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: respiratory distress major surgical or invasive procedure: intubation double lumen intubation arterial line placement picc line placement right subclavian central line placement skin biopsy bronchoscopy history of present illness: mr. is a 70m with hiv (cd4 350 in ), scc s/p rll lobectomy complicated by bronchopleural fistula treated with window, as well as empyema and invasive aspergillosis on outpatient voriconazole referred from for fever and hypoxemia. per v/s sheets from on had t100.6 o2sat 82%ra. v/s on 98.7 116 86/58 89%ra. referred to ed. en route, fsg 57 rec'd amp d50. in the ed, triage v/s 98.5 118 103/67 24 81%ra 93%15lnrb. cxr showed l-sided pna most pronounced in lul. cta showed no pe but ggo w/ septal thickening in rml, lul, lll. abg on nrb 7.40/26/60. given ns 1l, levo 750 iv, bactrim ds 2 tab, prednisone 60 mg. . upon arrival to micu, complains of dyspnea with minimal exertion, nonproductive cough, and chills. no fever, chest pain, palpitations, hemoptysis, abdominal pain, nausea, diarrhea, abd pain or rash. past medical history: pmh: -history of multivessel cad s/p pci of the proximal left circumflex with a bare metal stent w/ dr. ( hospital) -hiv-infection, diagnosed in , well-controlled. currently on truvada and raltegravir. last reported cd4 count 354 (), viral load <48 copies. pt states that his vl has always been undetectable -chronic lv dysfunction last ef 55% -severe migratory polyarthritis, on prolonged high-dose steroid use for presumed "adrenal insufficiency" -moderate mr -herpes labialis -tmj -b/l inguinal hernia repair -scc s/p rll lobectomy complicated by bronchopleural fistula treated with window, as well as empyema and invasive aspergillosis social history: currently residing in rehabilitation. the patient is not married and lives alone. he has a history of 150 pack-year, stopped smoking in . he does not drink alcohol. hiv sexually transmitted. family history: his mother had previous cva/stroke. physical exam: vitals: t 97.1 bp 94/48 hr 109 rr 19 o2 89%nrb general: respirations nonlabored, speaks in full sentences heent: sclera anicteric, dry mm, poor dentition, left > right pupil (stable) neck: no jvd lungs: lll rhonchi and coarse rales; r-sided chest dressing c/d/i cv: reg rate tachy nl s1s2 no m/r/g abdomen: soft ntnd normoactive bs diffuse ecchymoses ext: warm, dry +pp no edema pertinent results: admission labs: . 08:14pm glucose-95 urea n-8 creat-0.6 sodium-127* potassium-4.5 chloride-96 total co2-22 anion gap-14 08:14pm calcium-8.1* phosphate-2.5* magnesium-1.7 04:23pm urine osmolal-280 12:19pm type-art po2-60* pco2-26* ph-7.40 total co2-17* base xs--6 12:19pm glucose-97 11:15am urine color-yellow appear-clear sp -1.008 11:15am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-150 bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 10:31am lactate-1.4 10:30am glucose-112* urea n-10 creat-0.7 sodium-125* potassium-4.5 chloride-90* total co2-18* anion gap-22* 10:30am alt(sgpt)-51* ast(sgot)-46* alk phos-88 tot bili-0.2 10:30am ctropnt-0.01 10:30am probnp-1627* 10:30am tot prot-5.7* albumin-3.3* globulin-2.4 10:30am osmolal-252* 10:30am asa-neg acetmnphn-neg 10:30am wbc-12.3* rbc-4.30* hgb-11.2* hct-33.4* mcv-78* mch-26.1* mchc-33.6 rdw-15.8* 10:30am neuts-84.9* lymphs-13.0* monos-1.5* eos-0.4 basos-0.2 10:30am plt count-344 10:30am pt-13.9* ptt-36.7* inr(pt)-1.2* . micro: . hiv-1 viral load: undetectable . imaging: . cta chest: 1. ground-glass airspace opacity involving the majority of the left lung and also within the right middle lobe concerning for pcp . please note other etiologic considerations include atypical pneumonia, hypersensitivity pneumonitis. 2. status post right lower lobe resection with open window thoracoplasty changes and packing material in the right pleural space. 3. no evidence of pulmonary embolism. stable small filling defect within the right lower lobe pulmonary artery is compatible with chronic thrombus related to right lower lobe resection. 4. extensive left coronary artery calcification. 5. prominent but stable mediastinal lymph nodes. 6. multiple thoracic spine compression fractures, with a new t5 compression. 7. hypodense lesion in segment vii of the liver, incompletely characterized though appears new. consider mr for further evaluation. 8. nodular contour of the liver. recommend clinical correlation for cirrhosis. . echo: the left atrium is normal in size. there is moderate symmetric left ventricular hypertrophy. overall left ventricular systolic function is low normal (lvef 50-55%). doppler parameters are most consistent with grade iii/iv (severe) left ventricular diastolic dysfunction. right ventricular chamber size and free wall motion are normal. the right ventricular free wall is hypertrophied. with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. compared with the prior study (images reviewed) of , the heart rate is now higher so there is less time for lv relaxation. . path: 1. skin, abdomen, biopsy: - discrete inflamed scale crust overlying hair follicle consistent with resolving folliculitis (see note). - dermal hemorrhage. note: pas-d and gram stains are negative for fungal and bacterial organisms respectively. there is dermal hemorrhage, however, no significant dermal inflammation or vasculitis is observed. 