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: found minimally responsive major surgical or invasive procedure: endotracheal intubation history of present illness: 60 year old man, known to have schizophrenia for several years, was found by family to be minimally responsive with labored breathing at home. last seen about 4-5 days prior to presentation in good shape per mother. was brought by ambulance. he was unresponsive initially, then opening eyes, able to tell his name. in the ed, initial vitals were t 99, hr 102, bp 154/89, rr 42, sat 98% on nrb, rbs 145. ed spoke to the patient's family member, he's full code, doesnt know meds, gets injections at q 2 weeks. he had a cxr which showed hyperinfiltrated lungs otherwise no acute process or infiltrates. ekg showed sinus tachycardia, normal axis, normal intervals, inverted p,inverted t with q waves in v1 and v2 with poor progression of r waves. no hyper-acute t waves. his troponin was normal with mbi of 7.7%. duonebs were given for labored breathing, never hypoxic. not intubated. he was placed on nonrebreather mask. he was found to be hyponatremic and hyperkalemic. on bedside ultrasound, there was a questionable left adrenal gland mass (big, triangular, hollow). no hypertonic saline was given. he also had a non-contrast head ct which showed no acute inctracranial process (wet read). he also had ct abdomen which showed equivocal left adrenal mass with absent left kidney (wet read). he received 1l ns only to prevent overcorrection. on transfer to , vs were: hr 100, bp 122/65, rr 18, o2sat 100% on nonrebreather mask. in the , he was minimally responsive to calling his name. he couldn't follow commands. tachypneic. review of systems: unable to get history at this stage past medical history: schizophrenia social history: - tobacco: 1ppd x 30 yr - alcohol: none, stopped 20 year ago - illicits: none per mother - lives alone, mother visits him twice a week and provides with needs - never married, no children - does not work family history: noncontributory physical exam: admission physical exam: vitals: t: 96 bp: 149/76 p: 99 r: 28 o2: 99% 4l nc general: somnolent, opening eyes but not on command, not able to follow commands, spontaneously moving fingers and toes occasionally. heent: sclera anicteric, mm dry, pupils relatively small but not pinpoint, round and equal, reactive to light neck: supple, jvp not elevated but prominent upstroke, no lad lungs: (ant/axillary exam)labored breathing, good air entry bilaterally but has both insp and exp rhonchi scattered bilaterally, no rales. cv: fast rate and regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-distended, didn't seem tender given his limited responsiveness, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: cold feet, 1+ distal pulses bilaterally, no clubbing or cyanosis, +2 pitting edema bilaterally up to knees discharge physical exam: vs: normal gen: nad, cachectic neuro:awake, alert pertinent results: admission labs: 09:10pm blood wbc-8.3 rbc-4.63 hgb-14.4 hct-40.9 mcv-88 mch-31.1 mchc-35.2* rdw-13.8 plt ct-159 09:10pm blood neuts-88.9* lymphs-5.4* monos-5.5 eos-0.1 baso-0.1 09:10pm blood pt-11.8 ptt-32.7 inr(pt)-1.0 09:10pm blood glucose-119* urean-16 creat-0.7 na-109* k-5.9* cl-64* hco3-38* angap-13 09:10pm blood alt-64* ast-77* ck(cpk)-366* alkphos-110 totbili-0.8 09:10pm blood ck-mb-28* mb indx-7.7* 09:10pm blood ctropnt-<0.01 02:27am blood ck-mb-24* mb indx-8.4* ctropnt-<0.01 09:10pm blood albumin-4.3 02:27am blood calcium-8.2* phos-4.4 mg-1.9 09:10pm blood osmolal-234* 02:27am blood tsh-0.76 02:27am blood cortsol-31.8* 09:10pm blood lithium-< 0.2 09:10pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 09:22pm blood type- po2-69* pco2-89* ph-7.26* caltco2-42* base xs-9 comment-green-top 12:30pm blood type-art po2-78* pco2-156* ph-7.05* caltco2-46* base xs-6 09:22pm blood glucose-111* lactate-1.2 na-112* k-5.4* cl-64* 11:10pm cerebrospinal fluid (csf) wbc-1 rbc-4* polys-20 lymphs-40 monos-40 11:10pm cerebrospinal fluid (csf) totprot-23 glucose-96 11:10pm cerebrospinal fluid (csf) herpes simplex virus pcr-negative discharge labs: 05:52am blood glucose-96 urean-20 creat-0.7 na-137 k-4.2 cl-96 hco3-36* angap-9 microbiology: csf;spinal fluid gram stain-final; fluid culture-final - no pmns seen, no microorganisms seen sputum gram stain-final; respiratory culture-final {moraxella catarrhalis - heavy growth} mrsa screen mrsa screen-final - negative blood culture blood culture, routine-final - no growth blood culture blood culture, routine-final - no growth imaging: ct head w/o contrast () 1. no acute intracranial process. 