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: verapamil / levaquin attending: chief complaint: hypoxic respiratory distress major surgical or invasive procedure: none history of present illness: this is an 80 yo f with dementia, mental retardation, diastolic chf, restrictive lung disease, recurrent pnas, h/o intubation, anemia, who presents with hypoxic respiratory distress. pt was found to be in acute respiratory distress at her facility with o2 sats in the 40s. apparently the pt had been noted to have severe lethary and wheezing at her . she was placed on 100%nrb at her facility and was then brought to ed. . in , pt was found to be satting at 46%on ra and 91-100%nrb, t98.5, hr 90, bp 165/76, rr22. she appeared to be in respiratory distress with dusky cyanotic hands. pt was confused, disoriented, agitated and was placed in restraints. she was given a/a nebs, solumedrol, levofloxacin 500 mg iv x1, vancomycin 1gm iv x1. initial abg revealed: 7.34/72/96 on 100% nrb. she had a wbc of 14 with 92%pmn. cxr revealed rll atelectasis vs infiltrate. past medical history: -dementia -mild mental retardation -diastolic chf -htn -svt -restrictive lung dz -mult pnas -gerd -diverticulosis -djd lower spine -osteoporosis -arthritis, left hand contracture -urinary/fecal incontinence -mult utis--indwelling foley -cri, bl cr 0.8-1.1 -anemia, bl hct 28 -depression -hard of hearing, deafness in left ear -headaches -hip surgery -breast surgery involving with removal of calcium deposits . cardiology report echo study date of : the left atrium is normal in size. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (tape reviewed) of , the findings are similar. . spirometry : fvc 49% pred, 0.61; fevq 82% pred, 0.61; fev1/fvc 169%pred social history: lives at . health care proxy (w), cell . wheelchair bound due to arthritis. the patient was never a smoker, does not drink alcohol. the patient obtains no exercise. family history: father--died of pe brother--died of lung ca physical exam: vitals: t 98.4 bp 165/65 hr 86 rr 25 sat 83-86% 4lnc gen: pleasant elderly woman, in mild resp distress with accessory muscle use, able to speak in partial sentences, often smiling heent: eomi, perrl, op clear with poor dentition neck: no lad, jvp elevated to jaw on r but difficult to assess due to accessory muscle use cvs: rrr, nl s1 s2, 2/6 systolic murmur at rusb chest: lungs cta anteriorly abd: soft, nt/nd, nabs ext: no tenderness, no le edema neuro: mafe pertinent results: 09:11pm type-art po2-62* pco2-62* ph-7.33* total co2-34* base xs-3 intubated-not intuba comments-nasal 09:11pm lactate-3.1* 09:11pm o2 sat-90 09:11pm freeca-1.13 09:07pm glucose-151* urea n-31* creat-1.5* sodium-144 potassium-4.0 chloride-98 total co2-31 anion gap-19 09:07pm alt(sgpt)-21 ast(sgot)-21 ld(ldh)-226 ck(cpk)-192* alk phos-85 amylase-84 tot bili-0.3 09:07pm lipase-73* 09:07pm probnp-5793* 09:07pm ck-mb-3 ctropnt-<0.01 09:07pm albumin-4.1 calcium-8.9 phosphate-4.5 magnesium-1.7 09:07pm osmolal-304 09:07pm wbc-12.9* rbc-4.00* hgb-11.4* hct-35.8* mcv-90 mch-28.4 mchc-31.7 rdw-15.4 09:07pm neuts-97.8* bands-0 lymphs-1.5* monos-0.4* eos-0.1 basos-0.2 09:07pm hypochrom-1+ anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 09:07pm plt smr-normal plt count-263 09:07pm pt-13.0 ptt-22.2 inr(pt)-1.1 05:45pm urine color-straw appear-clear sp -1.012 05:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 03:14pm type- po2-35* pco2-76* ph-7.32* total co2-41* base xs-8 01:30pm ck(cpk)-179* 01:30pm ctropnt-<0.01 01:30pm ck-mb-3 01:30pm wbc-14.0*# rbc-4.39# hgb-12.6 hct-38.9 mcv-89 mch-28.8 mchc-32.5 rdw-15.6* 01:30pm neuts-92.0* lymphs-4.3* monos-3.1 eos-0.1 basos-0.5 01:30pm hypochrom-1+ 01:30pm plt count-272 01:30pm pt-12.4 ptt-23.1 inr(pt)-1.1 01:30pm d-dimer-566* 12:55pm type-art temp-36.7 o2-100 po2-96 pco2-72* ph-7.34* total co2-41* base xs-9 aado2-558 req o2-91 intubated-not intuba comments-nrb . cxr : impression: left basilar atelectasis vs. pneumonia.there is a right diaphragmatic hernia which extends across the midline to the left, unchanged from . there is linear atelectasis at the right base. . ekg: nsr, nl axis, biphasic t in precordial leads, q in lead iii, atrial enlargement? brief hospital course: on admission to the icu, the pt was satting in the 80s on both ra and 4lnc. her abg revealed: 7.33/62/62/34 with a-a gradient of 95. pt was started on a 500 cc bolus of ns and then d51/2 at 70 cc/hr. pts sats dropped back down to 79% on 