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: capoten attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation, central line, picc line, peg tube placement history of present illness: this is a morbidly obese 53-year-old man with dmii, hypertension, af, and cocaine-induced mi in the past who p/w 3 days of worsening sob. he was recently admitted /08 for chf exacerbation cocaine use. now presents with 3 days of increasing dyspnea at rest and on exertion, pnd, and orthopnea. the patient does not know if his le edema has increased. the patient denies any chest discomfort, cough, fevers or chills but feels like "fluid on the lungs". he does note some abdominal distension after meals but no abdominal pain, n/v/diarrhea. he states that he has been taking all his medications and has actually been taking 120mg po lasix for 2 days prior and then 160mg po bid for 2 days before admission but states that he did not increase his urination. patient notes that he has been eating primarily vegetables and fruits but occasionally eating sardines. adamantly denies using cocaine but positive on tox screen. . ems was called and by report etco2 was 80 but improved to 50s after a neb. in the ed, initial vitals 98.9 128 (af) 164/106 37 88%ra, --->96%cpap. a cxr showed no definite evidence of pulmonary edema but severe cardiomegaly. he was started on bipap, nitro gtt, heparin gtt, given lasix 100mg iv and then another 60mg iv, solumedrol 125mg, levofloxacin, and ceftriaxone to treat multiple causes of dyspnea. lle lenis showed no dvt. cta was not done because of inability to lay flat even with bipap. bnp was elevated at 663. past medical history: history of cocaine-induced myocardial infarction in . , , echocardiogram showed bilateral atrial dilation, severe concentric left ventricular hypertrophy, ejection fraction of greater than 55%, trace mitral regurgitation, diastolic dysfunction. on , a persantine mibi showing a moderate reversible perfusion defect in the anterior and inferolateral walls with an ejection fraction of 23%. on , there was a catheterization that showed normal coronaries and global hypokinesis. pmibi showed mild reversible inferior wall perfusion defect in the presence of considerable soft tissue attenuation, although the calculated left ventricular ejection fraction is 46%, visual observation suggests that the ejection fraction is normal. # congestive heart failure, systolic (most recent ef from pmibi of 46%), diastolic w/ severe lvh # severe pulmonary htn noted on c. cath # gout. # morbid obesity, osa, uses bipap at night # atrial fibrillation, chronically anticoagulated w/ coumadin. # hypertension. # hypercholesterolemia. # sleep apnea on cpap, baseline oxygen requirements of 2-3l # degenerative joint disease. # s/p right ankle fracture in , s/p orif social history: lives in w/ his wife and 2 . on disability, used to be a grocer. denies tobacco use, occasional etoh use, denies illicit drug use. is fairly active and goes out into the community. family history: father and mother alive and in good health. physical exam: vs: 98.4, 120 (af), 148/85, 90% on bipap 12/10 wt: 390lbs up from 340 gen: morbidly obese male, in moderate respiratory distress, aox3 heent: perrl, eomi, mmm, op clear, unable to evaluate jvd to habitus pulm: difficult exam to habitus but no obvious rales/rhonchi/wheezes heard cv: tachy, , no mrgs appreciated abdominal: obese, soft, nt/nd, +bs extremities: 3+ le edema, l>r with bilateral erythema, 1+ dp pulses bilaterally neuro/psych: aox3, strength 5/5 in all extremities. pertinent results: admission labs: wbc-6.7 rbc-4.23* hgb-11.4* hct-38.6* mcv-91 mch-26.9* mchc-29.5* rdw-18.0* plt ct-145* neuts-73.7* bands-0 lymphs-15.5* monos-7.7 eos-2.7 baso-0.4 pt-18.1* ptt-24.0 inr(pt)-1.7* glucose-169* urean-31* creat-1.2 na-139 k-4.7 cl-95* hco3-34* alt-42* ast-77* ck(cpk)-355* alkphos-339* lipase-56 ck-mb-8 ctropnt-0.03* probnp-663* calcium-9.0 phos-5.3* mg-2.1 caltibc-319 vitb12-1015* folate-12.3 hapto-177 ferritn-79 trf-245 lactate-1.2 urine color-yellow appear-clear sp -1.011 urine blood-neg nitrite-neg protein-500 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg urine rbc-0 wbc-0-2 bacteri-occ yeast-none epi-<1 urine bnzodzp-neg barbitr-neg opiates-neg cocaine-pos amphetm-neg mthdone-neg ekg - atrial fibrillation with rapid ventricular response. low qrs voltage in the limb leads. poor r wave progression which is probably a normal variant. lateral st-t wave changes which are non-specific. compared to the previous tracing of rapid ventricular response is new. otherwise, no other significant diagnostic change. ekg - impression: limited study due to poor penetration. severe cardiomegaly with no definite evidence of pulmonary edema. left retrocardiac region was not completely evaluated. underlying pneumonia can not be excluded. bilat le ultrasound - impression: no evidence of dvt in either lower extremity. cxr - findings: as compared to the previous examination, the patient is now intubated. the tip of the endotracheal tube projects 2 cm above the carina and should be pulled back by 1 to 2 cm. the newly placed nasogastric tube shows a normal course, but the tip of the tube is not visible. extensive cardiomegaly that is unchanged as compared to the previous examination, subsequent retrocardiac atelectasis at both the left and the right lung base. nobvious evidence of overhydration. cxr - impression: right subclavian central venous catheter ends in the right atrium. ct abdomen/pelvis - impression: 1. diverticulosis without diverticulitis. 