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, fractures major surgical or invasive procedure: endotracheal intubation peg tube placement, interventional radiology, casting of left wrist picc placement. history of present illness: this is an 89 year old male with a history of copd, hypertension, chronic kidney disease, hypertension and end stage congestive heart failure who was found down in his living days prior to admission. he hit his head but denied history of loss of consciousness. he initially was taken to where ct neck revealed a c2 fracture. he was tranferred to this hospital for further management. in the ed, initial vs were: t: 97.3 p: 130 bp: 124/78 r: 28 o2 sat 100% on nrb. patient was given two liters of normal saline, morhine 2 mg iv x 1, zofran 4 mg iv x 1 and metoprolol 5 mg iv x 1. he was admitted to the tsicu for further management. since arrival to the tsicu he has had an mri which shows a type ii odontoind fracture. he also has had a right forearm xray which revealed distal radial and ulnar styloid fractures which have been casted. he has been in a c-collar throughout. while in the tsicu he has been noted to be inattentive and inconsistent answering questions with periods of frank agitation where he has been combative and refusing care. he has required haldol and zyprexa prn for these symptoms. per discussion with the patient's son, at baseline his speech is interpretable 50% of the time and that he often talks about the past. he was briefly transferred to the floor on . there he was receiving gentle hydration as well as prn zyprexa, haldol and morphine. he was noted to be tachycardic and received significant doses of prn metoprolol although telemetry strips appear to show sinus tachycardiac versus mat. he was initially requiring 35% facemask but this required titration during the day. he was also noted to be increasingly somnolent. of note his lasix has been held since admission and on the day of intubation he received lasix 40 mg iv x 2 without significant increase in his urine output. he was ultimately intubated for hypoxic and hypercarbic respiratory failure. abg at the time of intubation was 7.29/65/85 on a non-rebreather. peri-intubation he was transiently hypotensive and required neosynephrine. he had a non-contrast ct of the test which showed a possible pneumonia versus atelectasis. he was started on vancomycin, cefepime and ciprofloxacin for presumed hospital acquired pneumonia given an isolated fever to 102 degrees. subclavian line was attempted but was unsuccessful and a femoral line was placed for access. he also had an arterial line placed and an ngt to allow for tube feeds. he is now being transferrd to the micu for management of respiratory failure. past medical history: copd - has been on inhalers in the past but is not on currently hypertension stage iii chronic kidney disease (baseline creatinine 1.4-1.6) polyarticular gout - on prednisone 2.5 mg daily congestive heart failure (preserved ef, severe aortic regurgitation, moderate mitral regurgitation) benign prostatic hypertrophy home oxygen requirement (2l) for unclear reasons. notes attributed both to emphysema and congestive heart failure social history: patient currently lives with his wife and his eldest son. uses a walker and/or cane to get around. he occasionally dresses himself, is able to toliet on his own. he cannot before iadls. he does not drink alcohol. he quit smoking 20 years ago but has a 50 pack year history. notes his diet consists of nectar thickened liquids and ground solids. family history: coronary artery disease, hypertension. physical exam: vitals: t: 97.5 bp: 112/33 p: 83 r: 14 o2: 100% (ps 10/5, fio2 50%) general: intubated, sedated, no distress heent: c-collar in place, sclera anicteric, mmm, oropharynx clear neck: supple, bounding carotid pulse, jvp at 10 cm, no lad lungs: coarse breath sounds throughout, trace crackles cv: irregular, normal s1 + s2, ii/iv diastolic murmur at rusb, high pitched ii/vi systolic murmur at apex abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining dark urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, right femoral line in place, left wrist cast in place, right arterial line in place pertinent results: labs on admission: 12:50am blood wbc-14.4*# rbc-3.75* hgb-10.8* hct-33.7* mcv-90 mch-28.7 mchc-32.0 rdw-18.5* plt ct-317 12:50am blood neuts-84.7* lymphs-10.6* monos-4.2 eos-0.4 baso-0.1 12:50am blood pt-13.8* ptt-30.9 inr(pt)-1.2* 12:50am blood glucose-127* urean-25* creat-1.8* na-140 k-3.7 cl-99 hco3-25 angap-20 12:50am blood alt-5 ast-16 ck(cpk)-124 alkphos-92 totbili-0.4 12:50am blood lipase-36 12:50am blood ck-mb-2 12:50am blood albumin-4.0 calcium-9.0 phos-3.8 mg-2.2 03:01am blood caltibc-224* vitb12-807 folate-5.0 hapto-131 ferritn-88 trf-172* labs on discharge: cbc: wbc8.4 hgb8.1* hct26.2* platelets187 potassium on discharge: 4.6 