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: sob major surgical or invasive procedure: intubated extubated history of present illness: year old male with h/o parkinsons disease, orthostatic hypotension on midodrine, afib on coumadin and aspiration pna presenting to ed with respiratory distress and admitted to micu with respiratory failure. patient had chronic cough since d/c from rehab in of this year. over the last week the cough has gotten worse and he has stopped eating. he has not had fevers or chills, dysuria or frequency, diarrhea or bleeding from his rectum. his wife said last night she could hear him "gurgling" and that he sounded like a "child with croup". she became concerned about him this morning and thus called ems. ems found him tachypneic, initially started on cpap in the field. satting low-90s on nrb and 100% on cpap but looked "terrible" on arrival to ed. . past medical history: parkinson;s disease af on warfarin cervical spine stenosis constipation orthostatic hypotension on midodrine hearing loss aspiration pneumonia social history: the patient was born in , . he went to and and then went to the armed forces. he was an accountant and worked for the irs for many years. he then lived in for many years, but four years ago moved to , to live close to his daughter. they have home health aide who comes in three days a week for shower and shave. he smoked half a pack a day for 18 years. alcohol, he used to drink one drink five nights a week, but has not done this for many years. he has lived with his wife for 61 years. he has two daughters. is somewhat estranged from his first daughter, , lives in the same two family home, as his daughter, . family history: significant for the fact that his mother had heart disease. physical exam: in micu vitals: t: 97.5 bp:145/60 p:70 r: 12 o2:1005 on 550x12 fio250 peep 5 general: intubated, sedated heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: irregularly irregular. no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: erythematous sacrum on general: sleepy, confused, little verbalising. difficulty with secretions heent: sclera anicteric, dry mm, oropharynx clear neck: supple, no lad. appears dry lungs: markedly decresaed breath sounds r base with few crackles l base cv: irregularly irregular. hs i+ii+ soft esm no radiation, depressed jvp abdomen: soft, non-tender, non-distended, bowel sounds present, gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema skin: erythematous sacrum neuro: a+o x1. r arm resting tremor. perrla. gcs13-14/15 e3-4 v4 m6 pertinent results: admission labs: 10:50am blood wbc-13.6*# rbc-4.21* hgb-12.4* hct-39.1* mcv-93 mch-29.4 mchc-31.7 rdw-14.3 plt ct-501*# 10:50am blood neuts-89.4* lymphs-5.1* monos-4.3 eos-1.0 baso-0.3 10:50am blood pt-54.9* ptt-39.9* inr(pt)-6.1* 10:50am blood glucose-110* urean-27* creat-0.8 na-137 k-7.6* cl-100 hco3-31 angap-14 10:50am blood alt-18 ast-81* alkphos-104 totbili-0.5 10:50am blood probnp-* 10:50am blood ctropnt-0.04* during stay: 01:43am blood wbc-13.2* rbc-3.61* hgb-10.9* hct-31.8* mcv-88 mch-30.1 mchc-34.1 rdw-14.2 plt ct-404 04:54pm blood wbc-12.1* rbc-3.65* hgb-10.8* hct-32.5* mcv-89 mch-29.7 mchc-33.3 rdw-14.2 plt ct-406 06:35am blood wbc-10.5 rbc-3.83* hgb-11.4* hct-34.5* mcv-90 mch-29.7 mchc-33.0 rdw-14.4 plt ct-411 06:15am blood wbc-9.2 rbc-3.66* hgb-10.7* hct-33.2* mcv-91 mch-29.2 mchc-32.1 rdw-14.3 plt ct-428 10:50am blood neuts-89.4* lymphs-5.1* monos-4.3 eos-1.0 baso-0.3 06:15am blood neuts-85.3* lymphs-7.6* monos-4.5 eos-2.2 baso-0.3 10:50am blood pt-54.9* ptt-39.9* inr(pt)-6.1* 01:43am blood pt-72.8* ptt-45.9* inr(pt)-8.6* 04:54pm blood pt-30.4* ptt-40.4* inr(pt)-3.0* 04:08am blood pt-23.6* ptt-35.6* inr(pt)-2.2* 06:35am blood pt-22.6* ptt-31.6 inr(pt)-2.1* 06:25am blood pt-25.4* ptt-31.2 inr(pt)-2.4* 06:15am blood pt-30.9* ptt-32.9 inr(pt)-3.1* 10:50am blood glucose-110* urean-27* creat-0.8 na-137 k-7.6* cl-100 hco3-31 angap-14 01:43am blood glucose-88 urean-24* creat-0.7 na-141 k-4.0 cl-106 hco3-25 angap-14 06:35am blood glucose-86 urean-21* creat-0.7 na-141 k-4.3 cl-105 hco3-26 angap-14 06:15am blood glucose-93 urean-20 creat-0.7 na-141 k-4.2 cl-104 hco3-32 angap-9 01:43am blood ld(ldh)-149 ck(cpk)-47 totbili-0.5 dirbili-0.2 indbili-0.3 10:50am blood probnp-* 10:50am blood ctropnt-0.04* 04:14pm blood ck-mb-4 ctropnt-0.03* 01:43am blood ck-mb-3 ctropnt-0.04* 10:50am blood albumin-3.8 calcium-9.3 phos-4.0 mg-2.3 06:15am blood calcium-8.5 phos-2.8 mg-1.9 01:43am blood hapto-220* 06:35am blood vitb12-1083* folate-14.8 06:25am blood caltibc-200* ferritn-293 trf-154* 06:35am blood tsh-1.7 12:25pm blood type-art rates-/16 tidal v-600 peep-5 fio2-100 po2-403* pco2-29* ph-7.54* caltco2-26 base xs-3 aado2-306 req o2-55 -assist/con intubat-intubated 04:54am blood type-art temp-37.2 rates- tidal v-450 peep-5 fio2-50 po2-141* pco2-35 ph-7.47* caltco2-26 base xs-2 intubat-intubated 05:42am blood type-art po2-87 pco2-40 ph-7.39 caltco2-25 base xs-0 05:18pm blood type-art temp-35.9 po2-60* pco2-42 ph-7.44 caltco2-29 base xs-3 12:18pm blood k-5.4* 01:17pm blood lactate-3.5* k-4.2 10:08am blood lactate-0.7 05:18pm blood lactate-1.4 microbiology 11:45 am sputum ett. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci. in pairs and chains. respiratory culture (final ): sparse growth commensal respiratory flora. bcx2 pending from mrsa screen negative time taken not noted log-in date/time: 10:02 am urine specimen taken from m. **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. time taken not noted log-in date/time: 11:05 am serology/blood chem# m. **final report ** rapid plasma reagin test (final ): nonreactive. reference range: non-reactive. 12:10 pm urine source: catheter. **final report ** urine culture (final ): no growth. bcx2 from pending radiology cxr findings: et tube tip is 5 to 5.5 cm above the carina. the endogastric tube side port is just below the ge junction. the cardiomediastinal contours are unremarkable. patchy right basilar and retrocardiac opacities may be due to infection or aspiration. hazy opacity primarily overlying the right lower lung may represent a layering pleural effusion. the full extent of the right costophrenic angle is not appreciated on this study. trace blunting of the left costophrenic angle suggests a small pleural effusion. there is no pneumothorax. impression: 1. et tube 5 to 5.5 cm above the carina. 2. endogastric tube side port just below the ge junction, would recommend advancing 4 to 5 more centimeters to ensure that it is well below the ge junction. 3. patchy opacities in the lung bases may be due to infection or aspiration with right layering pleural effusion, and trace left pleural effusion. the study and the report were reviewed by the staff radiologist. dr. dr. approved: sat 3:36 pm cxr findings: in comparison with the study of , there is little overall change. the side hole of the nasogastric tube is probably just above the gastroesophageal junction. layering right pleural effusion has a somewhat different configuration on this semi-upright image. bibasilar atelectasis and probable small left effusion also seen. no evidence of acute pneumothorax. dr. approved: sun 11:36 am cxr ap upright radiograph of the chest: moderate bilateral pleural effusions are slightly worse, right more than left. there is also worsening bibasilar atelectasis. there is no edema. heart size and cardiomediastinal silhouette are obscured by the bibasilar opacities. calcified aortic contour is present and unchanged. the ng tube and et tube have been removed. impression: bilateral pleural effusions and bibasilar opacities slightly worse than prior, could be atelectasis, however, superimposed infection in the right clinical setting is not excluded. the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 5:05 pm video swallow assessment clinical indication: -year-old male with parkinson's, recurrent pneumonia, and concern for aspiration. comparison: none available. technique: oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. multiple consistencies of barium were administered. findings: barium passes freely through the oropharynx without evidence of obstruction. trace aspiration was seen with thin liquids. for details, please refer to the speech and swallow division note in omr. impression: trace aspiration of thin liquids. the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 11:51 am cardiology cardiology report ecg study date of 10:14:36 am atrial fibrillation with ventricular premature beat. right bundle-branch block. left axis deviation may be due to left anterior fascicular block and/or possible prior anterior myocardial infarction. no previous tracing available for comparison. brief hospital course: yo m with parkinson's disease, orthostatic hypotension, af on warfarin presented on with acute on chronic cough, increased secretions with difficulty managing secretions. in ed found to be tachypneic, placed on a nrb with sats in the high 80s and was trialled on bipap and intubated. cxr with rll and retrocardiac opacities in addition to a high serum wbc count and was started on antibiotics to cover cap with ceftriaxone and levofloxacin and admitted to critical care. after a brief period of intubation, he was successfully extubated. he was noted to have difficulty clearing his own secretions although his sputum production as well as initial leukocytosis improved - his wcc normalised on transfer to the medical . on a sputum culture returned with 1+ gpcs although culture revealed no growth and his ceftriaxone was stopped and levofloxacin was continued initially iv then changed to oral on . his initial inr was 8.6 on admission and he received vitamin k, this quickly falling into the normal therapeutic range. he was restarted on warfarin on and his inr remained therapeutic. due to concern for aspiration risk, he