2. no evidence of colitis. 3. small amount of free fluid throughout the abdomen and mild edema within the subcutaneous tissues of the back. 4. small bilateral pleural effusions, with consolidation at the visualized lung bases, likely reflects atelectasis. however, superimposed developing pneumonia cannot be excluded. 5. right adrenal nodule is larger. adrenal ct washout study suggested. result posted in critical readings dashboard. incompletely characterized. bilateral lower extremity veins - impression: no evidence of deep vein thrombosis in either leg. ct sinus/mandible - impression: 1. pansinus opacification as detailed above. 2. opacification of the mastoid ear cells and fluid in the bilateral middle ear cavities. 3. exophthalmos with prominent retrobulbar fat suggesting possible thyroid ophthalmopathy. clinical correlation is recommended. tte - the atria are markedly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the number of aortic valve leaflets cannot be determined. no masses or vegetations are seen on the aortic valve. there is no aortic valve stenosis or regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: no vegetations seen (poor-quality study). normal global biventricular systolic function. in presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. cxr - findings: in comparison with the study of , the central catheter has been removed. endotracheal tube remains in place, with the tip above the level of the clavicles and approximately 5 cm above the carina. unchanged cardiomegaly with widening of the mediastinum that could reflect vascular engorgement. relatively mild prominence of interstitial markings, raising the possibility of cardiomyopathy. probable bilateral pleural effusions without definite pneumonia. the left subclavian catheter extends to the upper portion of the svc. cxr - impression: 1. dobbhoff tube with tip in the stomach. 2. patient is status post tracheostomy. 3. increased width of the mediastinal vascular pedicle, which is may be due to supine patient positioning, however mediastinal hematoma cannot be excluded and would recommend short-term radiographic followup and measurement of the patient's hematocrit. 4. mild pulmonary vascular congestion and bibasilar atelectasis. cxr - impression: 1. tip of right-sided picc catheter cannot be determined and repeat radiograph will need to be performed. 2. marked improvement in bilateral pleural effusions and bilateral pulmonary edema. 3. stable marked cardiomegaly. ekg - atrial fibrillation with a slow ventricular response.. compared to the previous tracing of no change. cxr - impression: right base collapse and/or consolidation, probably with a moderate-sized effusion. increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. no significant change is detected compared with . however, the opacity at the right base is entirely new compared with and the opacity at the left base may be slightly worse. left upper extremity ultrasound - impression: no left upper extremity dvt. brief hospital course: mr. is a morbidly obese 53 year old male with dmii, htn, afib, and a history of a cocaine-induced mi who presented with acute dyspnea and subsequent respiratory failure whose hospital course has been complicated by fevers, c. difficile infection, and difficulty weaning from the ventilator. # respiratory failure: the patient's initial respiratory failure was likely multifactorial due to chf, osa, and morbid obesity in the setting of decompensated heart failure from dietary noncompliance (sardines) and beta adrenergic stimuli secondary to cocaine use. in addition he was volume overloaded on presentation with marked pulmonary edema. all of these factors combined with body positioning (leaning forward) contributed to his acute decompensation that required intubation. as he was diuresed, ventillator settings were gradually able to be weaned. his oxygenation worsened and ventillator settings had to be increased when the patient became ill with a c. diff. infection. on he was empirically started on zosyn for presumed vap due to continued fevers, though sputum cultures never grew any organisms. the patient required high levels of peep to maintain oxygenation, likely due to body habitus. he had a transeosophageal balloon placed to calculate pleural pressures and had an initial peep of 26, which was weaned down over several weeks to 12. the patient had frequent problems with -recruitment and atelectasis following decreases in peep, slowing his wean significantly. following tracheostomy placement on , the patient became hypoxic and peep had to be increased to 20 again. weaning from the vent was once again begun, but the patient acutely decompensated on the morning of and cxr showed opacification of the left lung field. this worsening of his clinical status was thought to be related to aspiration from extensive nose bleeds that he had the night prior. the patient underwent bronchoscopy on