creatinine: 1.1 arterial blood gases: 03:53pm blood po2-47* pco2-58* ph-7.34* caltco2-33* base xs-3 06:36pm blood po2-85 pco2-65* ph-7.29* caltco2-33* base xs-2 09:39pm blood po2-71* pco2-57* ph-7.33* caltco2-31* base xs-1 03:26am blood po2-263* pco2-52* ph-7.40 caltco2-33* base xs-6 11:38am blood po2-133* pco2-58* ph-7.33* caltco2-32* base xs-3 02:15pm blood temp-38.3 fio2-35 po2-74* pco2-51* ph-7.41 caltco2-33* base xs-5 intubat-not intuba 02:10pm blood fio2-35 po2-83* pco2-54* ph-7.45 caltco2-39* base xs-11 intubat-not intuba comment-nebulizer 12:38pm blood po2-67* pco2-52* ph-7.43 caltco2-36* base xs-8 intubat-not intuba 12:38pm blood po2-67* pco2-52* ph-7.43 caltco2-36* base xs-8 intubat-not intuba studies: ct chest/abdomen/pelvis w/contrast : 1. mild atelectasis at the left lung base. 2. cardiomegaly. 3. stable ascending aortic aneurysm measuring up to 5.8 cm. 4. emphysema. 5. diverticulosis. mri c-spine w/o contrast : 1. ill-defined area of heterogeneous signal identified at the odontoid process, the possibility of chronic degenerative changes and an old unhealed fracture are considerations, however, correlation with a dedicated mri of the cervical spine with contrast is recommended for further characterization. 2. multilevel disc degenerative changes throughout the cervical spine as described in detail above. 3. there is no evidence of focal or diffuse abnormalities within the cervical spinal cord. right forearm xray : study is limited due to the overlying cast material. evaluation for subtle fractures cannot be made on these images. however, there is gross alignment of the elbow joint as well as of the distal radioulnar joint. there is again seen innumerable erosions within the carpal bones which appear similar to the prior study of . no fractures of the distal humeral shaft or of the ulnar and radial shafts are identified. if there is high clinical concern for subtle fractures, imaging without the cast may be more helpful. pelvis xray : no evidence of trauma. cardiomegaly. subtle atelectasis at the left lung base. transitional vertebral body. ekg: sinus tachycardia with frequent pacs, first degree av block, no acute st segment changes, no change from prior dated . mri head (): no evidence of acute infarct. moderate-to-severe changes of small vessel disease and moderate brain atrophy. small amount of fluid in both mastoid air cells. right hand (): there are innumerable erosions consistent with the history of gouty arthritis, little changed from . left wrist (): the left distal radial fracture line is still visible, though there is some small amount of adjacent callus formation. overall, the degree of angulation of the fracture fragments is near anatomic, though small impaction persists. a non-united ulnar styloid fragment is also unchanged. there is no new fracture or dislocation. extensive cystic changes and erosions of multiple carpal bones with is also unchanged. abd xray (): no signs of perforation or obstruction. brief hospital course: 1. pt to follow up with orthopaedics re: j collar (needed for wks) and wrist fracture 2. at this time decision was made with family to hold coumadin at this given the patients fall risk. given patients history of atrial fibrillation. the decision to restart coumadin should occur after patient is stabilized and not a fall risk. 3. speech/swallow should reevaluate patient's ability to swallow safely without aspiration in the next one - two months. pt showed improvement while hospitalized. 4. colchicine/prednisone which patient took for gout was stopped while hospitalized given patient was between flairs. these should be restarted as needed. patient discharged on allopurinol. 5. medication for benign prostatic hypertrophy should be restarted after patient's delirium resolves. patient previously on proscar daily and flomax 0.4 qhs. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ 89m h/o severe copd, hypertension, chronic kidney disease, hypertension and end stage chf, originally found down in his living room two days prior to admission, found to have multiple fractires, admitted to micu with hypoxic and hypercarbic respiratory failure, now s/p intubation, intermittent desaturations often relieved with sunctioning. mental status waxing and , continues to improve and is better when family is available to speek in cantonese to patient, patient somewhat conversational in english. # ams: delirium. waxing and mental status but consistently below baseline, with ongoing altered level of sensorium and unclear level of orientation. language barriers contributing to difficulty in assessing, but clear some level of change from baseline. unclear etiology but top of differential includes post-intubation status, intubation meds, infection, other medications, metabolic abnormalities. patient without signs of infection, blood cultures, urine cultures have been negative. chest