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: shortness of breath major surgical or invasive procedure: none history of present illness: 75m with a hx of progressive dysphagia, shortness of breath within the past 2 weeks who was transferred to from for further evaluation of an undiagnosed progressive muscular disorder. . in the ed, the patient's nif was noted to be 24. after speaking with the respiratory therapist it had since trended down to 10. cxr was concerning for left lower lobe pneumonia. the patient was started on levaquin and flagyll. . during his admission to hospital he was seen by speech and swallow. he was noted to have mild to moderate oropharyngeal dysphagia. a fiberoptic endoscopic evaluation of swallowing (fees study) was performed which showed severe pharyngeal dysphagia. ent saw the patient and felt that he could tolerate a full liqiuid diet. the patient was also noted to be dyspneic at rest. he had a high o2 requirement ( 4l, non-rebreather, bipap--for co2 retention). neurology also saw the patient and they were concerned about lower motor neuron disease most likely als with bulbar symptoms. the patient's course was complicated by afib w/ rvr which responded to diltiazem. . specifically, has had difficulty swallowing for almost 10 years and weight loss of 60 pounds in the past year or so. more recently had been having trouble bringing up secretions. and also had to give himself the heimlich maneuver 4 times prior to presentation. notes change in his voice low to higher pitch. . he's noted worsening dyspnea without orthopnea, le edema or history of heart failure. does have extensive smoking history 50-60 years 1ppd and used to drink 4-5 beers/day. gets short of breath walking down the . . ros: gen: 60 pound wt loss slightly over a year card: no chest pain pulm: shortness of breath gi: daughter notes several severe choking episodes neuro: progressive neuromuscular weakness, difficulty walking past medical history: progressive neuromuscular disorder of unknown etiology prior to this admission recent treatment for aspiration pneumonia atrial fibrillation with rvr oropharyngeal dysphagia dyspnea on bpap 30 minutes four x daily hoh, usually uses left hearing aid (recently broken) social history: 30 pack year smoking history, extensive alcohol use (per daughter over 50yrs). worked as a foreman and may have been exposed to chemicals. family history: unknown to patient physical exam: micu admission pe: t 96 hr 89 bp 115/82 r 23 o2 95% 2l gen: at rest he appears comfortable, when speaking for prolonged period of time appears to be working slightly to breath heent: extremely dry mucous membranes, op clear heart: nl rate, s1s2, no gmr lungs: bronchial breath sounds abd: positive bowel sounds, no guarding, no rebound tenderness ext: thin, warm and well perfused neuro: perrla, ii-xii grossly intact, tongue midline, 5/5 strength in upper and lower extremity, 1+ brachioradialis, 1+ patellar reflexes bilaterally, sensation to light touch is intact neurology admission pe: t- 98 bp- 117/70 hr- 62 rr- 22 96 o2sat 4l nc, nif -24 vc 1l gen: sitting up straight in stretcher, very hoh, mildly out of breath when speaking heent: nc/at, moist oral mucosa, tms wnl neck: supple, no carotid or vertebral bruit cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: bibasilar crackles to auscultation abd: +bs soft, nontender ext: no edema neurologic examination: mental status: awake and alert, cooperative with exam, normal affect. oriented to person, place, and date. attentive, says backwards. speech is fluent with normal comprehension and repetition; naming intact. mild dysarthria. intact. registers , recalls w/clues w/choices in 5 minutes. no right left confusion. no evidence of apraxia or neglect. cranial nerves: pupils round and reactive to light, r 4 to 2mm and l 3 to 2mm. visual fields are full to confrontation. extraocular movements intact bilaterally, no nystagmus. sensation intact v1-v3. bifacial weakness with fasciculations of left eye lid, upper lip and tongue. decreased hearing r>l. palate elevation symmetrical. sternocleidomastoid and trapezius normal bilaterally. tongue midline. motor: atrophy of hand muscles bilaterally. tone normal. fasciculations in pectoralis, deltoids, biceps, hand muscles and quadriceps. no pronator drift tri wf we fe ff io ip h q df pf te tf r 4 5 4 5 5- 5- 4+ 5- 5- 5 5 5 5 4 5 l 5 5 5 5 5 5 5 5- 5- 5 5 5 5 4 5 sensation: intact to light touch, cold and proprioception throughout. decreased vibration r (absent toe, intact at ankle) >l (toe secs). reflexes: tri br pat ach r 2+ 0 0 2 0 l 2+ 2 2 2 0 toes downgoing bilaterally coordination: finger-nose-finger normal, heel to shin normal, rams normal. gait: narrow based, normal stride but associated with severe dyspnea. romberg: negative pertinent results: ct torso: 1. a combination of atelectasis, aspiration, and superimposed pneumonia is noted in the lung bases. there is also associated asbestos-related pleural plaque calcification. 2. right lower lobe nodule that needs to be followed up by ct scan examination in six months. 3. a small left pleural effusion and smaller right pleural effusion is noted. 4. hyperplastic left adrenal gland. 