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: 76 year-old male with history of severe copd requiring intubation, trach, and multiple hospitalizations in the past. on day of admission, he knew "something wasn't right." he felt chills and began having shortness of breath. he used his inhalers (advair and combivent), without relief. he called 911 and was brought in the the ed by ems. he said he knew he had a pneumonia, because his symptoms were so similar to his previous admissions. he denied sick contacts, but uses public transportation. he denied having a cough, chest pain, or gu/gi symptoms. at his baseline he uses combivent 4 times a day and advair twice a day. he does not have oxygen at home. he can walk approximately blocks. in , he was admitted to other hospitals for 4 exacerbations. twice he was told he had viral colds. the most recent admissions he was also diagnosed with pneumonia. last admission . past medical history: copd severe pneumonias in the past requiring intubation and trach (both in ) bilateral pneumonia no cardiac/gi/renal history no history of diabetes social history: lives alone in , never married. grew up in and visits family there once a week. was in the marine corps for 8 years. has also lived in and . worked in insurance and at department stores. has been retired for over 20 years. tobacco: >40 pack history, quit in alcohol: none physical exam: admission physical exam: vitals: t103.1 hr140 bp168/80 gen: well appearing, pleasant male lying in bed, intubated. heent: anicteric, op clear, eomi cv: reg rate, s1 s2 no m/r/g lung: intermittent expiratory wheezes, diminished airmvt bilat. abd: soft, nt/nd, +bs ext: no c/c/e, +2 pulses. pertinent results: admission labs: chem 7: glucose-143 urea n-34 creat-1.2 sodium-145 potassium-5.0 chloride-105 total co2-26 anion gap-19 cbc: wbc-11.2 hgb-13.0 hct-39.7 plt-170 diff: n80 bands6 l8 m4 e1 11:30 pm ck 221 ck-mb 4 tropt 0.02 5:02 am ck 279 ck-mb 7 tropt 0.02 6:25 am ck 96 tropt <0.01 5:45 pm ck 93 tropt <0.01 abg (): po2:63 pco2:47 ph:7.38 ecg : sinus tachycardia, conduction defect of rbbb type inferior/lateral st-t changes may be due to myocardial ischemia since previous tracing, inferolateral st-t wave changes ecg : sinus tachycardia, right bundle branch block diffuse st-t wave abnormalities - are in part primary and cannot exclude in part ischemia. since previous tracing of same date, no significant change. ecg :sinus tachycardia. right bundle branch block. diffuse st-t wave abnormalities - are in in part primary and cannot exclude in part ischemia. since previous tracing of , no significant change. admission cxr: the heart, mediastinum, and pulmonary vessels are within normal limits. emphasematous changes are present in the lungs. there is an interstitial opacity in the left lower lobe, which appears nonspecific and, in an appropriate clinical setting, may represent pneumonia. cxr : 1) slight improvement in left lower lobe opacity, likely improving pneumonia. 2) continued cardiac failure, with cardiomegaly, increased pulmonary vascular markings, and bilateral small pleural effusions. cxr: radiology final report chest (pa & lat) 9:14 am chest (pa & lat) reason: eval for worsening failure, lll pna medical condition: 76 year old man with history of copd, lll pneumonia, now increased oxygen requirement from previous reason for this examination: eval for worsening failure, lll pna indication: followup pneumonia. there are changes of emphysema with bullous disease in the upper lobes. the heart is normal in size. the infiltrate posteriorly appears somewhat improved since . mediastinal contours are normal. there is no effusion or bone destruction. impression: emphysema with improvement in the appearance of the chest over the past three days. radiology final report cta chest w&w/o c &recons 2:46 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast reason: evaluate for pe contrast: optiray medical condition: 76 year old man with copd, resolving pneumonia, continues to have persistent tachycardia and hypoxia reason for this examination: evaluate for pe contraindications for iv contrast: none. indication: copd and resolving pneumonia. persistent tachycardia and hypoxia. assess for pe. comparison: chest x-ray of . technique: ct angiogram of the chest before and after the administration of optiray nonionic contrast due to fast bolus technique. multiplanar reformatted images were obtained. ct angiogram of the chest: there is no sign of filling defect within the pulmonary arteries to suggest pulmonary embolism. there is a high-grade stenosis within the left subclavian artery. there is diffuse severe emphysema bilaterally. focal areas of consolidation are noted on the right, some of which are slightly mass like. attention to these areas on followup is recommended after treatment. there is no pleural or pericardial effusion. there is a small pericardial effusion. there is no axillary lymphadenopathy. a small upper mediastinal node measuring 7 mm in greatest short axis dimension is noted. there are dense calcifications within the aortic arch and within the coronary arteries. small left hilar lymph nodes are also seen. limited images of the upper abdomen demonstrate dense calcifications within the aorta and branches. no other gross abnormality is appreciated. bone windows: there are degenerative changes within the spine including a thoracic kyphosis. impression: 1) no evidence of pulmonary embolism. 2) diffuse emphysema. right-sided consolidation consistent with pneumonia. follow up chest ct in 6 weeks after treatment is recommended to ensure that these changes resolve. attention should be paid to several more nodular opacities on the right. 3) 8-mm anterior superior mediastinal node as well as small lymph nodes in the left hilum. attention to these regions on followup is recommended. 