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: ambien attending: chief complaint: shortness of breath major surgical or invasive procedure: none history of present illness: is a 67 yo male with severe copd, s/p recent hospitalization for copd exacerbation and atypical pneumonia in , cancer of the layrnx who presents with shortness of breath and productive cough. the patient finished his prednisone taper approximately 1 week ago. his wife reports that his breathing worsened as the steroids were tapered but that it has been much worse since the steroids were off 1 week ago. when his breathing is at it's best, he is able to do some household chores and walk across the room. however, for the past few days he has not been able to get out of his chair. he has a chronic cough with white/ sputum at baseline, but the sputum turned green approximately 3 days ago. he was started on azithromycin and levofloxacin approximately 2 days ago without improvement in his symtoms. he denies fevers and rigors, but reports feeling chilled and sweaty. he does not feel like he has a cold or flu. he reports increased wheezing. his wife reports poor po intake and increased confusion, which is typical of his copd exacerbation. patient's steroids were increased around and then quickly tapered. of note, pt takes bactrim for pjp ppx while on steroids. in the ed, initial vs were: t 98.2 hr 95 bp 151/67 rr 28 o2sat: 90% 4l. he was tachypneic, wheezy on exam and with poor airflow. cxr was negative for infiltrates. his ekg was unchanged. he was hypoxic to 88% on 4l so was placed on non-invasive ventilation with improvemetn in o2 sats to 94-95%. patient was given ipratropium bromide & albuterol nebs, methylprednisolone sodium succ 125mg iv x1, and levofloxacin 750mg iv x1. vs prior to transfer were af 92 133/53 25 95% cpap: fio2 .35 peep 8. in the icu, patient is no longer on non-invasive ventillation. past medical history: - copd, on 4l home o2, followed by dr. . pt uses cpap at night and has done so for a long time possibly for osa vs night time ventilatory support for copd. - newly diagnosed t1 larynx cancer - 8 prostate adenocarcinoma - depression - h/o pyloric stenosis - memory loss: no formal diagnosis of dementia social history: patient lives with his wife. 2 grown children. reports 4 pack per day times 35 years. quit in . served in ; history of exposure. no current alcohol consumption. denies any other illicit drug use. family history: brother died of emphysema, also was a smoker physical exam: general: alert, pursed-lip breathing, but not tachypneic. heent: ncat, perrla, eomi, sclera anicteric, dry mm, oropharynx clear neck: supple, jvp 5cm, no lad lungs: poor airflow, no wheezes, rales, rhonchi cv: distant heart sounds, regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: + epigastric scar,soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley rectal: nl tone, guiaic + stool. ext: warm, well perfused, 2+ radial, dp & pt pulses, no clubbing, cyanosis or edema neuro: a&ox2 (person & place only), strenght in ue & le bilat, sensation grossly intact. pertinent results: 06:00am wbc-7.3 rbc-3.99* hgb-10.9* hct-37.7* mcv-95 mch-27.2 mchc-28.8* rdw-15.1 06:00am neuts-93.7* lymphs-4.8* monos-1.2* eos-0.3 basos-0.1 06:00am plt count-135* 06:00am pt-10.9 ptt-26.7 inr(pt)-0.9 06:00am caltibc-295 vit b12-272 folate-13.8 ferritin-372 trf-227 06:00am iron-54 06:00am glucose-201* urea n-21* creat-0.6 sodium-147* potassium-5.1 chloride-96 total co2-47* anion gap-9 06:04am lactate-2.7* 06:19am type-art po2-162* pco2-67* ph-7.36 total co2-39* base xs-9 comments-green top 01:18pm lactate-2.4* 03:04pm fibrinoge-763* 03:21pm lactate-1.3 03:21pm type-art po2-77* pco2-82* ph-7.36 total co2-48* base xs-16 07:46pm lactate-0.8 07:46pm type-art po2-59* pco2-79* ph-7.38 total co2-49* base xs-16 echo : the left atrium is mildly dilated. the right atrium is moderately dilated. a right-to-left shunt across the interatrial septum is seen during valsalva maneuver release (bubble study). right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: right-to-left shunt at atrial level (note that neither the size, nor the predominant directionality, nor the anatomic classification of the atrail shunt can be determined on thre basis of a positive bubble study; however, this most likely represents either a patent foramen ovale or a small secundum type atrial septal defect) cxr : impression: no evidence of pneumonia. ct chest impression: 1. resolution of left lower lobe pulmonary nodule, consistent with infectious or inflammatory etiology. 2. new patchy consolidations involving the left upper lobe and lingula, consistent with bronchopneumonia. 3. severe emphysema and diffuse bronchial wall thickening. 4. right renal cystic structure, incompletely characterized. if clinically warranted, ultrasound on a non-emergent basis could be considered. brief hospital course: 67 y/o male with a pmhx significant for severe copd on 4l of home oxygen, who presented with worsening shortness of breath and productive cough. # dyspnea: likely related to copd exacerbation. he has gold stage iv copd. there was a question of an underlying pneumonia based on ct findings; however, he was not noted to have fevers or a leukocytosis. he was placed on bipap overnight and tolerated this well. he was transitioned back to nc on th emorning following admission. of note, echo showed evidence of r-to-l shunt, which could be contributing to hypoxemia. he was placed on ipratropium and albuterol nevs. his dose of advair was increased. he was also started on prednisone. given concern for possible infection, cefepime was started. he was also continued on his previously-started 5-day course of azithromycin. he completed the 5-day course of azithro and cefepime was discontinued on as there was low suspicion for infection. pulmonary recommended the following: - consider switching to bipap 14/10 qhs. - continue high-dose