xray without clear pneumonia. patient at discharge continued to be afebrile. during the hospitalization patient was provided olanzapine for agitation followed by soft restraints and mittens. geriatrics was also consulted and provided recommendations for improving patient's delirium. foley was removed and we attempted to normalize sleep/wake cycle. # anemia: anemia of chronic inflammation and iron deficiency (low iron, low tibc, ferritin normal). occult positive stool on , brbpr (thought to be related to supratherapeutic inr). b12, folate, hemolysis labs normal. trending down since, now ~21. no previous signs of active blood loss. retics 2.7. during his stay an active type and screen was maintained and transfusion goal was set at 21. when peg tube was placed iron was restarted. baseline: - hct ~41 since admission: - hct ~ 26-32 - hct ~ 22-26 ~ 21, inr ~ 4, given 2 units prbc + vit k ~ 27.9, inr = 1.2 - 26.8, inr=1.2 aspiration: very high-risk. swallowing pattern correlates to a functional oral intake scale (fois) rating of 1 out of 7. speech/swallow re-evaluated after pt pulled out ngt but patient still failed. speech/swallow evaluated again per families reguest to determine the effect the neck collar had on swallowing. based on their evaluation the neck collar was not contributing to dysphagia. on video swallow patient did show some improvement however not enough to change from npo. given the chronic nature of this problem peg tube was placed and tube feeds were started. speech/swallow should re evaluate in the future when patient gets closer to his baseline with the hopes of continued improvement and the possibility of removing the peg tube. further during the hospitalization moist spongettes or humidified shovel mask for comfort and q4 oral care was provided. # hyperkalemia: prior to dc to rehab facility patient developed hyperkalemia. thought to be nutrional as it developed after tube feeds were initiated. banana flakes were dc'd from tube feed regimen. potassium 5.5, no ekg changes. pt given kayexalate and potassium eventually resolved. pt continued on ace i at this time given benefit. # respiratory failure: patient required intubation in micu for hypoxic and hypercarbic respiratory failure. multifactorial etiology including underlying copd and co2 retention, possible cap, +/- fluid overload from ivf and cessation of chf medications on admission (including lasix and lisinopril). abg intially showed well-compensated respiratory acidosis, later with acute decompensation. patient now stable on ra - 2l with sats in mid to upper 90s. patient benefits from frequent suctioning. copd: baseline 2l o2 at home but w/unknown sats, h/o co2 retention. he does not take inhalers at home but has been prescribed them in the past. prescribed inhalers in past but not using prior to admission. restarted albuterol and ipratropium nebulizers on admission. pna: history of aspiration, some evidence of small infiltrates versus atelectasis on his ct chest. induced sputem was contaminated. patient treated with eight day course of vanc/zosyn (start date ) for hosptial acquired pneumonia. after completion of course patient has been afebrile, with white blood cell count that continues to trend down. on chest xray concern for aspiration pneumonitis. since that time cxr has been stable with segmental atelectasis. chf: end-stage diastolic chf complicated by severe ar and moderate mr. likely fluid resuscitation as well as withholding of chf meds. lasix held (last dose ) due to rising creatinine, dry exam. during hospitalization creatinine significantly improved and bnp began to increase to 10,000 from 2,000 on admission. lasix was restarted at half home dose and captopril was restarted when patient's peg tube was placed. metoprolol was continued throughout the hospitalization. daily weights and i/0s were followed daily. # ckd: baseline since ~1.5, 1.8 on admission. has fluctuated while hospitalized however has remained stable at 0.9 prior to discharge. while renal function was fluctuating renal toxic medications were held. on improvement of renal function meds were reinitiated. meds were renally dosed. fluctuation in renal function was thought to be secondary to fluctuations in volume status. # thrombocytosis: platelet count rose to ~750 and is now trending down. likely just reactive, also could be iron deficiency. thrombocytosis resolved without intervention. # af w/rvr: rate and rythm controlled on beta-blockade. hr 90-120s in icu, now rate controlled on metoprolol. pt receiving subq heparin. per discussion with family/attending decision was made to hold coumadin at this time given the fall risk. # htn: controlled on metoprolol, captopril. # right wrist fracture: s/p reduction and splinting. no plan for operative intervention. will follow up with orthopaedics. # dens fracture: type ii dens fracture. non-operative. currently