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: patient recorded as having no known allergies to drugs attending: chief complaint: transfer for tracheostomy & peg tube placement major surgical or invasive procedure: tracheostomy peg tube placement lumbar puncture red blood cell transfusion platelet transfusion chemotherapy history of present illness: mr. is a 22yo male with pmh significant for mediastinal germ cell tumor with airway obstruction s/p cycle 3 of cisplatin & etoposide ()who presents for elective tracheostomy & peg tube placement. patient was recently discharged from on after undergoing stent placement in the left mainstem bronchus and y stent placement in the trachea. . patient initially presented to osh in respiratory distress and was found to have an anterior mediastinal mass on cxr, confirmed by ct. patient continued to desat from 80s to low 50s and was eventually intubated. patient was transfered to on per request of family. according to family, patient was in his usual state of health until he started to have generalized symptoms 6 months prior to presentation to osh including sore throat, cough, and respiratory symptoms. patient had been treated for 2 weeks for bronchitis without resolution. . at , patient was intially intubated with double lumen ett for acute respiratory distress. patient had multiple episodes of desaturation requiring intervention with bronchoscopy for better ett positioning. on bronchoscopy, the anterior mass was noticed to cause tracheal narrowing and obstruction of the mainstem bronchi bilaterally. patient's double lumen ett was changed to a single lumen on for better ventilation. course complicated by bilateral pneumothoraces requiring bilateral chest tube placement which were d/c'ed on and . patient was extubated on but reintubation on due to hypercarbic respiratory failure. he was transferred at this time to for y stent placement and then transferred back to . he was extubated on and initially did well but could not adequately handle the secretions so he was taken to the or on for tracheostomy by ent. the procedure was technically difficult since the y stent was too high. he was reintubated (nasotracheal tube) in or with bronchoscopy to remove mucous plugging in right middle and lower lobes. . he underwent an ultrasound guided biopsy of his anterior mediastinal mass on . given elevated afp (4093 on ) and biopsy of undifferentiated carcinoma, patient was treated for germ cell tumor with neoadjuvant cisplatin and etoposide from . patient prophylaxed for tls with alopurinol, dexamethasone, and iv fluids. chemotherapy complicated by pancytopenia and neutropenic fever, requiring prbc transfusions on neupogen. cycle 2 of chemotherapy delayed due to development of pseudomonas sepsis and arf. however, with stabilization, patient underwent cycle 2 of carboplatinum and etoposide on . at the time of transfer, patient is reportedly at his chemo-induced neutropenic nadir. however, hct and platelets have been stable. . from an id perspective, following cycle 1 of chemotherapy, patient was diagnosed with a vap on and was started on vancomycin and cefepime. both were continued with the addition of fluconazole for neutropenic precautions following chemotherapy. cefepime was changed to zosyn when patient's sputum culture was (+) for achromobacter on . patient then developed an abscess in his r groin at the site of a prior line which was i&ded by surgery on and was also the source of the above mentioned mdr pseudomonas sepsis. patient had pseudomonas in blood, urine, and r groin abscess cultures. he completed a 15 day course of gentamicin and cefepime, despite nephrotoxicity as pseudomonas in wound culture was only sensitive to gentamicin. patient was then started on vancomycin due to mrsa from r quinton tip culture. also started on amikacin for pseudomonas in sputum and urine. diarrhea started on . c diff was negative x 3 and was thought to be secondary to chemotherapy. he was placed on empiric flagyl at this time. a ct scan was obtained on showing ileocecal thickening and ? typhlitis (necrotizing enterocolitis) as well as some ? intusseception fo ascending colon, although there was no evidence of obstruction. patient then had temp spike through above broad antibiotic coverage and empiric caspofungin started on . with persisting fevers patient was continued on cefepime, amikacin, for pseudomonas in sputum and urine. . hospital course was also complicated by arf thought to be secondary to pseudomonas sepsis and hypotension on . patient developed poor uop and lasix gtt started with poor response. patient eventually required cvvh for volume overload on with 6l removal, and on with 4l removal. r quinton placed in r ij and patient was started on hd on . quinton eventually clotted on and he recent emergent dialysis through a newly placed left femoral line. he then went to ir for possible l quinton placement for hd, but was discovered to have bilat dvts in ijs which prevented placement. he eventually responded to 140 mg iv lasix with good uop on and the l femoral line was d/c'ed to prevent further infection. arf eventually resolved with normal cr and good uop. past medical history: # germ cell tumor in mediastinum - s/p 2 rounds of chemotherapy # pancytopenia chemotherapy social history: patient was a student at in accounting. he was a non smoker, no alcohol or tobacco use. family history: non-contributory physical exam: vitals t 99.4 bp 181/107 ar 127 rr 21 vent ac fio2 0.40 tv 400 rr 12 peep 5 gen: patient awake, responsive to commands heent: nasopharyngeal tube in place heart: distant heart sounds, no audible m,r,g lungs: abdomen: soft, distended, nt/nd, decreased bss extremities: no edema, 2+ dp/pt pulses bilaterally pertinent results: 04:07pm plt count-411# 04:07pm wbc-16.0*# rbc-3.06* hgb-9.2* hct-29.6*# mcv-97# mch-30.0 mchc-31.0# rdw-16.1* 05:40pm pt-12.8 ptt-36.7* inr(pt)-1.1 05:40pm plt count-402 05:40pm wbc-16.3* rbc-3.13* hgb-9.6* hct-28.2* mcv-90# mch-30.5 mchc-33.9 rdw-16.4* 05:40pm albumin-3.5 calcium-10.2 phosphate-3.9 magnesium-1.9 05:40pm lipase-40 05:40pm alt(sgpt)-35 ast(sgot)-16 ld(ldh)-349* alk phos-182* amylase-58 tot bili-0.6 05:40pm estgfr-using this 05:40pm glucose-115* urea n-22* creat-0.4* sodium-134 potassium-4.2 chloride-93* total co2-30 anion gap-15 05:41pm urine rbc-21-50* wbc-0-2 bacteria-few yeast-none epi-0 05:41pm urine blood-lg nitrite-neg protein-tr glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 05:41pm urine color-straw appear-clear sp -1.014 . infectious disease data: : vap/ neuropenia (cefepime/vanc/fluc) - (cefepime changed to zosyn) for achromobacter in sputum : r groin abscess - mdr pseudomonas (gent and cefepime) date?: r quinton mrsa+ - vancomycin : febrile neutropenia - vanc, cefepime, amikacin - projected to complete 14day course , continued indefinitely given sputum with ongoing growth . microbiology data: - sputum --> 2+gnr, 3+ pseudomonas, 2+ mrsa, 3+ achromobacter - pseudomonas : amikacin, tobramycin res: colistin, gent, cefepime, aztreonam, pip-tazo, cipro, impenem : blood --> no growth : urine --> no growth : blood --> no growth : c. diff a+b negative : blood --> no growth : urine --> no growth : sputum --> 1+ gnr, 3+ pseudomonas, 3+ stenotrephomonas - pseudomonas : tobra, amikacin, gent res: pip-tazo, cefepime, cipro, imi, gent, levo, : spumtum --> 3+ mrsa, 3+ pseudomonas, 3+ achromobacter - pseudomonas : tobra, amikacin, gent res: aztreonam, pip-tazo, cefepime, cipro, imi, levo . . imaging: cxr: impression: ap chest compared to through : infiltrative abnormality right mid and lower lung zones with the suggestion of nodular coalescence as well as multiple nodules in the left lower lobe and lingula have all increased extent since consistent with lymphoma and/or infection. the extent of severe adenopathy in the upper mediastinum has not changed appreciably. stent positions, including the tracheal and left main bronchus components, is unchanged. tip of the upper tracheal tube is at the level of the sternal notch, approximately 2 cm higher than previously. nasogastric tube is looped in a very distended stomach. . kub: no evidence of obstruction is noted. . cxr: comparison is made to and examinations. amount of bilateral perihilar streaky opacities is improved since most recent examination likely reflecting resolving atelectasis or edema. mild left lower lobe atelectasis persists. position of tracheostomy tube, right picc catheter, and anterior mediastinal widening is not significantly changed. no evidence of pneumothorax or large effusions. impression: interval improvement to perihilar opacities likely reflect resolving atelectasis or edema. persistent mild left lower lobe opacity. . . brain mri. conclusion: multiple small enhancing lesions within the cerebral hemispheres, but apparently sparing the posterior fossa structures. some of these may well be leptomeningeal in location. given the history of a malignancy elsewhere, hemorrhagic metastatic lesions (where susceptibility is seen) are suspected. given the apparent negative head ct scan of , it is possible that the hemorrhagic contents may not be acute or, less likely, that they might have developed in the relatively short interval between the two scans. . . brain mri. impression: since , increase in size of right parietal leptomeningeal metastasis as well as the right frontal and left superior parietal metastases. no significant change in size of small metastases involving the left centrum semiovale and the left occipital lobe. . . total spine mri. impression: no spinal metastases seen. a focus of hyperintensity on t1 and t2 but not on stir likely represents focal fat or hemangioma in the l5 vertebral body. . : head mri mpression: since , increase in size of right parietal leptomeningeal metastasis as well as the right frontal and left superior parietal metastases. no significant change in size of small metastases involving the left centrum semiovale and the left occipital lobe. . : ct head, neck, chest: impression: 1. large mediastinal mass extending cranially through the thoracic inlet up to the level of the thyroid glands with thyroid invasion. cranial to this level, no lymphadenopathy is seen. 2. multiple pulmonary metastases, better evaluated on today's chest ct. . impression: 1. interval progression in size of innumerable lung metastases. 2. stable anterior mediastinal mass and hilar adenopathy. 