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: cc: fever, altered mental status, hypotension, sepsis major surgical or invasive procedure: -open tracheostomy -percutaneous endoscopic gastrostomy tube history of present illness: . pcp: . office , hospital ed (. . hpi: 74yof with pmh of tobacco use and glaucoma (no regular medical care with last pcp 6 years ago) who developed fever and body aches and progressively worsening confusion since then presented to her pcp's office today with complaints of generalized malaise and feeling unwell. she specifically complained of inability to sleep and requested sleep medication however also endorsed generalized weakness and perhaps some dizziness. her pcp referred her to hospital ed given her symptoms and she reportedly looked "overall unwell". she (and family) report that her symptoms began on at which time she developed "body aches" and subjective fevers/chills. she also had a very mild dry cough. her daughter reports progressive confusion mainly over the past few days. she has also had poor po intake (food and fluid) poor appetite. she denies sore throat, runny nose, n/v/diarrhea/abdominal pain, dysuria/hematuria. she further denies night sweats, signifiant weight loss. she also denies ha, changes in vision, neck stiffness. . at the osh ed, noted peripheral blood wbc >60k with a reported "left shift". rul infiltrate was noted on cxr and she received 1 dose levofloxacin iv. abg initially showed pco2=59 however she became increasingly lethargic and repeat abg showed pco2=78. she was simultaneously noted to be hypoxemic (pao2 not clear), but sao2 70% on nrb prior to intubation. she was intubated and was noted to be hypotensive with nadir 65/40 (? post sedation vs. before) and was started on dopamine via peripheral iv initially at 20mcg/kg/min. dopamine was decreased to 5mcg/kg/min prior to transfer with maintenance of sbps 90s. she became tachycardic to the 140s on dopamine so was changed to levophed without tachycardia and maintenance of maps approximately 50-60. . transferred to micu for presumed sepsis. . ros: as above, also denies rashes. + doe when walking up stairs, no pnd, orthopnea (per family history). no melena/hematochezia. medications: glaucoma eye gtts . allergies: nkda past medical history: past medical history: tobacco use, ? copd glaucoma social history: social history: quit tobacco 15years ago, previously has approximately 20-30packyear history. no etoh nor other illicits. formerly worked in parking permit department at the police dept. has 9 children (7 daughters, 2 sons). family history: family history: non-contributory physical exam: physical exam: vs: temp: 97.0 bp: 96/61 hr: 101 st rr: 12 o2sat 95-96% ac 500/12 peep 10 fio2 0.60 gen: intubated heent: perrl, eomi, anicteric, dry mm, op without lesions, superior lip with mild blood oozing under ett tape neck: no supraclavicular or cervical lymphadenopathy appreciated, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: rhonchorus anteriorly cv: rrr, s1 and s2 wnl, systolic murmur heard greatest lusb abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: trace to 1+ edema b/l feet, warm, good pulses skin: no rashes/no jaundice neuro: somnolent on sedation, but arousable and able to answer yes/no to questions, nods appropriately. able to cooperate with strength exam/follow commands. 5/5 strength throughout. no sensory deficits to light touch appreciated. pertinent results: ekg: sinus tachy rate 103, normal access, q ii, iii, avf, 1mm st depression ii and avf, 1mm st depression v5, 1mm st elevation v2. isolated biphasic tw in avl. . imaging: . osh cxr: per verbal report showed opacity upper portion of rll. (need to review cd) . cxr on presentation to icu (wet): opacity superior portion of right lower lobe, left upper lobe opacity and hiatal hernia vs. left hemidiaphragm elevation. hilar fullness likely representing lad. . admission labs: . 08:55pm blood neuts-91* bands-3 lymphs-2* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-1* 08:55pm blood hypochr-normal anisocy-1+ poiklo-occasional macrocy-1+ microcy-normal polychr-occasional schisto-occasional 08:55pm blood plt smr-high plt ct-538* 10:55pm blood pt-12.5 ptt-23.4 inr(pt)-1.1 05:58pm blood glucose-188* urean-63* creat-1.3* na-136 k-3.5 cl-98 hco3-28 angap-14 05:58pm blood estgfr-using this 05:58pm blood alt-33 ast-37 ld(ldh)-311* alkphos-235* totbili-1.2 05:58pm blood albumin-2.2* calcium-7.4* phos-4.5 mg-2.5 05:58pm blood cortsol-59.3* 08:05pm blood type-art po2-62* pco2-70* ph-7.26* caltco2-33* base xs-1 09:34pm blood type-mix temp-36.7 08:05pm blood lactate-1.3 k-3.3* 09:34pm blood hgb-10.9* calchct-33 o2 sat-74 08:05pm blood freeca-0.99* . . micro data 11:42 am sputum site: endotracheal source: endotracheal. legionella culture (preliminary): no legionella isolated. aspergillus fumigatus. identification performed on culture # 244-2449b (). . 