in j collar. per discussions with spine service this fracture is new, and accordingly he should continue to wear the collar for the next 8 weeks. patient should follow up with orthopaedics for further evaluation. # gout: at discharge prednisone/colchicine held given patient does not appear to have a current gout flair. patient discharged on allopurinol. # benign prostatic hypertrophy: held while inpatient. medications should be restarted after patients mental status improves. # goals of care: family meeting : -- at this time patient is full code. pt is the elder of the family and when the patient is clear has told family that he would like everything done. discussion of code status has continued. medications on admission: lopressor 25 lisinopril 5 daily lasix 60 prednisone 2.5 mg daily allopurinol 300 iron 65 proscar daily flomax 0.4 qhs discharge medications: 1. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours). 2. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours). 6. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po tid (3 times a day) as needed for agitation: please monitor qtc daily when using medication. 7. furosemide 40 mg tablet sig: 1.5 tablets po daily (daily). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po qid (4 times a day). 9. captopril 12.5 mg tablet sig: one (1) tablet po tid (3 times a day). 10. allopurinol 300 mg tablet sig: one (1) tablet po bid (2 times a day). 11. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 12. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 13. pantoprazole 40 mg iv q24h 14. heparin 5,000 units sub cutaneous three times daily, for dvt prophylaxis 15. captopril 12.5 mg tablet sig: one (1) tablet po three times a day. 16. insulin sliding scale please refer to provided scale. discharge disposition: extended care facility: at medical center discharge diagnosis: primary: 1. respiratory failure 2. aspiration pneumonitis 3. type ii dens fracture and non-displaced right wrist lunate and distal radius fracture 4. congestive heart failure 5. acute on chronic renal failure 6. lower gi bleed 7. anemia 8. copd 9. delirium: multifactorial discharge condition: hemodynamically stable, afebrile, mental status waxing/ discharge instructions: dear mr. , it was a pleasure participating in your care during your admission to . you were originally admitted for fractures after falling down at home. you then developed respiratory failure which required intubation. when your respiratory status improved you were transfered out of the icu and were continued to be medically stabilized and treated for a hospital acquired pneumonia. because you had difficulty swallowing with high risk of aspiration a peg tube was placed so you could receive tube feeds. after intubation you also developed a delirium that has waxed and waned. we have changed several of your medications. please take all of your medications exactly as prescribed. please see list provided for these changes. please call your physician or come to the hospital if you experience any of the following new pains that are not controlled with your usual pain regimen, chest pain, shortness of breath, fevers, chills, changes in your vision, weakness or numbess in your extremities, or slurring of your speech. followup instructions: pcp: . please follow up with your primary care physician in the next 2-4 weeks. md: dr. specialty: orthopedics date and time: , at 11:00am location: , bldg , , ma phone number: special instructions if applicable: please arrive at 11:00am for x-rays and then you will see dr. at 11:20am. rheumatology: , md phone: date/time: 10:30 md, procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] closed reduction of fracture without internal fixation, radius and ulna injection of therapeutic substance into joint or ligament diagnoses: pneumonia, organism unspecified congestive heart failure, unspecified toxic encephalopathy long-term (current) use of steroids acute posthemorrhagic anemia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation obstructive chronic bronchitis with (acute) exacerbation acute on chronic diastolic heart failure personal history of tobacco use mitral valve insufficiency and aortic valve insufficiency hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) chronic kidney disease, stage iii (moderate) other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure closed fracture of second cervical vertebra other complications due to other vascular device, implant, and graft hemorrhage of gastrointestinal tract, unspecified hyperosmolality and/or hypernatremia accidents occurring in residential institution fall from other slipping, tripping, or stumbling mixed acid-base balance disorder other dependence on machines, supplemental oxygen closed fracture of lower end of radius with ulna essential thrombocythemia 

Answer: The patient is high likely exposed to