and was noted to have mucous plugging in his airways. a sample of washings showed gram positive cocci on gram stain, cultures ended being negative with subsequent cx's negative as well. with increased urine output starting pt improved on vent and able to reduce peep to 5 before discharge. # chf: the patient had a history of a cocaine-induced mi and severe diastolic dysfunction by echo. he was diuresed over 11 liters over 3 weeks using at first a lasix drip and later combined with metolazone. diuresis had to be slowed given worsening renal function and frequent infections also required slowing or suspension of diuresis. pt eventually began to autodiurese with no pharmacologic intervention and improvement in cr and decreased peep requirements. # fevers: the patient developed low-grade fevers and had a positive c.diff toxin on , for which he was first started on iv flagyl, and later placed on po vancomycin as well. the patient had decreased stool output, but abdominal ct scan showed no colitis or ileus. he defervesced, but then began spiking low-grade fevers again. he had purulent nasal discharge, ct of the sinuses showed opacification, and he was placed on unasyn, which was stopped briefly over concern for worsening c.diff colitis. the patient continued to spike fevers, and had 1 bottle on grow coagulase negative staph, which was oxacillin resistant, vancomycin sensitive. on , he had 2/2 bottles growing the same and was started on iv vancomycin and had his central line and arterial line pulled and replaced. neither tip had any bacterial growth on culture. the patient subsequently began having increased thick, tan secretions, and zosyn was started empirically on for vap. sputum gram stain from showed gram positive cocci but grew nothing on culture. the patient's fevers defervesced, but he began spiking fevers again after his tracheostomy was placed. no localizing source could be found. on he underwent bronchoscopy and washings contained 2+ gram positive bacteria, but culture revealed oropharyngeal flora. blood, urine, and subsequnt bronchial/sputum cx's never grew anything. no infectious source was identified. white count remained low in midst of fevers suggesting another source. the etiology of the fevers is unclear, but infectious source was deemed unlikely after multipls attempts during the course of the last two weeks to identify a source. # bleeding: the patient had several episodes of epistaxis, which did not respond completely to oxymetazoline and nasal saline. ent was consulted and cauterized the bleeding site in the right nares. bleeding subsequently resolved until the patient was placed on a trial of anticoagulation with a heparin gtt. prior to admission the patient was on coumadin for afib and this medication was held during his admission. he was started on a heparin gtt to determine if he could tolerate anticoagulation on discharge. he began bleeding from both nares again, and in addition, bled at the insertion sites of his picc and central lines, despite being within the therapeutic range for heparin. the heparin gtt was stopped and the patient was continued on heparin sc 5000 units tid for dvt prophylaxis. he will likely not tolerate anticoagulation for his atrial fibrillation in the near future. # proptosis: per the family, this is a long-standing issue. he had a normal-high tsh, not consistent with . ct imaging showed excess retro-orbital fat. # ischemic cardiomyopathy: the patient has a prior history of an mi and had a positive cocaine tox screen on admission. echo showed diastolic dysfunction, mild pulmonary hypertension and tricuspid regurgitation. the patient is ace allergic, so he did not receive an ace. the patient had diastolic dysfunction with ef 60-70%, so would not benefit from afterload reduction. beta blockade was instituted with labetalol, but was not up-titrated given the patient's fevers, diuresis, and critical illnesses. carvediolol and diovan were added during this admission with good bp control. if blood pressure increases consider adding on diovan. # atrial fibrillation: on metoprolol and coumadin as an outpatient. was briefly on a heparin gtt, but that was stopped secondary to bleeding complications. his chads score is 2 (chf, dm). carvediolol for rate control. hr in 70-90s on average, with intermittent asymptomatic dips to 50s during sleep. # normocytic anemia: chronic issue, with slight downward trend since admission. iron study labs are not conclusive with a low reticulocyte count suggesting a mild production problem. may be mildly iron deficienct with a superimposed elevated ferritin as an acute phase reactant. he did not have any evidence of hemolysis. we did not start iron replacement therapy given his resolving ileus several days prior to discharge. # gout: outpatient allopurinol regimen was continued. pt had knee swelling , had knee tapped and was positive for gout. started on colchicine for 2 week total course - last day is . continue on allupurionol. please ensure both allopurinol and colchicine are renally dosed. # le erythema/edema: consistent with chronic stasis dermatitis secondary to edema and venous insufficiency. improved with aggressive diuresis. no evidence of cellulitis. # agitation: brief periods of