9:31 pm sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs in short chains. 2+ (1-5 per 1000x field): budding yeast. respiratory culture (final ): oropharyngeal flora absent. streptococcus pneumoniae. sparse growth. presumptively penicillin sensitive by oxacillin screen. sensitivities: mic expressed in mcg/ml _________________________________________________________ streptococcus pneumoniae | penicillin------------ s . 10:33 am urine site: catheter **final report ** legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. (reference range-negative). performed by immunochromogenic assay. a negative result does not rule out infection due to other l. pneumophila serogroups or other legionella species. furthermore, in infected patients the excretion of antigen in urine may vary. . 2:24 pm bronchoalveolar lavage **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. viral culture (final ): herpes simplex virus type 1. confirmed by monoclonal fluorescent antibody.. . 3:05 pm skin scrapings **final report ** viral culture: r/o herpes simplex virus (final ): no virus isolated. . 2:40 pm ear left ear. site confirmed by dr . **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. smear reviewed; results confirmed. respiratory culture (final ): staphylococcus, coagulase negative. sparse growth. yeast. moderate growth. . 2:40 pm swab site: ear right ear. site confirmed by dr . **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. 3+ (5-10 per 1000x field): gram positive rod(s). smear reviewed; results confirmed. respiratory culture (final ): staphylococcus, coagulase negative. moderate growth. staphylococcus, coagulase negative. sparse growth. 2nd type. corynebacterium species (diphtheroids). moderate growth . 5:29 pm aspirate site: sinus source: sinus. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): no growth. potassium hydroxide preparation (final ): test cancelled by laboratory. patient credited. inappropriate specimen for fungal smear (koh). fungal culture (preliminary): no fungus isolated. relevant imaging echo : the left atrium is normal in size. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no definite aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. there is mild functional mitral stenosis (mean gradient 7 mmhg) due to mitral annular calcification. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the prior study (images reviewed) of , the findings are similar. . ct sinuses impression: 1. improvement of the mucosal thickening in the paranasal sinuses as described above. resolution of the fluid within the middle ear cavities bilaterally. 2. persistent partial opacification of mastoid air cells bilaterally. . chest ct impression: 1) persisting multifocal consolidation, not significantly changed. 2) interval development of underlying pulmonary edema with increasing, now moderate, bilateral pleural effusions. 3) enlarged mediastinal lymph nodes likely reactive to the underlying infectious process and/or chf. 4) lobulated, hypodense hepatic dome lesion, likely a cyst. 5) left adrenal mass with hounsfield units between 5 and 15, most likely an adenoma. . -ct orbit, sella, iac impression: 1. paranasal sinus opacification as described above. 2. soft/fluid density within the bilateral mastoid air cells and right middle ear cavity without bony erosions or other destructive changes. findings may represent effusions of the mastoid air cells and right middle ear cavity, versus otomastoiditis. 3. 7-mm well-circumscribed lytic area within the left occipital lobe, likely an arachnoid granulation. if there is clinical concern or previous history of malignancy, a bone scan could be considered for further characterization. . ct torso 1. extensive bilateral pulmonary consolidations that are most consistent with pneumonia. 2. small bilateral pleural effusions. 3. suboptimal position of the right internal jugular central line with its tip in the inferior vena cava. 4. ascites. 5. cholelithiasis. 6. left adrenal mass, which cannot be further characterized on this study. further evaluation with mri may be obtained when clinically feasible . echo the left atrium is mildly dilated. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. left ventricular systolic function is hyperdynamic (ef 70-80%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. 