3. decreased posterior mediastinal mass component on the left. . impression: marked interval progression in size of all metastatic lesions since mri of . the largest lesions demonstrate internal hemorrhage and surrounding vasogenic edema. . : mri head impression: new large hemorrhages with surrounding edema centered around the previously seen enhancing lesions. there is minimal mass effect upon the right lateral ventricle, but there is no subfalcine herniation. the above findings likely represent hemorrhage related to tumor necrosis following radiation therapy. extensive hemorrhage into abscesses is thought to be a much less likely possibility. . : non-contrast head ct mpression: 1. no significant interval change from mri. hemorrhage and surrounding edema within multiple metastatic lesions, again likely related to post-radiation tumoral necrosis. 2. mild mass effect on the right lateral ventricle but no evidence of herniation. . : non-contrast head ct impression: 1. no evidence of significant interval change. 2. multiple hyperdense foci with surrounding edema consistent with metastatic hemorrhagic parenchymal lesions. 3. mild mass effect that is stable exerted on the right lateral ventricle. . : non-contrast head ct mpression: no significant change compared to prior study, with multiple hyperdense masses, with surrounding edema, consistent with metastatic lesions. relatively stable-appearing mass effect on the right lateral ventricle with mild leftward shift. : neck ct mpression: no significant change seen compared to prior study, with large mediastinal mass again identified. the svc is narrowed as before. : chest ct impression: 1. no significant change compared to prior study, with large anterior mediastinal mass again identified, abutting the svc, which appears slightly narrowed, however, appears to remain patent. 2. innumerable pulmonary metastases again identified. hilar lymphadenopathy also again seen. : non-contrast head ct mpression: no significant change in multiple hyperdense lesions with surrounding edema most consistent with metastatic disease. stable leftward shift of the midline and subfalcine herniation. . sputum. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): oropharyngeal flora absent. pseudomonas aeruginosa. moderate growth. staph aureus coag +. moderate growth. _________________________________________________________ pseudomonas aeruginosa | staph aureus coag + | | amikacin-------------- 16 s cefepime-------------- 16 i ceftazidime----------- 32 r ciprofloxacin--------- =>4 r erythromycin---------- =>8 r gentamicin------------ 4 s =>16 r imipenem-------------- =>16 r levofloxacin---------- =>8 r meropenem------------- =>16 r oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- =>128 r piperacillin/tazo----- 64 s rifampin-------------- <=0.5 s tetracycline---------- =>16 r tobramycin------------ <=1 s trimethoprim/sulfa---- s vancomycin------------ <=1 s brief hospital course: mr. is a 22 yo male with pmh significant for a mediastinal germ cell tumor s/p tracheostomy and peg tube placement, who was transferred to the oncology service, underwent radiation therapy and chemotherapy, but unfortunately expired on . . #. respiratory failure: respiratory distress secondary to anterior mediastinal mass compressing the trachea. he was first intubated in and since then has been intubated/extubated several times. he was recently discharged from after a y stent was placed and extubated and did well for 1 week; he was subsequently reintubated at due to increased secretions and transferred to for tracheostomy. he tolerated the procedure well on and has been stable post- tracheostomy. he tolerated sbt and was placed on tracheal mask at 5pm on and tolerated well. propofol was been weaned. he was put on pressure support due to thick respiratory secretions, however was weaned to trach mask after 5 days. . he was transferred to the for increasing respiratory secretions. he was found to have a mrsa and pseudomonas pna. he was treated with vancomycin, cefepime, and tobramycin. he completed a 3 week course of these antibiotics, finished on . he was initially requiring mechanical ventillation but then tolerated trach collar mask after a few days. . patient continued on trach collar during his stay, with a stable oxygen requirement of 35-40%. he completed a course of treatment for mrsa and pseudomonas pneumonia. . internventional pulmonology downsized the patient's tracheostomy during the last week of . . during the week prior to his death, patient was noted to have worsening right lower lobe infiltrates, likely representing a new pneumonia. vancomycin, cefepime, tobramycin and flagyl were all re-started. . #. germ cell tumor: patient was found to have an anterior mediastinal mass consistent with a germ cell tumor. s/p 3 cycles of etoposide & cisplatin (). a tissue biopsy was obtained during tracheostomy. he began xrt to chest wall on . he was found to have small brain metastases, but no metastases to the spine. l spine mri showed no metastases in the spine. an lp on was negative for malignant cells. a repeat brain mri showed an increase in size of brain metastases in just one week. . he completed a course of whole brain () and chest (15/15) radiation therapy. he then underwent another course of chemotherapy on . . patient was noted to have increasing weakness on left side of body, with tingling feeling. a ct scan done revealed edema and hemorrhage of known masses in the right