agitation causing increased respiratory work as sedation was weaned. considered secondary to pain since he is also tachycardic and goes up in bp during these episodes. methadone used for pain and with weaning of versed and fentanyl with start of seroquel. pt more clear and interactive today. plan is to wean fentanyl and continue seroquel until pt improves. now that pt is improving seroquel was changed to 150 mg tid. as mental status improves seroquel should be weaned further (150 tid on discharge), as well as methadone as tolerated. please check ekgs for length of seroquel course as qtc was found to be prolonged during treatment. # acute renal failure: pt developed arf during hospitalization which responded to fluid boluses during hospitalization. creatinine slowly improved with hydration and renally dosed medications with diuresis and return to baseline at discharge. will need to follow electrolytes with further diuresis. prior to discharge, creatinine was 1.3. # elevated transaminases ?????? slight bump in lfts noted on - no abdominal pain or complaints from pt. likened to the change in seroquel, which in long term will be weaned as pt's mental status continues to improve. # dm: iss with standing glargine - well controlled during hospitalization requiring 92 units of glargine at night with sliding scale starting at 6 units of humalog at fsbg of 151 with increases in 2 units for each increase of 50 points in fsbg. max dose is 14 units iss for 351-400 fsbg. medications on admission: albuterol - qid prn aldactone - 50mg po daily allopurinol - 300 mg po daily betamethasone dipropionate - 0.05 % ointment - apply qd twice a day as needed for qd furosemide - 80 mg po bid lantus 25 units before breakfast humalog 15 units with meals ipratropium bromide - 17 mcg inh lipitor - 20mg po daily metoprolol tartrate - 25 mg po bid pantoprazole 40mg po daily warfarin 10mg po daily aspirin - 325 mg discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. fentanyl citrate (pf) 50 mcg/ml solution sig: 25-100 mcg injection q6h (every 6 hours) as needed for pain. 4. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 5. quetiapine 25 mg tablet sig: two (2) tablet po q6h prn (). 6. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 7. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day). 8. white petrolatum-mineral oil 42.5-56.8 % ointment sig: one (1) appl ophthalmic prn (as needed). 9. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). 10. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 12. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 13. humalog 100 unit/ml cartridge sig: one (1) dose subcutaneous acqhs: per sliding scale, 6 units for 151-200 8 units for 201-250 10 units for 251-300 12 units for 301-350 14 units for 351-400. 14. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily) for 10 days. 15. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q6h (every 6 hours). 16. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 17. methadone 10 mg tablet sig: two (2) tablet po q6h (every 6 hours). 18. acetaminophen 160 mg/5 ml solution sig: 1000 (1000) mg po q6h (every 6 hours) as needed for pain/fever. 19. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4-q6 (). 20. heparin (porcine) 5,000 unit/ml solution sig: one (1) dose injection tid (3 times a day). 21. sodium chloride 0.65 % aerosol, spray sig: three (3) spray nasal tid (3 times a day). 22. nystatin 100,000 unit/ml suspension sig: five (5) ml po tid (3 times a day). 23. insulin glargine 100 unit/ml solution sig: ninety two (92) units subcutaneous at bedtime. 24. seroquel 150mg po tid *please taper slowly and check ekg for length of seroquel course discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses respiratory failure - not ards/ fever, unknown source ams arf diarrhea electrolyte/fluid disorder secondary diagnoses morbid obesity chf pulm htn afib anxiety discharge condition: stable, remains on vent discharge instructions: seek emergent medical care: * if you are vomiting and cannot keep in fluids or your medications. * if you have shaking chills, worsening fevers, increased redness, swelling or discharge from tube or line sites, chest pain, shortness of breath, or anything else that is troubling you. * any serious change in your symptoms, or any new symptoms that concern you. followup instructions: you are scheduled to see dr. on at 1115am. if you cannot make your appointment or need to change your appointment you can reach his office at . md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more other endoscopy of small intestine enteral infusion of concentrated nutritional substances other bronchoscopy arterial catheterization temporary tracheostomy closed [endoscopic] biopsy of bronchus diagnoses: obstructive sleep apnea (adult)(pediatric) anemia, unspecified pure hypercholesterolemia congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified atrial fibrillation acute on chronic diastolic heart failure acute respiratory failure intestinal infection due to clostridium difficile primary pulmonary hypertension morbid obesity fever, unspecified ventilator associated pneumonia epistaxis venous (peripheral) insufficiency, unspecified 

Answer: The patient is high likely exposed to