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: cefepime / ciprofloxacin / levofloxacin attending: chief complaint: respiratory distress major surgical or invasive procedure: - removal of tunneled line history of present illness: mr. is a 58-year-old man with a history of aml s/p allogeneic transplant complicated by graft-versus-host disease, multiple vertebral fractures and ultimately development of paraplegia in the setting of a vertebral fracture during a code situation. admitted multiple times, most recently for bacteremia and upper resp infection (cx: staph epi) and completed a course of vancomcyin, aztreonam. discharged from rehab and home (wheelchair bound) with recent clinic followup noting baseline health. wife also states he was in his usual state of health until the morning of admission when she went to wake him he was more somnolent than usual and seemed to be having difficulty breathing taking rapid shallow breaths. his wife attributed his somnolence to recently starting ambion and valium 3 days prior to admission in addition to his home narcotic regimen of oxycontin and dilaudid. she also noted that he looked more pale than usual. she reports that he had a cough starting over the weekend productive of yellow sputum. no history of fevers, and outside of baseline pain, he had no complaints. given his somnolence, ems was called and administereed narcan in the field without improvement so he was admitted to study hospital on for acute respiratory failure. on arrival he was afebrile, tachycardic to 160s (sinus), hypotensive to 91/58 (though fell to 60s-70s per wife), rr of 8, and was satting 94% on bipap. he was bolused 500cc with improvement of hr to 130s. he was bolused more ns (unclear how much) and remained hypotensive so was started on norepinephrine 2mcg/min and given stress dose hydrocortisone. he does have a triple lumen port, but given poor peripheral access, an intraosseous was placed. he was given an additional dose of narcan given continued somnolence and transferred to the at the family's request given that all of his care has been here. in the ed, initial vs were t 98.6 hr 128 bp 89/69 rr 17 99% on bipap and initial abg was 7.27/61/83. labs were notable for leukocytosis to 14.2, trop-t: 0.18, lactate:3.4, creatinine of 1.1 (baseline 0.6-0.8), and a grossly positive urinalysis with > 182 whites and moderate bacteria. he has an indwelling foley catheter that was changed this past thursday. a chest x-ray was notable for lll consolidation. he had received emperic vancomycin at the osh and received a dose of zosyn in the ed here. on arrival to the micu, patient's vs were t: 99.5 hr: 115 bp 121/69 rr 20, o2 sat 93% 100% nrb and was receiving levo at 1mcg/min on arrival. he was somnolent but arousable and oriented x 3, but slow to answer questions. complained of pain from the chest up, but otherwise no complaints. review of systems: (+) per hpi. his wife notes that he did a few episodes of loose stools. morning headaches recently. (-) denies fever, chills, chest pain, chest pressure, palpitations. denies dark or bloody stools. past medical history: past medical history: - ckd (baseline cr 0.6-0.7) - hyperlipidemia - htn - type 2 dm (last a1c 6.8 ) - depression - chronic pain - pericardial effusion s/p drainage. - nephrolithiasis, lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage. - left interpolar renal lesion, followed with mrs - basal cell carcinoma, resected. - squamous cell carcinoma left cheek, s/p mohs' 6/. - multiple back surgeries: lumbar l5-s1 surgery x 3, and cervical spine fusion (bone graft, no hardware). - anterior cervical diskectomy and instrument arthrodesis at c5-c6 and c6-c7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at c5-c6 and c6-c7 - dr. . - chronic numbness, neuropathic pain in left upper extremity. - sleep apnea, planned bipap, followed by dr. . - lower extremity wound, s/p debridement by plastics, grew resistent pseudomonas oncologic history: - diagnosed with aml in 04/. - underwent unrelated allogeneic stem cell transplant with busulfan and cyclophosphamide as his conditioning regimen. - continues bactrim, voriconazole, acyclovir ppx post transplant complications: - gvhd of the liver and skin. question of pulmonary cgvhd as often requires oxygen and steroids in the setting of respiratory infections (h/o rsv, parainfluenza) - paraplegia vertebral fractures during code - chronic lower extremity and abdominal edema, refractory to lasix, suspected to be gvhd - abdominal spasm - on valium (?etiology paraplegia) - cop/boop: home o2 1-2liters - avascular