4) high-grade stenosis of the left proximal subclavian artery. clinically correlate. brief hospital course: mr. is a 76 year-old male with a history of severe copd requiring intubation, trach and multiple hospitalizations in the past. on the day of admission, he called 911 and was brought in to the ed by ems for increased dyspnea. he became febrile earlier that day with chills. he denied gi/gu symptoms, cough and chest pain. he was given albuterol and atrovent nebs in the ambulance without improvment. in the ed he was found febrile to 103.1 and tachycardiac. his rr was in the 40's, with o2 sats in the low 80's. he was intubated for acute respiratory distress. his wbc count was 11.2, with 80% neutrophils and 6 bands. a cxr revealed a lll opacity. he received levofloxacin and iv steroids for copd exacerbation. enzymes revealed a troponin leak, though ecg in the ed showed only tachycardia and rbbb. he was then admitted to the micu. vancomycin was added for mrsa coverage, given history of hospitalizations at va with mrsa. he was weaned and extubated on and transferred to the floor . once extubated, levofloxacin and vancomycin were continued. he was on scheduled albuterol and ipratropium nebulizer treatments every 4-6 hours and he continued to use his home advair inhaler. he was switched from iv steroids to 60mg of prednisone. on he continued to have tachycardia. subsequent ecg's revealed inferior-lateral st changes. two sets of enzymes were negative, and his ecg changes were attributed to demand phenomenon in the setting of hypoxia and tachycardia. the patient had no chest pain, other clinical symptoms or signs of ischemia. repeat chest xray revealed lll opacity, pleural effusions and signs of pulmonary edema and left heart failure. he was diuresed with 10 mg of furosemide to improve his pulmonary status. patient denied orthopnea, did not have lower extremity edema, and follow-up chest x-rays continued to show improvement, as the patient auto-diuresed. issues upon transfer to the floor: 1.)lll pna: this continued to show radiographic and symptomatic improvement on levofloxacin (10 day course) . his wbc trended down, and he remained afebrile. vancomycin was stopped after four days as it use was not supported by cultures. this was felt to be the main exacerbant of his copd flair. 2.) sob/copd: this was treated by addressing both the likely exacerbant, his pneumonia, as well as the underlying pulmonary disease. this latter approach included scheduled albuterol and ipratropium nebs (hope to eventually transitioned to mdi's), a twice daily fluticasone/salmeterol inhaler, and a prednisone taper. mr. unfortunately responded relatively slowly to this treatment, following a gradual waxing and course of both symptoms and oxygen saturations. given his slow improvement and low oxygen sats there was some concern for a pe and a cta was obtained.in addition, patient received fluids in the micu, and chest x-ray at that time was consistent with heart failure, however patient diuresed well on his own with improvement. however, since then he remained quite sob and was low 90s on five liters nc, a cta was done- no evidence of pe. please see the results section. patient now being transfered to hospital and we recommend a pulmonary consult (patient transfered prior to consult being obtained- if pulmonary is able to see the patient prior to dc - we will attach their recommendation). patient will likely need a repeat ct in weeks to look for resolution of changes associated with pneumonia. his prednisone was increased back to 40 mg qd given his persistent hypoxemia and will need a slow taper. 3.)elevated cardiac enzymes: mr. has no known history of cad, with no prior anginal symptoms. he had minimally elevated troponin-t (0.02) with a ck of 279 and 221 on two separate values when first admitted that subsequently trended down to <0.01 (with normal ck's), where they remained. this was felt to be secondary to his copd flair; the resultant hypoxia and tachycardia may have induced a moderate degree of demand ischemia. he also had inverted t-waves and st-depression laterally that similarly improved with his symptoms. 4.)anemia -- his hematocrit remained low but stable throughout the admission. iron studies were checked that demonstrated an anemia of chronic disease. b12 and folate were both normal. his hct remained stable. 5.)anxiety -- mr. appears to have some baseline anxiety that was certainly made worse by his marked dyspnea. to help alleviate this in the acute period, he was started on clonazepam 0.25mg twice daily with good effect. 6) c. diff- upon transfer to floor, patient had some diarrhea and tested positive for c. diff, this was treated with flagyl for a 14 day course. medications on admission: ipratropium/albuterol (combivent) mdi 18mcg/90mcg 2 puffs four times daily fluticasone/salmeterol (advair) dpi 1 puff twice daily discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) puff inhalation (2 times a day). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q4h (every 4 hours) as needed. 5. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 6. heparin sodium (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection q8h (every 8 hours). 7. clonazepam 0.5 mg tablet sig: 0.5 tablet po bid (2 times a day). discharge disposition: extended care discharge diagnosis: chronic obstructive pulmonary disease exacerbation pneumonia secondary: chronic obstructive pulmonary disease with history of intubations in past discharge condition: fair, with improved o2 saturation and decreased work of breathing, patient being transfered to va for further evaluation discharge instructions: please call your pcp or return to the emergency department for worsening shortness of breath, chest pain, lightheadedness, worsening cough, fevers/chills or other concerning symptoms. take all medications as prescribed. follow-up as below. followup instructions: please see your primary care doctor in one week; you will need to call to make an appointment. please follow-up with a pulmonologist. your primary care doctor can arrange this for you. you will likely need a repeat chest ct in weeks patient is being tranfered to va for further evaluation procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube fiber-optic bronchoscopy diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified anemia of other chronic disease congestive heart failure, unspecified obstructive chronic bronchitis with (acute) exacerbation acute respiratory failure intestinal infection due to clostridium difficile acute diastolic heart failure 

Answer: The patient is high likely exposed to