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. there is severe mitral annular calcification. there is mild valvular mitral stenosis (area 1.5-2.0cm2). mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: mrs. was admitted to micu. 74f h/o tobacco use, glaucoma (no past regular medical care) developed fever and body aches , with progressively worsening confusion since then, presented to osh ed and was found to have wbc 60+, rul and hypotension requiring pressors, intubated and was transferred for further management of septic shock pneumococcal rul pna. now with resolved wbc but continued respiratory failure and ventilator dependancy; now s/p trach/peg. also now with new growth of mold out of sputum culture, and staph coag (-) off the cvl tip on , completed treatment for pneumococcal pneumonia, as well as herpes lung infection, still being treated for mold in sputum-aspergillus infection. . problems: . respiratory failure: she presented with a hypercarbic and hypoxic respiratory failure with an acute on chronic respiratory acidosis secondary to pneumonia which developed into ards. a chest ct showed multifocal pneumonia, sputum culture showed penicillin resistant strep pneumonia. empirical vancomycin and flagyl were discontinued, and levofloxacin and zosyn were continued for a completed course. there was also a component of underlying copd exacerbation for which she was on albuterol and atrovent. diuresis was initiated for a component of volume overload that was felt to be present. however she was allowed to self diurese after she became euvolemic. she was also found to have a herpetic pulmonary infection (tracheobronchitis). bal washings ()confirmed hsv-positive herpetic lesions in trachea. acyclovir was started , ending (2 week course); liver (ast 13. alt 17), renal function were monitored. she had previously had aspergillus in her sputum but negative beta-glucan and galactomannan. whether this was a pathogen or a contaminant was not clear. she was started voriconazole , ct sinus and ct chest did not show invasive disease. she should continue on this for two weeks and have lfts monitored weekly. she should also have a follow up sputum for koh and fungal culture in weeks after stopping voriconazole. . vent settings at d/c ventilator settings: cpap 46% fio2 peep 5 pt averaging tidal volumes of 20 respiratory rate 30 . she was in chronic respiratory failure and did not tolerate weaning of vent given need for high peep & fio2. thus, she had a tracheostomy placed and is now being slowly weaning from vent. trach: dead space:tidal volume 78%. she needs prn decreases in fio2, peep. . hypotension: on admission she had leukocytosis wbc 60, fever, tachycardia c/w sirs and since she had pneumonia and hypotension she was in spetic shock. she was requiring norepinephrine. in the presence of a murmur on exam subacute bacterial endocarditis was felt to be a possible etiology, thus an echo was done that was negative for vegetations, normal lvef >55%, +1mr. her random cortisol was 59, with an appropriate decrease with cortisol challenge. as there were no ischemic changes in continguous leads cardiogenic etiology was not felt to be likely. on she was weaned successfully off pressor support. she occasionally required small boluses for occasional decreases in blood pressure and to aid urine output. . acute renal failure: she had no known cri by history (although no consistent medical care for several years). bun/creatinine ratio suggestive of prerenal etiology, improved to nml range after ivfs. admission bun=63, cr=1.3, discharge bun=23, cr=0.5. . ileus: she had increasing abdominal distention with no bm. kub done on c/w ileus. abd ct demonstrated ascites but no sbo. she was on a bowel regimen and tf with appropriate holding for residuals were done. this resolved . . altered mental status: she had ards, infection, but also heavy sedation while intubated. on , decreased scheduled diazepam with goal for autotaper, and decreased fentanyl patch to 12.5mg. on the patient was found to be awakening, able to communicate somewhat with family and staff. diazepam was discontinued and ativan 1mg q6h:prn was started. . anemia: she had a slowly decreasing hct. she was guiaic negative and did not have any gross bleeding. likely secondary to blood draws, hemolysis labs were negative, should continue to monitor. admit hct was 32. discharge hct was 26, this was stable for 3 days prior to discharge. during admission patient was transfused 1 unit of packed rbcs w/o complications. . right otitis media: ent irrigated ear, no evidence of otitis externa, likely otitis media s/p perforation or drained fluid collection behind cerumen collection. recieved ciprofloxacin/dexamethasone drops 5 drops tid in ear for 10 days. started first full day , ended . now resolved. . nutrition: peg was placed at the time of tracheostopy. tube feed recs. tube feeds-nutren pulmonary full strength; additives:beneprotein, 10 gm/day starting rate: 