2. acute-on-chronic inflammatory disease in the paranasal sinuses; correlate clinically. ct abd () 1. normal adrenal glands. 2. left kidney not seen, either congenitally or surgically absent, or ectopic in the pelvis. cxr () the lungs are well expanded and clear. the trachea is midline. the descending thoracic aorta is well defined. the cardiac silhouette is within normal limits for size. no effusion or pneumothorax is noted. no displaced fractures are evident. mild degenerative disease is seen throughout the thoracic spine. ct head w/o contrast () no evidence of an acute intracranial process. eeg: per neurology, so slight slowing but no seizure activity echo (): the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. the right ventricular cavity is dilated with normal free wall contractility suggested (not well seen). there is abnormal septal motion/position (possible rv pressure overload). the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. ct chest : impression: emphysema. small lung nodule. followup in one year is recommended. brief hospital course: 60 year-old man known to have schizophrenia found by family to be minimally responsive at home with labored breathing, was admitted to icu for minimal responsiveness in setting of significant hyponatremia and hypercarbia. # metabolic encephalopathy: initially assumed to be to hyponatremia with na of 109, although also appeared to have copd exacerbation with paco2 of 89. all home antipsychotics were initially stopped in setting of unclear history and concern for their contribution. initial tox screens normal. troponins wnl x 2. unclear with urine studies showing low na as well as elevated osm. due to lethargy to low na, was initially given hypertonic saline with na up to 116, 7 hours later. also received head ct and lp initial evening and one dose of acyclovir which was stopped when lp studies came back not concerning for infection. when mental status did not change despite na of 116 and gas next am showed paco2 of 156, thought most likely that mental status due to hypercarbia with help from hyponatremia. pt was intubated for hypercarbic respiratory failure and after improvement in paco2 we saw improvement in mental status. later that afternoon pt with 4 witnessed episodes (all < 4min) of generalized seizure activity. the 4th was while neurology was at bedside and they recommended loading with dilantin. this medication was continued for 48hrs but after no further seizure activity was seen on 48hr eeg and since neurology thought seizures had been multiple metabolic derangements, neuro recommended that dilantin could be stopped with pt at low risk to resume seizing. mental status slowly improved until time of icu callout on at which point some anti-psychotic medications had been restarted. # hypercarbic respiratory failure: pt without firm past diagnosis of copd but with hyperinflated lungs on imaging, significant co2 retention with chem bicarb of 38 on presentation indicating chronic compensation, and severely limited air movement with wheezing on presentation. was intubated morning after admission for paco2 of 156 as noted above and improved with this, iv steroids, nebs, and azithromycin. was extubated 48hrs later and ultimately had heavy growth of moraxella catarrhalis in sputum as likely trigger for exacerbation. received 5 days of azithromycin had iv steroids had been tapered to 15mg iv solumedrol q24 at time of icu c/o. paco2 at time of icu c/o in 70s with hco3 in low 40s, thought to be near home baseline. pt still on small amount of nasal cannula oxygen but may not need. # emphysema / copd: started patient on tiotropium and albuterol for treatment of copd # hyponatremia: initial sodium was 109 and thought main cause of mental status as noted above. received hypertonic saline. urine studies and history suggestive of dehydration. siadh was considered, but the exact etiology of hyponatremia was unclear. ct showing no cns process. cxr without mass or infiltrate although presentation of significant copd exacerbation may have been pulmonary process that was worsening sodium. smoking history does raise concern for lung mass. ct chest eventually performed which revealed very small nodules, but no lung mass. tsh and cortisol normal. fact that sodium came up with normal saline boluses makes unlikely that purely siadh and probably that at least a component of dehydration playing a part. initial sodium up 10 meq in first 24hrs and then gradually came up to low 130s with hydration and free water restriction. patient's psych meds not common cause of hyponatremia but held