necrosis (bilateral hips and left shoulder) - multiple compression fractures of the spine with chronic pain - pulmonary embolus in and , no with ivc not on anticoagulation - s/p l5 vertebroplasty - ruptured left calf hematoma () complicated by mrsa wound infection - influenza a - bilateral achilles tendon rupture ( attributed to levoflox). social history: discharged from rehab in and has now been living at home wiht vna services and aid from his wife. is retired, worked as a technician. he smoked for 40 pack years, now quit. he denies etoh or drugs. family history: mother died suddenly in 70s. father died of unknown cancer. one sister with thyroid cancer. one brother has diabetes. one sister has . physical exam: admission physical exam vitals: t: 99.5 hr: 115 bp 121/69 rr 20, o2 sat 93% 100% nrb general: somnolent, but arousable, oriented x 3, no acute distress, answers one question before falling asleep heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl, copious secretions neck: supple, jvp not elevated, no lad cv: tachycardic regular rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: transmitted upper airway sounds bilaterally, good air movement abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: skin laceration on dorsum of left wrist neuro: cn 2-12 intact, strength 5/5 in ue; paralyzed from the waist down. physical exam pertinent results: admission labs: 11:00am blood wbc-14.2* rbc-3.56* hgb-12.5* hct-39.2* mcv-110* mch-35.1* mchc-31.9 rdw-17.7* plt ct-334 11:00am blood neuts-78* bands-7* lymphs-6* monos-8 eos-0 baso-0 atyps-1* metas-0 myelos-0 11:00am blood hypochr-3+ anisocy-1+ poiklo-normal macrocy-3+ microcy-normal polychr-1+ 11:00am blood pt-9.1* ptt-28.5 inr(pt)-0.8* 11:00am blood glucose-174* urean-17 creat-1.1 na-140 k-4.0 cl-103 hco3-27 angap-14 05:51pm blood ck(cpk)-111 02:30am blood alt-46* ast-56* alkphos-106 totbili-0.3 11:00am blood ctropnt-0.18* 05:51pm blood ck-mb-7 ctropnt-0.16* 02:30am blood calcium-8.7 phos-4.2 mg-1.5* 06:29pm blood type-art o2 flow-15 po2-91 pco2-70* ph-7.23* caltco2-31* base xs-0 intubat-not intuba 11:31am blood glucose-167* lactate-3.4* k-4.0 labs: micro: blood culture ( myco/f lytic bottle: pending catheter tip-iv wound culture- no significant growth (preliminary) blood culture ( myco/f lytic bottle) blood/fungal culture-pending; blood/afb culture-pending urine urine culture- no growth blood culture blood culture, routine-pending blood culture ( myco/f lytic bottle) blood/fungal culture-pending; blood/afb culture-pending blood culture blood culture, routine-pending blood culture ( myco/f lytic bottle) blood/fungal culture-no growth; blood/afb culture-no growth blood culture blood culture, routine-pending blood culture ( myco/f lytic bottle) blood/fungal culture-preliminary { (torulopsis) glabrata}; blood/afb culture-final; myco-f bottle gram stain-final blood/fungal culture (preliminary): (torulopsis) glabrata. blood/afb culture (final ): due to overgrowth of yeast, unable to continue monitoring for afb. myco-f bottle gram stain (final ): budding yeast. urine urine culture-final {yeast} urine culture (final ): yeast. 10,000-100,000 organisms/ml.. blood culture blood culture, routine-pending blood culture blood culture, routine-pending urine legionella urinary antigen -final - negative for legionella serogroup 1 antigen. sputum gram stain-final; respiratory culture-preliminary {yeast} source: expectorated. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): budding yeast. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and chains. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). respiratory culture (preliminary): moderate growth commensal respiratory flora. yeast. moderate growth. blood culture blood culture, routine-pending studies: ct chest w/o contrast: chest (portable): right pleural effusion has decreased in size with associated improvement in adjacent right basilar atelectasis. multifocal areas of heterogeneous consolidation involving the left lung to a greater degree than the right, have slightly improved. a small hyperlucency is present in the periphery of the left upper lobe at the level of the second and third anterior ribs, but no discrete visceral pleural line is identified. this may represent an area of spared lung parenchyma from the presumed multifocal pneumonia, but attention to this area on short-term followup radiograph may be helpful to exclude an atypical presentation of pneumothorax, given clinical suspicion for this entity. chest (portable ap): widespread combined alveolar and interstitial opacities affecting the