40 ml/hr; do not advance rate goal rate: 40 ml/hr residual check: q4h hold feeding for residual >= : 100 ml other instructions: please add 150 ml h20 tid to tf . glaucoma: she remained on her home medications of timolol and travatan . access: picc line placed : no signs of infection at picc site. . follow up: pt will continue voriconazole until for a total of 2weeks of therapy -pt needs lfts drawn on . -sputum culture needed (for fungal culture and koh) -galactomannan and b-glucan -please contact your pcp . for a follow up appointment within 2 weeks. -pt has an appointment with the infectious disease clinic; , 11:00am, dr. on the building . medications on admission: `glaucoma eye gtts discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) injection q8h (every 8 hours). 2. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic daily (daily). 3. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 4. albuterol 90 mcg/actuation aerosol sig: 6-10 puffs inhalation q4h (every 4 hours). 5. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours). 6. outpatient lab work lfts on monday 7. outpatient lab work sputum culture (for fungal culture and koh) 8. outpatient lab work galactomannan and b-glucan 9. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 10. acetaminophen 160 mg/5 ml solution sig: one (1) po q6h (every 6 hours) as needed for pain or fever. 11. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 13. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day). 14. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po q8h (every 8 hours) as needed. 15. chlorhexidine gluconate 0.12 % mouthwash sig: five (5) ml mucous membrane (2 times a day). 16. voriconazole 200 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 8 days: last day . 17. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 18. lorazepam 1 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed: re-assess as necessary with intention to taper. 19. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 20. insulin lispro 100 unit/ml cartridge sig: as per scale subcutaneous every six (6) hours: as per scale. discharge disposition: extended care facility: - discharge diagnosis: pneumococcal pneumonia herpetic pulmonary infection aspergillus acute respiratory distress syndrome history of tobacco use glaucoma discharge condition: stable -------- tube feeds-nutren pulmonary full strength; additives:beneprotein, 10 gm/day starting rate: 40 ml/hr; do not advance rate goal rate: 40 ml/hr residual check: q4h hold feeding for residual >= : 100 ml other instructions: please add 150 ml h20 tid to tf ------------------- ventilator settings: cpap 46% fio2 peep 5 pt averaging tidal volumes of 20 respiratory rate 30 discharge instructions: you were admitted with pneumonia and required intubation for respiratory failure. you also had a herpetic pulmonary infection and continued to require ventilation so a tracheostomy was done. you also had a peg tube placed for feeding. you were treated for your pneumonia and herpetic lung infection with antibiotics which you have completed. you also had mold in your sputum requiring treatment with an antibiotic called voriconazole. you will continue to take this and complete a two week course, during which your liver function tests should be checked weekly. you are being discharged to a pulmonary rehab facility. you should call your doctor for any fevers, chills, increased sputum production, or any other concerning symptoms. please follow up as outlined below. followup instructions: follow up: pt will continue voriconazole until for a total of 2weeks of therapy -pt needs lfts drawn on . -sputum culture needed (for fungal culture and koh) -galactomannan and b-glucan -please contact your pcp . for a follow up appointment within 2 weeks. -pt has an appointment with the infectious disease clinic; , 11:00am, dr. on the building . md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] arterial catheterization temporary tracheostomy closed [endoscopic] biopsy of bronchus transfusion of packed cells diagnoses: anemia, unspecified congestive heart failure, unspecified acute kidney failure, unspecified other pulmonary insufficiency, not elsewhere classified unspecified protein-calorie malnutrition severe sepsis chronic airway obstruction, not elsewhere classified unspecified glaucoma septic shock paralytic ileus pneumococcal septicemia [streptococcus pneumoniae septicemia] pneumococcal pneumonia [streptococcus pneumoniae pneumonia] acute diastolic heart failure hyperosmolality and/or hypernatremia aspergillosis herpes simplex with other specified complications acute suppurative otitis media with spontaneous rupture of eardrum 

Answer: The patient is high likely exposed to