5.superior wall thickening of the urinary bladder.cystoscopic evaluation is recommended. . emg: complex, abnormal study. there is electrophysiologic evidence for a moderate, generalized, predominantly axonal, sensorimotor polyneuropathy. in addition, there are severe, widespread denervation/chronic reiinervation changes which cannot be explained by polyneuropathy. these findings are consistent with a disorder of motor neurons or their axons (as in amyotrophic lateral sclerosis). . video swallow: moderate-to-severe pharyngeal dysphagia with reduced opening of the upper esophageal sphincter. a small amount of aspiration identified on today's study, although tougher solids were not administered and would likely produce larger amounts of aspiration. . ct c-spine: 1. moderate-to-severe cervical spondylosis predominating from c4 through c7 with central canal narrowing and neural foraminal narrowing as described. evaluation of thecal detail is limited on ct and if clinically indicated, mri can be pursued. 2. sinus mucosal disease with evidence of right mastoid air cell opacification of unknown chronicity. clinical consideration for mastoiditis and sinusitis should be considered. 3. emphysema and scarring at the lung apices bilaterally. . cxr: 1. patchy opacities involving the left lower lobe concerning for aspiration, pneumonia or a combination. 2. likely pleural plaques identified suggesting prior asbestos exposure. . mri cspine: findings: there is no evidence of fracture. there is reversal of the normal cervical spine lordosis in the upper cervical spine. vertebral body heights are normal, but there is loss of intervertebral disc space height at multiple levels, most prominently at c4/5, c5/6, and c6/7. there is degenerative retrolisthesis in conjunction with reversal of lordosis at these levels as well. there is mild-to-moderate multilevel degenerative disease extending from c2/3 through c6/7, with mild-to-moderate spondylotic ridging at multiple levels, as well as moderate bilateral uncovertebral osteophyte formation. there is mild- to- moderate central canal stenosis along this entire length, most severe at c5/c6. there is mild neural foraminal narrowing on the left at c3/4, and c4/5. there is marked thickening of the ligamentum flavum at multiple levels, and thickening of the posterior longitudinal ligament, most prominent at c1/2. impression: mild-to-moderate cervical spondylosis extending from c2/3 to c6/7, secondary to multilevel spondylotic ridging and uncovertebral osteophyte formation, most severe at c5/6, where there is moderate ventral indentation of the thecal sac. . mri brain: findings: there is no evidence of hemorrhage, edema, mass, mass effect, or infarction. no diffusion abnormality is detected. the ventricles and sulci are normal in size and configuration. there are scattered foci of mild flair signal hyperintensity in the periventricular and subcortical white matter, most consistent with chronic small-vessel ischemic disease. there is no abnormal enhancement after contrast administration. there is moderate mucosal thickening, with mild peripheral enhancement in the left maxillary sinus. note is also made of fluid within the bilateral mastoid air cells, right greater than left, and a small amount of fluid in the right middle ear. incidental note is made of moderate degenerative disease of the cervical spine, better evaluated on dedicated cervical spine mri, concurrently performed. impression: 1. no evidence of brainstem abnormality, or other finding relating to als. 2. moderate left maxillary sinus mucosal thickening, bilateral mastoid air cell opacification, and right middle ear fluid may relate to sinusitis. please correlate clinically. 3. degenerative disease of the cervical spine, better evaluated and reported separately in concurrently performed mri of the cervical spine. . ekg: baseline artifact. atrial fibrillation with moderate ventricular response. borderline left axis deviation. poor r wave progression, probably a normal variant. no previous tracing available for comparison. . . vitamin b12: 1657 mma 108 (normal) tsh: 2.6 ft4: 1.0 brief hospital course: 75 y/o man presented with shortness of breath in the setting of progressive neuromuscular disease. . 1. shortness of breath: the patient was admitted to the micu with breathing difficulty secondary to underlying neuromuscular weakness, as demonstrated by clear paradoxical breathing on exam. patient was also found to have a question of pneumonia on chest x-ray and likely atelectasis. video swallow with dysphagia. monitored in the icu by nifs and vcs which were stable. patient clear about desire not to be intubated. treated with levofloxacin for aspiration pneumonia for two days, but in the absence of fever and leukocytosis, the internal medicine team stopped this medication prior to transfer out of the micu to neurology service. dnr/i status was confirmed with the patient, and he tolerated bipap at night for sleep with nasal mask, settings with 2l o2. he should be continued on this setting at night until further notice, as it ensures that he is awake and comfortable during daytime hours. . 2. neuromuscular disorder: he was evaluated by neurology as an inpatient. he had an emg that demonstrated the new diagnosis of motor neuron disease, thought to be most likely consistent with als. he had a torso ct scan to evaluate for malignancy for ? paraneoplastic syndrome leading to symptoms. ct c-spine demonstrated spondylosis but thought to be only a minor contributor to symptoms. bladder wall thickening was seen, and urology recommended an outpatient cystoscopy (not to be done emergently). he also had a sub-centimeter pulmonary nodule that will need to be re-assessed in 3 months if the patient desires. he had an mri of the brain and cspine; mri of the brain showed some chronic opacification of sinuses, and mri of the cspine showed multi-level disc disease with foraminal stenosis at many levels. though this can cause lower motor neuron signs and symptoms (including fasciculations, as he has), it did not explain his bulbar symptoms, and thus als was felt to be the more likely diagnosis. several discussions were held with the patient and with his stepdaughter, and they wished to change the goals of care to comfort measures. he will decide in the future if he wants certain disease processes worked up or treated, but for now, the goal is comfort. hospice options were explored and the patient was discharged to a nursing home with hospice services. if there are any remaining questions or concerns about the diagnosis, dr. (neurology, bimdc) has agreed to answer questions and see him in follow-up if needed. . 