2. skin, right shin, biopsy (b): diffuse dermal hemorrhage consistent with ecchymosis (see note). note: there is dermal hemorrhage, however, no significant dermal inflammation or vasculitis is observed. . bal cytology: atypical. rare group of atypical epithelioid and squamous cells. numerous neutrophils and pulmonary macrophages. . brief hospital course: 70m with hiv (undetectable vl), inflammatory arthritis on chronic steroid therapy, scc s/p rll lobectomy complicated by bronchopleural fistula treated with window, as well as empyema and invasive aspergillosis on outpatient voriconazole admitted with hypoxemic respiratory failure and septic shock from pneumonia. . # hypoxemic respiratory failure: patient presented with hypoxemic respiratory failure. he required intubation on . due to right sided air leak and dense disease on left lung it was difficult to ventilate the patient with a single endotracheal tube. he was switched to a double lumen endotracheal tube on that was much better tolerated. history, exam, and imaging were suggestive of infectious etiology. multiple blood and sputum cultures were obtained without definitive results. due to the severity of his illness and his compromised immune status and risk for infection(hiv, chronic steroid use, malnutrition, and extended hospitalizations) he was treated broadly for hcap with a 14 day course ending of as well as a 21 day course of therapeutic bactrim and steroids for pcp. infectious symptoms (fevers, tachycardia, hypoxia) improved and he was extubated on . he had significant difficulty managing his airway due to increased secretions and had repeated episodes of hypoxia from mucus plugging. he elected to undergo tracheostomy and peg placement to improve comfort. after tracheostomy fever and increased sputum returned. cultures again were negative and patient was started on another 7 day course of hcap treatment (cefepime, cipro, vancomycin with last dose on ). with initiation of antibiotics fevers resolved. at time of discharge patient was tolerating trach mask for the majority of the day and required ventilator during the night. recommend completing 7 day course for presumed health care associated pneumonia. continue weaning patient on ventilator and encourage use of valve for communication. . #hypotension: patient presented with septic shock physiology. on arrival to the icu he had persistently low blood pressures, tachycardia, and low urine output despite agressive volume resuscitation in the setting of active lung infection. after initial treatment of infection subsequent hypotension was thought to be multifactorial including medication induced vasodilation (versed, propofol), overdiuresis, relative adrenal insufficiency and diastolic heart failure. on day of discharge patient maintained systolic blood pressures 90-100s and maps of 60-75. of note, noninvasive blood pressure readings were found to be consistently 10 points below arterial line blood pressure readings. . #sinus tachycardia: patient with persistent tachycardia throughout most of admission. tachycardia was believed to be multifactorial due to intravascular depletion, fever, infection, pain, hypoxia, pressors, and withdrawal of sedation. with resolution of infection and management of oral secretions his rate fell to 90-110s. he was ultimately started on metoprolol to improve cardiac output given his diastolic heart failure. recommend continuing to titrate up metoprolol as blood pressure will tolerate. at time of discharge patient is maintaining hrs of 90s with noninvasive systolic blood pressure readings of 90s-100s with metoprolol 37.5 mg po tid. . # invasive aspergillosis: patient was continued on outpatient regimen of voriconazole until . recommend patient follows up with his outpatient id physician . after discharge from rehab. . # liver lesion/nodularity: incidental finding on admission imaging. recommend outpatient mrcp vs ultrasound to better assess liver lesions. . # bp fistula: no evidence of infection during hospitalization. dressing changes were decreased to daily during hospitalization. recommend follow up with thoracic surgery for future wound care and management. . # hiv: patient continued on home haart regimen. recommend continuing home haart regimen and following up with dr. after discharge from rehab. . #cad: patient with known history of cad s/p pci. during admission he was continued on aspirin and statin. his metoprolol was restarted at a lower dose and titrated up after pressors were weaned off. recommend continuing to titrate up metoprolol to improve heart rate control. # nutrition: isosource 1.5 goal rate of 50 ml/hr; currently requiring daily phosphate and magnesium supplementation. # glycemic control: fsbs qid with sliding scale insulin # lines: picc placed # prophylaxis: - continue lovenox 40 mg sc daily for dvt prophylaxis. - continue ranitidine 150 mg daily for stress ulcer prophylaxis while on ventilator. - continue vap prophylaxis with mouth care tid while using ventilator # contact: sister # status: dnr (confirmed with sister his hcp) # disposition: to do: titrate up metoprolol dosing as blood pressure will allow. advance diet as recommended by speech and language pathologist monitor electrolytes twice a week. as nutrition improves and patient finishes antibiotic course he may no longer require phosphate supplementation. ensure follow up with patient's primary