4lnc. she was given combivent neb and suctioned, bringing her o2 sat back up to 96% on 50%fio2. repeat abg: 7.31/65/74 with a-a of 135. fluids were stopped and stat cxr revealed likely volume overload. bnp came back 5793 and pt was given lasix 20 mg ivx1, inch nitropaste, hydral 10 mg po. her abx were changed from ceftriaxone/azithro to zosyn given possibility of nosocomial infxn. vancomycin was continued to cover for aspiration pna. on the morning after admission, it was decided to again stop diuresis and start gentle hydration. it was felt the pt was initially dry on admission, leading to her hypernatremia, arf. she likely became volume overloaded in the setting of the ns bolus of 500 cc over 1 hr. following that fluid bolus, her na did improve to 144. she was restarted on ns at 100 cc/hr for 1 l. the hydralazine was discontinued and the diltiazem was continued to maximize filling time. she was then discharged to the floor and was intermittantly hypoxic on ra with sats between 88 - 95%. therefore she needs rehab for pulmonary toilet. . # hypoxic resp distress/hypercarbic respiratory distress/respiratory acidosis: ddx on admission--noscomial pna, aspiration pna, chf, pe, ?contribution from chronic lung dx. leading dx is probably combination of aspiration and chf. pt admitted with radiologic signs of a pna. she was treated with levofloxacin, vanc, and solumedrol in the ed. d dimer elevated to 556, however pt with stable hemodynamics and no other evidence of pe. pts volume status is unclear by pe, however bnp elevation to 5793 assists in dx of chf. a-a gradient of 95, up to 135 after volume overload. ruled out for an mi. we continued empiric treatment for nosocomial and asp pna with zosyn; add vanc 1gm iv q48 hr given likely asp pna. diltiazem was continued for rate control to improve diastolic dysfunction. she was given a/a nebs prn. on the night of admission the pt satted upper 80s-90s on 50%vm. the pt developed hypercarbic resp distress and was intubated the am of . pt developed hypercarbia on with delta ms and with abg of 7.13/105/81 on 50% face tent. pt was intubated in the morniing and placed on ac. it was unclear if the hypercarbia was due to ms changes or an aspiration or volume overload event. she was extubated and reintubated the same day for hypoxic resp distress (sat 80% nrb) unresponsive to nitropaste and lasix. again, the etiology of the hypoxia was unclear, but was felt to be due to laryngeal edema given she had no leak on trach collar. the pt was started on prednisone 40 mg po qd on . she successfully was weaned to ps on with spontaneous breathing trials on and lasting 3 hrs at a time. she finished her 10 day course of zosyn and vanc. she needs rehab for pulmonary toilet, as the last time she had an aspiration event, she required weeks to be weaned from o2. . #delta ms: the pt was noted to have an altered ms the am of when she was having the episode of hypercarbic respiratory distress. it is unclear if the pts delta ms caused her hypercarbic respiratory distress or vice versa. pt was noted the am to have intermittent myoclonic activity, however able to follow commands making seizure unlikely. neuro felt pt has polymyoclonus which is stimulus dependent. there was concern for meningitis given ?nuchal rigidity by neuro consult exam, however there is no evidence of this today. head ct is negative for acute process. . #arf: pts bl cr is 0.8-1.1. cr up to 1.6 on admission. suspect prerenal etiology given elevated bun/cr ratio and na 147. as per below under "pump", the pt was initially rapidly hydrated with 500 ccns resulted in flash pulmonary edema. she was restarted on gentle hydration the am after admission. the pts creatinine was noted to rise to 1.6 on and her uo dropped over the night into . she was intially given several ns boluses and then was given lasix 20 mg ivx1. her uo then improved. it was felt the pt had a delicate fluid balance given her diastolic dysfunction and will likely need intermittent hydration with lasix to optimize forward flow. the pts cr improved to 1.4 with lasix and hydration, however it never returned to her original baseline. the pt likely has a new baseline cr level of 1.3-1.5. . #elevated na: na 147 on admission. pt appeared volume depleted. pt desatted after intial fluid bolus but na did improve to 144. the morning after admission the pt was started on slow rate of ns given episode of hypoxia s/p ns bolus. dilt was continued to maximize