left lung to a greater degree than the right have progressed in the interval, particularly in the right lower lung where there is also an increasing pleural effusion with adjacent consolidation and/or atelectasis. small left pleural effusion also appears increased from prior radiograph. chest (portable ap): status post removal of right subclavian vascular catheter. widespread heterogeneous combined alveolar and interstitial opacities affecting the left lung to a greater degree than the right, have progressed in the interval, and may represent a multifocal pneumonia with or without coexisting pulmonary edema. pulmonary hemorrhage is also possible in the appropriate clinical setting. ct abd & pelvis w & w/o 1. no evidence of ivc or iliac vein thrombosis. ivc in place. 2. stable lung base findings include, lingular pneumonia and bibasal peribronchovascular nodular opacities suggestive of aspiration. bilateral small effusions and right lower lobe pulmonary emboli. 3. hepatic steatosis. cta chest w&w/o c&recon 1. right lower lobe lobar to subsegmental pulmonary acute embolism. the most proximal portion of the filling defect is peripheral in the artery raising the question if this could be chronic but new since . there is no dilatation of main pulmonary artery or right heart . 2. worsening of bilateral multifocal pneumonia. ct head w/o contrast 1. limited study due to motion artifact, within this limitation, no acute intracranial pathology. 2. multifocal paranasal sinus and bilateral mastoid air cell opacification. bilat lower ext veins no deep venous thrombosis in right or left lower extremity. bilateral calf edema. echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. impression: suboptimal image quality. right ventricular cavity dilation with free wall hypokinesis. mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. compared with the prior study (images reviewed) of , the right ventricular cavity is now dilated with free wall hypokinesis c/w an acute pulmonary process (e.g., pulmonary embolism, bronchospasm, etc.). ecg sinus tachycardia with increase in rate as compared to the previous tracing of . diffuse non-specific st-t wave changes are more prominent in the context of wandering baseline and much baseline artifact. there appears to be more st segment depression in leads v3-v6 without diagnostic interim change. eeg this is an abnormal eeg due to disorganized and slow background mostly consisting of mixed delta and theta suggestive of moderate encephalopathy but non-specific etiologically. there was no focal slowing or epileptiform discharges seen. study limited by electrode artifact. recommend repeat study if clinical concern for seizures persists. chest (portable ap) previous pulmonary vascular congestion has improved, but there is still very extensive consolidation in the left lung due to pneumonia, without improvement, possibly worsened. smaller region of consolidation in the right lower lung medially is either a second focus of pneumonia or atelectasis. mild cardiomegaly is stable. dual-channel right supraclavicular central venous set ends in the region of the superior cavoatrial junction. no pneumothorax. chest (portable ap) progressive heterogeneous opacification in the left mid and lower lung zone is most likely pneumonia worsening since . there could be a second focus of right infrahilar pneumonia, also advancing. cardiomediastinal silhouette is essentially unchanged over several years. dual-channel right supraclavicular central venous set ends close to the superior cavoatrial junction. no pneumothorax. chest (portable ap) 1. worsening opacification in the left lung base with associated bronchial wall thickening concerning for infection. 2. slight interval improvement in previously noted airspace disease within the right upper lobe. 3. no definite pulmonary edema. brief hospital course: 57-year-old man with aml s/p matched unrelated allogeneic stem cell transplant in , complicated by gvhd on chronic prednisone with multiple admission for infections now presents with somnolence in the setting if increased sedative medication use, hypercarbic respiratory distress, cough and cxr with lll consolidation found to have segmental pe. # goals of care: after frequent discussions with family and physicians involved in the pt's case and gradual reduction in number of interventions performed, it was decided to transition to comfort measures only on . the below medical treaments, lab draws, and imaging procedures were held. the pt was kept in iv morphine, tylenol, and ativan to keep comfortable. he died peacefully