infectious disease provider . on discharge ensure patient makes it to follow up appointment with thoracic surgery in clinic post discharge after completion of antibiotics (vancomycin, ciprofloxacin, cefepime) can discontinue picc line. if fever recurs whould have high suspiscion for extrapulmonary source (i.e. picc line, urine, c. diff). medications on admission: asa 81 mg atorvastatin 10 mg calcium carbonate 500 mg cholestyramine/sucrose 4 mg truvada 1 tab daily celexa 40 mg daily gabapentin 300 mg tid medrol taper started (12 mg , 8 mg ) metoprolol 12.5 mg miracle cream mvi protonix 40 mg daily kcl 20 meq daily raltegravir 400 mg saccharomyces 250 mg sucralfate 1 g qid sulfasalazine 1000 mg tiotropium 18 mcg daily voriconazole 400 mg metformin 1000 mg oxycontin 20 mg tylenol prn bisacodyl prn dilaudid 2 mg q4h/prn loperamide prn polyethylene glycol prn compazine prn trazodone prn discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for yeast. 2. enoxaparin 40 mg/0.4 ml syringe sig: one (1) inj subcutaneous daily (daily). 3. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob/wheeze. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob/wheeze. 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. prednisone 2.5 mg tablet sig: three (3) tablet po daily (daily). 7. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr). 8. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 9. sulfasalazine 500 mg tablet sig: two (2) tablet po bid (2 times a day). 10. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: five (5) ml po daily (daily). 11. gabapentin 300 mg capsule sig: one (1) capsule po q8h (every 8 hours). 12. escitalopram 10 mg tablet sig: four (4) tablet po daily (daily). 13. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po daily (daily). 14. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po daily (daily). 15. emtricitabine 200 mg capsule sig: one (1) capsule po q24h (every 24 hours). 16. raltegravir 400 mg tablet sig: one (1) tablet po bid (2 times a day). 17. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 18. acetaminophen 650 mg/20.3 ml solution sig: 1-2 doses po q6h (every 6 hours) as needed for fever. 19. heparin, porcine (pf) 10 unit/ml syringe sig: two (2) ml intravenous prn (as needed) as needed for line flush. 20. vancomycin 1000 mg iv q 12h 21. cefepime 2 g iv q12h 22. ciprofloxacin 750 mg tablet sig: one (1) tablet po q12h (every 12 hours). 23. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 2-4 puffs inhalation q6h (every 6 hours) as needed for sob/wheeze. 24. neutra-phos 2 pkt po/ng 25. sliding scale humalog insulin at meals and bedtime discharge disposition: extended care facility: - discharge diagnosis: hcap diastolic chf hiv malnutrition invasive aspergillus discharge condition: hemodynamically stable: stable on trach mask throughout most of the day and requires ventilator overnight. can communicate with valve. patient afebrile and off pressors for several days prior to discharge. noninvasive blood pressure consistently 10 points below arterial blood pressure tracing. baseline systolic blood pressure 85-100. tolerating tube feeds. currently requires assistance for all adls. discharge instructions: you presented to the emergency department in respiratory distress. you were admitted to the icu and ultimately required intubation for your lung infection. your hospital course was complicated by elevated heart rates, persistent fevers, altered mental status, malnutrition. once your infection improved you were extubated. unfortunately you continued to have great deal of secretions that caused you to become short of breath and you were too weak to protect your lungs. you had a tracheostomy placed to help protect your airway from secretions and to help aid suctioning. you received nutrition during the majority of your admission via a feeding tube through your nose. because you continued to be too weak to safely swallow regular food you underwent placement of a percutaneous feeding tube. you tolerated the procedure well and were fed through this external feeding tube. followup instructions: please schedule a follow up appointment with dr. in , nh within one week of discharge from rehab. you have the following appointment wiht thoracic surgery: provider: , md phone: date/time: 11:00 procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube other lavage of bronchus and trachea percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy closed [endoscopic] biopsy of bronchus closed biopsy of skin and subcutaneous tissue diagnoses: pneumonia, organism unspecified hyperpotassemia esophageal reflux mitral valve disorders congestive heart failure, unspecified long-term (current) use of steroids unspecified septicemia unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia severe sepsis personal history of malignant neoplasm of bronchus and lung acute on chronic diastolic heart failure percutaneous transluminal coronary angioplasty status human immunodeficiency virus [hiv] disease acute respiratory failure other specified cardiac dysrhythmias pneumocystosis septic shock glucocorticoid deficiency herpes simplex without mention of complication aspergillosis empyema with fistula other specified disorders of liver other specified diseases of hair and hair follicles unspecified inflammatory polyarthropathy 

Answer: The patient is high likely exposed to