3. dysphagia: the patient's dysphagia was felt to be related to als. he declined peg tube placement, despite the knowledge that he was at risk for aspiration with a modified diet, and considering the knowledge that als is a progressive disease with no cure. . 4. atrial fibrillation: aspirin was continued for protection from stroke, considering his atrial fibrillation, as a disabling stroke (ie, hemiplegia with aphasia) was felt to likely impair his quality of life. 5. pt pulled out his foley catheter while in the icu. after this, he complained of penile pain. he was treated with tylenol - small effect; lidocaine jelly and pyridium (last day of admission) = no effect. pyridium was not continued upon discharge. 6. diarrhea noted upon arrival from icu. he was checked for cdiff--> found to be negative; empirically started on flagyl while awaiting cdiff. flagyl was d/c'ed prior to discharge to hospice. medications on admission: albuterol/ipratropium neb q6h asa 81 qd dulcolax 10mg pr qd diltiazem 100mg advair inh folate 1mg qd hsc 5000u tid metoprolol 12.5mg q6h morphine sulfate 1mg q3hrs prn dyspnea mvi senna 2 tabs qhs thiamine 100mg qd trazodone 25mg qhs prn ceftriaxone 1gm/flagyl 500mg q6h until discharge medications: 1. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed. 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 3. calcium carbonate 500 mg tablet, chewable sig: two (2) tablet, chewable po qid (4 times a day) as needed. 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed: use as suppository or orally - part of "comfort pack.". 5. zinc oxide-cod liver oil 40 % ointment sig: one (1) appl topical tid (3 times a day) as needed. 6. aspirin 325 mg tablet sig: one (1) tablet po once a day. 7. acidophilus tablet, chewable sig: one (1) tablet, chewable po qday (). 8. lorazepam 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 9. benadryl 25 mg capsule sig: 0.5 capsule po every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 10. haloperidol 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 11. reglan 10 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea: use as suppository or orally - part of "comfort pack.". 12. haloperidol lactate 2 mg/ml concentrate sig: 0.5 ml ml po every six (6) hours as needed for agitation: sublingual. 13. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) sublingual every six (6) hours as needed for secretions: part of "comfort pack.". 14. lorazepam 1 mg tablet sig: one (1) tablet po every six (6) hours as needed for agitation: part of "comfort pack.". 15. morphine concentrate 20 mg/ml solution sig: fifteen (15) ml po every four (4) hours as needed for pain: =5mg/dose; part of "comfort pack." also prn breathlessness. 16. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea: part of "comfort pack.". 17. prochlorperazine 25 mg suppository sig: one (1) rectal every six (6) hours as needed for nausea: part of "comfort pack.". discharge disposition: extended care facility: house (hospice home) - discharge diagnosis: amyotrophic lateral sclerosis aspiration pneumonia - resolved polyneuropathy bladder wall thickening seen on ct torso discharge condition: fair - swallows with some risk of aspiration but declines peg placement; on hospice medication regimen; continues to have widespread fasiculations of face, tongue and limbs; some upper and lower motor neuron pattern of weakness in arms and legs. mild sensory changes at the feet. discharge instructions: please follow up with your hospice specialists; we have also scheduled you a visit with a primary care physician, . . your appointment will be in and you will need transportation to and from the appointment. if there are any problems with health and particularly neurological issues pertaining to the als, please contact the office of dr. () or ask page operator at to page neurology resident on call (). followup instructions: you will need a follow-up ct of the chest in 6 months to evaluate a right lower lobe lung nodule. you should also have an outpatient cystoscopy of the bladder (primary care may schedule) to evaluate for bladder wall thickening, as recommended by urology. we have scheduled you a visit with a primary care physician at - dr. , at 2:30pm. , . provider: , md phone: date/time: 2:30 if you have new neurological problems that you are concerned about, please contact dr. () or ask page operator at to page neurology resident on call (). you may schedule an appointment to see dr. at your convenience (will be a 'new' appointment). procedure: non-invasive mechanical ventilation diagnoses: atrial fibrillation acute respiratory failure amyotrophic lateral sclerosis pneumonitis due to inhalation of food or vomitus diarrhea encounter for palliative care unspecified hereditary and idiopathic peripheral neuropathy personal history of alcoholism cervical spondylosis without myelopathy unspecified disorder of bladder 

Answer: The patient is high likely exposed to