initially over this concern and altered mental status. sodium was 133 at time of icu c/o. pt had no history of psychogenic polydipsia and urine lytes not suggestive of this. # schizophrenia: pt had been living at home by himself, followed closely by mass psychiatric health. his psych rn : was in contact with medical team every day and visited the patient in the hospital. she confirmed his outpt psych meds were: -abilify 30mg qam and 15mg qpm -lamictal 200mg -seroquel 30mg qhs -prolixin decanoate 15mg im q2weeks all his psych meds were held on admission although lamictal was briefly restarted (24hrs) over concerns that its withdrawal had helped predispose to seizures. psych saw the patient in the hospital and recommended iv haldol until able to take pos. on morning of , pt able to take small amount of po with applesauce and was restarted on abilify and seroquel with decision to hold prolixin and lamictal for now. is his outpatient case worker. she helped us coordinate extra help for the patient at home. if the patient refuses the extra help at home, then it will be a consideration to pursue guardianship. # hypertension: no diagnosis of hypertension and on no home antihypertensives. however, before icu discharge bps were noticed to be 160-190s systolic and started on low dose of captopril and then switched to lisinopril. # lung nodule: consider repeating ct chest in about one year to monitor for interval change of the nodule. medications on admission: -abilify 30mg qam and 15mg qpm -lamictal 200mg -seroquel 30mg qhs -prolixin decanoate 15mg im q2weeks discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*1* 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). disp:*30 cap(s)* refills:*0* 3. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. aripiprazole 15 mg tablet, rapid dissolve sig: po : take 2 tablets in the morning and 1 tablet in the evening. disp:*90 tablets* refills:*0* 5. quetiapine 25 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*0* 6. nicotine 14 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). disp:*30 patch 24 hr(s)* refills:*0* discharge disposition: home with service facility: nizhoni discharge diagnosis: - severe hyponatremia, possibly from poor oral intake - respiratory failure, from encephalopathy from severe hyponatremia - chronic obstructive pulmonary disease - schizophrenia - hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with altered mental status and found to have very low sodium (hyponatremia) that may be a result of inadequate oral food intake. very low sodium levels can cause an impairment in basic functions like breathing and is likely why your breathing failed (respiratory failure). you required mechanical ventilation when you arrived to the hospital for support. you did improve as you became more alert. you were treated with steroids, inhalers, and antibiotics in case you had an exacerbation of your copd. your medical condition has stabilized and your sodium level is now normal and breathing status is also normal. we have arranged some outpatient services to come provide additional support for you at home to make sure you make a good transition. you should also get your blood tests checked at least once every week to make sure your electrolyte levels remain normal. medication instructions: 1. albuterol inhaler 1-2 puffs every 4-6 hours as needed for shortness of breath or wheezing 2. tiotropium (spiriva) 18 mcg capsule, 1 capsule inhaled daily (copd med) 3. lisinopril 5 mg daily (high blood pressure med) 4. nicotine 14 mg patch to skin daily (to help quit smoking) 5. quetiapine (seroquel) 25 mg before bedtime (schizophrenia med) 6. aripiprazole 30 mg in the morning, 15 mg in the evening (schizophrenia med) followup instructions: psychiatry appointment: monday, at 2pm with: dr. location: health center -, ma phone: department: when: friday at 2:10 pm with: , md building: sc clinical ctr campus: east best parking: garage ***dr is your new physician at . he works closely with dr. , both will be involved in your care. please call your insurance company and name dr. as your primary care physician. must be done before your appt.*** procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances other bronchoscopy diagnoses: acidosis hyperpotassemia tobacco use disorder unspecified essential hypertension hyposmolality and/or hyponatremia obstructive chronic bronchitis with (acute) exacerbation other convulsions acute respiratory failure metabolic encephalopathy solitary pulmonary nodule schizophrenic disorders, residual type, chronic 

Answer: The patient is high likely exposed to