advair (500/50) on discharge. - slow prednisone taper on discharge with prompt outpatient pulmonary clinic follow-up within 1 month while still on taper. - outpatient sleep study as soon as possible following discharge. - follow up in sleep clinic following sleep study to titrate nippv settings. the patient may benefit from bipap. he will discuss with primary pulmonologist or at sleep clinic appointment to get bipap approved for home use. it would be more for ventilatory failure rather than osa. in the meantime, he will continue with cpap. # hypernatremia: on admission, it was felt that this was hypovolemic hyponatremia in the setting of poor po intake. given ivfs overnight and sodium was improved this morning. # anemia: hematocrit noted to drift down during the first day of admission. guiaic positive on exam. fe studies c/w borderline acd. hematocrit was stable. # thrombocytopenia: plt count trended down following admission, and were also noted to be down from recent baseline. thrombocytopenia could possibly be secondary to ppi. coags wnl. was placed on ranitidine. thrombocytopenia improved in the end. # memory difficulties/delirium: the patient was a&ox2 on admission. the etiology is liekly multifactorial from a combination of hypoxemia, hypercapnia, hypernatremia, and chronic dementia. he was continued on aricept and an outpatient mri of his brain should be considered. mental status improved on the morning following admission. # t1 larynx cancer: patient is status post radiation therapy. there was concern about possible metastatic disease on last chest ct. repeat chest ct did not show evidence of metastatic disease # 8 prostate adenocarcinoma: patient reports worsening urinary symptoms, increased avodart as outpatient. continue avodart at 1mg po daily # depression: continue prozac. medications on admission: 1. fluticasone-salmeterol 250-50 mcg/dose disk 1 inhalation 2. donepezil 10mg po am 3. avodart 1 mg po once a day. 4. with handihaler 18 mcg capsule, inhalation once a day. 5. fluoxetine 40 mg capsule po daily 6. ipratropium bromide 0.02 % 1 inhalation q6h 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) 1 neb q6h prn 8. omeprazole 20 mg capsule, 2 tabs po daily 9. albuterol sulfate 90 mcg/actuation hfa 1-2 puffs qid prn wheezing. 11. levofloxacin 500mg po daily for past 2 days 12. azithromycin 500mg po x1 day, now 250mg po daily discharge medications: 1. prednisone 10 mg tablet sig: taper po for 4 weeks: take 40mg daily for 7 days; then 30mg daily for 7 days; then 20mg daily for 7 days, then 10mg daily until otherwise advised by your pulmonologist. disp:*70 tablet(s)* refills:*0* 2. avodart 0.5 mg capsule sig: two (2) capsule po daily (). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) unit dose inhalation q6h (every 6 hours). 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) unit dose inhalation q2h (every 2 hours) as needed for sob, wheeze. 5. fluoxetine 20 mg capsule sig: two (2) capsule po daily (daily). 6. donepezil 5 mg tablet sig: two (2) tablet po daily (daily). 7. ipratropium bromide 0.02 % solution sig: one (1) unit dose inhalation q6h (every 6 hours). 8. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). disp:*1 disk with device(s)* refills:*2* 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po once a day. discharge disposition: home with service facility: discharge diagnosis: primary diagnoses: - acute exacerbation of severe chronic obstructive pulmonary disease - anemia, hct stable - guaiac-positive stools - thrombocytopenia, resolved, possibly ppi secondary diagnoses: - larynx cancer - prostate adenocarcinoma - depression - history of pyloric stenosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted for evaluation and management of an exacerbation of your copd. your symptoms seemed to have flared after you finished your taper of steroids. initially, you had some episodes of confusion likely from your ventilatory status being so poor. you were restarted again on prednisone and gradually improved over the last several days with regard to your mental status, ambulatory status, and breathing ability. pulmonology consultation recommends a more formal assessment of your need for postitive pressure ventilation (i.e., cpap or bipap). a sleep clinic appointment has been arranged to assess these needs. rehabilitation may be very helpful for your condition. medication changes: 1. start prednisone taper: 40mg daily for week 1, then 30mg daily for week 2, then 20mg daily for week 3, then 10mg indefinitely until advised otherwise by your pulmonologist. 2. increase dose advair 500/50 one inhalation twice daily (previously 250/50 twice daily) 2. stop levofloxacin and azithromycin 3. if using ipratropium nebulizer treatments, there is no need to use your inhaler named . 4. if using albuterol nebulizer treatments, there is no need to use your inhaler for albuterol. 4. otherwise, there were no other changes made to your medication regimen. followup instructions: department: pulmonary function lab when: wednesday at 2:40 pm with: pulmonary function lab building: campus: east best parking: garage department: pft when: wednesday at 3:00 pm department: medical specialties when: wednesday at 3:00 pm with: dr. & dr. building: sc clinical ctr campus: east best parking: garage department: sleep when: thursday at 11:00 am with: dr. building: sc clinical ctr campus: east best parking: garage procedure: non-invasive mechanical ventilation diagnoses: thrombocytopenia, unspecified obstructive sleep apnea (adult)(pediatric) anemia, unspecified hyposmolality and/or hyponatremia personal history of malignant neoplasm of prostate obstructive chronic bronchitis with (acute) exacerbation depressive disorder, not elsewhere classified acute respiratory failure blood in stool delirium due to conditions classified elsewhere personal history of malignant neoplasm of larynx 

Answer: The patient is high likely exposed to