parietal lobe. on , patient had abrupt decline in his neurological status, and resultant left sided total paralysis. a stat head ct was completed at that time, and neurosurgery evaluated the patient. it was felt that there would be no benefit in neurosurgical intervention. the patient's platelet count was monitored closely and he was transfused for a goal of 100 to avoid further bleeding. keppra was initiated and continued as seizure prophylaxis. steroids were also initiated and increased at the time of the neurological decline. . # arf. renal function stable after initial bump in creatinine. creatinine had increased from 0.4 to 1.0 on . cause of renal failure is unclear. is not pre-renal as fena is 1.6. renal sono showed renal parenchemal disease, but no hydrophrosis. patient has good urine output. urine eos are negative. it is possible that this is a drug toxicity from chemotherapy (was given cisplatin and carboplatin) or that this is related to iv contrast for abdominal ct. however, arf developed weeks after last chemo dose and 4 days after getting contrast on . . # anxiety and depression: significant anxiety per family. this was also documented in his recent discharge summary from . depression was noted by family and staff, and patient also related this. psychiatry followed along closely and assisted with management of his anxiety and insomnia. . # tachycardia/htn: longstanding problem for patient. this was thought to be due to underlying agitation, fevers, and illness. . # anemia: patient noted to have anemia, felt to be secondary to his chemotherapy and chronic disease. he received several transfusions to help with his anemia. . # thrombocytopenia: patient developed thrombocytopenia after his chemotherapy, and was transfused frequently to keep his platelet count around 100, to avoid any further bleeding from his brain metastases. . # fen: given tube feeds via peg. was evaluated by speech and swallow and found to tolerate solids and thin liquids. in the days prior to his death, he was made npo given that he appeared to be aspirating and his mental status had declined. . # on , after extensive discussion with the patient's mother and father, decision was made to make the patient dnr/dni, and frequently address goals of care depending on the patient's progress. social work was also involved to help facilitate discussions and ensure that both of the patient's parents' points of view were heard and addressed. . sadly, the patient's status continued to deteriorate, and he began to develop fevers, worsening respiratory, and mental status. on the morning of , the patient's condition had further deteriorated, and the decision was made to initiate a morphine drip. the patient's father desired that antibiotics and intravenous fluids be continued, and these wishes were respected. patient was made comfortable and denied any pain. . overnight on , patient passed away with his family at the bedside. medications on admission: ipratropium bromide mdi 4 puff ih qid acetaminophen 650 mg po q6h:prn lansoprazole oral disintegrating tab 30 mg po daily albuterol 10 puff ih q4h lorazepam 1-3 mg iv q1h:prn anxiety albuterol 10 puff ih q2h:prn metoprolol 12.5 mg po tid amikacin 1100 mg iv q36h methadone hcl 20mg po q8h cefepime 2gm iv q8h miconazole powder 2% 1 appl tp tid diazepam 10mg po bid nephrocaps 1 cap po daily fentanyl citrate 25-100 mcg/hr iv drip infusion nystatin oral suspension 5 ml po qid haloperidol 5 mg im q4h:prn agitation olanzapine 5 mg po daily promethazine hcl 6.25 mg iv q6h:prn insulin sc sliding scale vancomycin 1.25gm iv q 12h . allergies: nkda discharge medications: none. discharge disposition: expired facility: - discharge diagnosis: metastatic germ cell tumor. discharge condition: expired. discharge instructions: expired. followup instructions: expired. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified spinal tap incision of lung fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] other intubation of respiratory tract other intubation of respiratory tract temporary tracheostomy injection of antibiotic injection of antibiotic bronchoscopy through artificial stoma bronchoscopy through artificial stoma transfusion of packed cells closed [percutaneous] [needle] biopsy of brain replacement of tracheostomy tube magnetic resonance imaging of brain and brain stem injection or infusion of cancer chemotherapeutic substance transfusion of platelets other radiotherapeutic procedure diagnoses: acidosis anemia, unspecified unspecified essential hypertension acute kidney failure, unspecified infection with microorganisms resistant to penicillins intracerebral hemorrhage malignant neoplasm of brain, unspecified nausea with vomiting anxiety state, unspecified acute respiratory failure pneumonia due to pseudomonas methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site septic shock antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use methicillin susceptible pneumonia due to staphylococcus aureus pressure ulcer, buttock secondary malignant neoplasm of lung other disorders of neurohypophysis drug induced neutropenia tachycardia, unspecified malignant neoplasm of anterior mediastinum other diseases of trachea and bronchus anisocoria paralysis, unspecified 

Answer: The patient is high likely exposed to