rate control and co. the pts na ultimately normalized after free water boluses. . #elevated lactate: lactate 3.2 on night of admission up from 1.2 in ed. likely due to hypoperfusion in the setting of chf. following fluid resusciation the pts lactate levels normalized. . #cv: a pump: pt has h/o diastolic dysfunction,nl ef. initial cxr did not show clear signs of volume overload, but second cxr was c/w volume overload. the pt likely flashed from rapid fluid infusion. however, it was felt the pt was dry given her clinical exam, arf, and hypernatremia. the goal was to ideally decrease hr for increased filling time and give gentle hydration to increase co. the pts diltiazem sr was changed to a qid regimen. she was intially given 500cc ns on the night of admission, however backflashed her fluids. she was given hydral 10 mg po x1, nitropaste, lasix 20 mg ivx 1 and then 40 mg ivx1 over the night of admission. on the morning after admission it was decided to restart gentle fluids to improve her co. the pt was given several fluid boluses on and then 20 mg iv lasix later that night due to decreased uo. dilt gtt was started on to optimize filling time. it was felt the pt had a delicate fluid balance given her diastolic dysfunction and would likely need intermittent hydration with lasix to optimize forward flow. tte on revealed nl systolic function with ef 55%, increased e:a ratio indicative of diastolic dysfunction, and no lvh. the pts dilt gtt was turned off the following day and was was restarted on dilt 45 mg po tid. her fluid balance was mostly determined by her uo; she received intermittent fluids and lasix. # atrial fultter: while on the floor, the patient developed atrial flutter with variable rate of conduction. her bp was stable the entire time and she was given iv dilt, which converted her. her dilt xr was increased to 180. she needs the lowest heart rate she can tolerated given her distolic dysfunction. . # aspiration: the patient has a known aspiration risk. she has had multiple admission for this inthe past, and the initial insult to prompt this admission was an aspiration event. the team as recommended that she be npo and communicated this to the neice, however, since eating is her main enjoyment, her neice would like her to continue eating. she remains full code. this needs to be addresed by her pcp with the again, since she will likley continue to have recurrent aspiration pneumonias if she continues to eat. medications on admission: --tylenol prn --sq heparin --protonix 40' --dilt hcl 120 sr qd --asa 81 --atorvastatin 10' --cholecalciferol 400 ' --lexapro 10 qd --tums 500 qd --mv --atrovent neb q6hr --lasix 20 mg po qd --trazadone 25 mg qhs prn discharge medications: 1. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. diltiazem hcl 180 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 5. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 6. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po once a day. 7. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 8. tums 500 mg tablet, chewable sig: one (1) tablet, chewable po once a day. 9. multivitamin capsule sig: one (1) cap po daily (daily). 10. atrovent 0.02 % solution sig: one (1) inhalation every six (6) hours: atrovent neb q6 please. 11. lasix 20 mg tablet sig: one (1) tablet po once a day. 12. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 13. lactulose 10 g/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed for constipation. discharge disposition: extended care facility: of discharge diagnosis: aspiration pna mental retardation diastolic dysfunction and heart failure discharge condition: good, 95% on ra. feeding self with help. discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 2l return to the ed if you have o2 sat < 90% or hr > 120 followup instructions: you have an appointment with dr. on wednesday at 8:30am procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube insertion of endotracheal tube diagnoses: acidosis esophageal reflux congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified acute on chronic diastolic heart failure atrial flutter other persistent mental disorders due to conditions classified elsewhere chronic kidney disease, unspecified acute and chronic respiratory failure pneumonitis due to inhalation of food or vomitus osteoporosis, unspecified hyperosmolality and/or hypernatremia mild intellectual disabilities 

Answer: The patient is high likely exposed to