on the morning of . # pe: patient with tachycardia, hypoxemia, hypotensive on admission and history of pe not anticoaguated, with ivc in place. tte on revealed large and hypokinetic rv and cta showed segmental pe. unclear if acute vs. subacute given appearance of clot on cta. this was not present in , however. is a potential source of clot as lenis were negative. ctv showed no evidence of clot in ivc . non contrast head ct was without hemorrhage, so started on heparin drip with intention to bridge to lovenox. per discussion with inpatient heme attending and outpatient hematologist, it was decided that the pt's risk of hemorrhage was greater than his risk of clot given the negative lenis and clean ivc , heparin gtt was held. he was continued on prophylactic heparin subc. # pneumonia: productive cough followed by somnolence in the setting of starting ambien and valium in addition to his home oxycontin. cxr with lll consolidation. sputum gram stain with gpcs in clusters, gpcs in pairs and chains and gnrs and yeast. started on vanco, (day 1: ), mica (day 1: ) in consultation with id. due to worsening cxr, vanco was changed to linezolid (day 1: ) per id recs. also question of possible pulmonary congestion, so pt was started on iv lasix. on , the pt appeared to have worsening wbc and respiratory distress. he was started on ambisome and given a dose of tobramycin. the tobramycin was thereafter uptitrated with little effect. antibiotics were continued despite little improvement. # fungemia: yeast in urine, sputum and mycolytic blood cultures positive. ophtho consulted and did not see evidence of fungal retinitis. patient does have gvhd of conjunctiva, however. he was continued on micafungin (day 1 = ) and will need two week course following clearance of fungus. mycolitic blood cultures were sent daily. cxr showed nodular areas, which was conserning for a mold pneumonia. pt was started on ambisone for presumed fungal pneumonia. an mr head was performed which ruled out fungal brain extension. ent was consulted for possible involvement of nasal sinuses, who recommended nasal irrigation as tolerated given sedation. # hypotension: he was hypotensive to 60s-70s at osh and required pressor support prior to transfer to the . possible sepsis as patient met sirs criteria with tachycardia and leukocytosis with possible sources of infection including pulmonary given lll opacity on cxr and productive cough. urine source also possible given dirty urinalysis in the setting of indwelling catheter. cardiogenic shock was considered given rising troponins, but they trended down and were likely elevated in the setting of tachycardia. ecg was without evidence of ischemia. hypovolemic shock also possible given that his po intake had been down prior to admission and his bp was fluid responsive on admission. he was started emperically on vancomycin and meropenem (day 1 = ) for pneumonia to complete an 8 day total course (through ). his urine, blood, and sputum cultures all returned positive for budding yeast (id is (torulopsis) glabrata), so he was initially started on iv fluconazole and was later transitioned to micafungin (day 1 = ). ambisome was started and uptitrated as above. # hypercarbic respiratory failure/somnolence: patient difficult to arouse at home on am of admission, and may have worsened since arriving to icu. likely multifactorial with hypercarbia from hypoventilation in the context of new sedating medications (ambien and valium, in addition to home narcotics), untreated osa with likely co2 retention at baseline, pneumonia, underlying gvhd of lung and pe. pt has expressed wishes not to be intubated. his pneumonia and pe were treated as per above. his dyspnea was treated with either non-rebreather, venti mask, or bipap as tolerated in order to achieve sat > 90%. ambien and valium were held. however, pt continued to complain of chest wall pain thought to be secondary to pna and was continuously requesting more pain medication. after a goals of care discussion was held with pt, family, and specialists, it was decided to make the pt comfortable and give ativant and morphine despite hypercarbia. # tachycardia: continues to be in sinus tachycardia in the 130s. initially in the 160s, but has improved with fluids. likely multifactorial with pe, pain, hypovolemia, and withdrawal from opioids all contributing. he was given several doses of narcan at osh and his home narcotics were initially held in the setting of hypotension. morphine drip was started to relieve any pain without any improvement in tachycardia. # : cr 1.1 from