disease discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker) discharge instructions: you were admitted with a diagnosis of shortness of breath. you were diagnosed with respiratory distress, pneumonia, and required icu admission. you improved with nebulizers, steroids, and antibiotics. please continue the following new medications: ciprofloxacin x 1 dose left to take on prednisone taper x 7 more days started albuterol inhaler as needed for shortness of breath you can resume using your regular inhalers: spiriva and advair. you can continue taking your home medications of atenolol and nifedipine. you were started on a small dose of morphine before walking to help improve your breathing so that you do not feel short of breath. followup instructions: please follow-up with your pcp 1 week of discharge department: medical specialties when: wednesday at 8:00 am with: dr. building: campus: east best parking: garage department: vascular surgery when: monday at 9:30 am with: vascular lab building: lm campus: west best parking: garage procedure: venous catheterization, not elsewhere classified diagnoses: pneumonia, organism unspecified anemia, unspecified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified obstructive chronic bronchitis with (acute) exacerbation occlusion and stenosis of carotid artery without mention of cerebral infarction chronic kidney disease, stage iii (moderate) acute respiratory failure primary pulmonary hypertension 

Answer: The patient is high likely exposed to