baseline of 0.6-0.7. unclear etiology, but likely prerenal in the setting of septic shock (above) with hypotension and tachycardia. creatinine improved back to baseline with treatment of septic shock. # uti: patient has indwelling foley catheter, so would be considered complicated infection. has grown e. coli most recently, though did have a negative urine culture on . continue with vancomycin and meropenem as per above. # troponinemia: patient with elevated troponin at osh, which has risen on arrival to the ed. he denies chest pain and ecg with sinus tachycardia without ischemic changes. likely troponin leak in the setting of tachycardia to the 160s. # aml s/p mud sct in : daily cbcs were checked and there was no evidence of reoccurance. he was continued on bactrim, acyclovir, and azithromycin. dr. , outpatient oncologist following. # chronic gvhd : in the past his chronic gvhc has primarily involved liver and lungs. his lft's were mildly elevated at osh, but has trended down while at . he was continued on prednisone 10 mg po daily, and ppx with with acyclovir, bactrim, and azithromycin. - ivig monthly (last dose thursday) # type 2 dm on insulin: most recent a1c is 6.8 from . his nph was decreased to 10 units (from 15) due to low sugars. he was also placed on a sliding scale. # hypertension: metoprolol was held given hypotension # clot history: prior pes for which he was previously anticoagulated. anticoagulation was discontinued in the setting of back surgery and an ivc was placed. now with segmental pe treated with heparin as per above. # right axillary mass: noticed by oncologist dr. and was planning on working up as outpatient with ct scan. # paraplegia: stable during this admission. a spine consult was called regarding further management. per spine, lumbar and thoracic spine x-rays were ordered -- these showed no significant interval change. # transitional issues: deceased medications on admission: the preadmission medication list is accurate and complete. 1. acyclovir 400 mg po q8h 2. albuterol 0.083% neb soln 1 neb ih q6h 3. atorvastatin 10 mg po daily 4. azithromycin 250 mg po q24h 5. bisacodyl 10 mg po daily constipation 6. bisacodyl 10 mg pr hs 7. duloxetine 30 mg po daily 8. fluticasone propionate nasal 1 spry nu 9. fluticasone-salmeterol diskus (250/50) 1 inh ih 10. folic acid 1 mg po daily 11. gabapentin 300 mg po bid 12. hydrocortisone cream 1% 1 appl tp qid apply to affected areas 13. hydromorphone (dilaudid) 2 mg po q4h:prn pain 14. nph 15 units breakfast nph 15 units bedtime insulin sc sliding scale using hum insulin 15. ipratropium bromide neb 1 neb ih q6h 16. methylphenidate (ritalin) 5 mg po noon 17. metoprolol tartrate 12.5 mg po bid 18. montelukast sodium 10 mg po daily 19. multivitamins 1 tab po daily 20. methylphenidate (ritalin) 5 mg po qam 21. oxycodone sr (oxycontin) 40 mg po bid 22. pantoprazole 40 mg po q24h 23. prednisone 10 mg po daily 24. senna 2 tab po hs 25. sodium chloride nasal spry nu qid:prn nasal congestion 26. sulfameth/trimethoprim ss 1 tab po daily 27. zolpidem tartrate 10 mg po hs:prn insomnia 28. docusate sodium 100 mg po bid 29. diazepam 5 mg po q8h:prn anxiety, spasm medications: deceased disposition: expired diagnosis: pneumonia, fungemia condition: deceased instructions: deceased followup instructions: deceased md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnostic ultrasound of heart removal of other device from thorax diagnoses: unspecified essential hypertension long-term (current) use of steroids diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified septicemia severe sepsis other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure other specified cardiac dysrhythmias personal history of other malignant neoplasm of skin long-term (current) use of insulin septic shock other complications due to other vascular device, implant, and graft mechanical complication due to other implant and internal device, not elsewhere classified other diseases of lung, not elsewhere classified encounter for palliative care do not resuscitate status encephalopathy, unspecified other pulmonary embolism and infarction paraplegia other and unspecified mycoses pneumonia in other systemic mycoses other specified disorders of skin other specified disorders of liver personal history of sudden cardiac arrest swelling, mass, or lump in chest personal history of myeloid leukemia conductive hearing loss, unspecified chronic graft-versus-host disease complications of transplanted organ, stem cell tear film insufficiency, unspecified 

Answer: The patient is high likely exposed to