was seen by speech and swallow and they recommeded a video swallow which showed an impaired oral stage with trace aspiration on thin liquids. they recommended thin fluids and soft solids with meds crushed in puree. they acknowledged that he was an aspiration risk with any diet type. he continued to receive chest physical therapy while on the and requierd intermittent suctioning for his secretions. his wcc remained stable and he was afebrile whilst on the although he continued to have bibasal opacities and effusions on cxr. on transfer to the , he was noted to be sleepy and agitated - he was initially given olanzapine and subsequently quetiapine for agitation but latterly this was not required. he was oriented only to person and was very confused initially and further screen for infection, ua was unremarkable, electrolytes were normal and it was felt likely to his recent icu stay, infection and constipation. his orientation improved and on discharge no longer required sedation. his constipation was treated. his midodrine was hled while in teh icu but restarted on the . his swallow and secretions remained a problem but he improved in this regard as he became less drowsy and confused. . # respiratory failure: etiologies include aspiration or community acquired pna given xr and preceding symptoms. has h/o smoking but no h/o copd so felt unlikely copd flare and unlikely pulmonary edema as no evidence on cxr. mi was ro with 3 sets of negative enzymes and ecg showed no change from prior. legionella urinary atigen was negative. patient treated for pneumonia with ctx/levofloxacin initially, and after successfully extubated on hd 2 the antibiotics were narrowed to levofloxacin. this was changed to oral on speech and swallow evaluated the patient and found him to be high risk of aspiration so the patient remained npo while on the unit. he remaine afebrile and wbcs were stable and not increasing. cxr repeat was oerhaps slightly worse but this did not match his clinical condition clinically although there is certainly evidence of a moderate r effusion. his levofloxacin was continued and whiel he initially requierd regular suctioning, as he became less drowy this improved. his respiratory parameters were stable on the . he should continue levofloxacin to complete a 7 day course as per gerontology - last day . . # confusion and agitation: he was noted to be confused and agitated while on teh , only oriented to person and this was not his baseline according to his wife who felt he was forgetful at times but was generally oriented. this was felt to likely be ? 2o to infection or unfamiliar surroundings/recent icu admission/constipation. he was investigated (cultures pending) and ua unremarkable and electrolytes and ca were normal. he was initially given neuroleptics (olanzapine and quetiapine each on 1 occasion) and this was no longer necessary by the end of his hospital stay and was more oriented on discharge. he initially was not cooperative with oral meds briefly but this improved in a matter of hours when he became less drowsy. . # poor swallow: difficulty managing secretion on admission and concern from speech and swallow, initially being npo. he was assessed with a video swallow which showed 1x trace aspiration and an impaired oral phase although they acknowledged that he ws at risk of aspiration on any diet type. diet changed on advice to thin liquids and soft solids. meds crushed with puree consistency. he still had trouble with secretions and is an aspiration risk. . # af on warfarin: patient's rate was well controlled without nodal blocking agents. initially treated with vitamin k 3mg for inr 8.6 with no active bleeding. he was initially held due to supratherapeutic inr but restarted on day 3 of hospital stay. his inrs were therapeutic. on day of discarge inr was 3.1 and his dose was decreased from 2mg to 1mg qd on tis day . . #anemia: 6 point hct drop on admission, no source of bleeding found so felt to be dilutional. hemolysis labs negative and his hb remained stable during his stay. . # pd. note prev intolerant to l-dopa with hallucinations. no medications started for this. . # orthostatic hypotension: on midodrine at home but given npo status and given initial concern for sepsis, midodrine was held and bps remained stable. this was restarted on the and posed no problems. . #microscopic hematuria: in context of catheterisation. 21-50 rbcs. this will need to be watched and repeat in 2 days . #fen: poor oral intake will need to monitor this. required small volume iv fluids on . #pt: was evaluated by pt and wanted himto be out of bed as much as possible. # dvt: pneumoboots and s/c heparin while on #bowels: standing laxatives (senna and docusate) started . # code: full (discussed with patient's hcp) medications on admission: warfarin 2 mg tablet - 1 tablet(s) by mouth monday through fri 2.5mg sat/sun, midodrine 2.5 mg t.i.d., multivitamins, vitamin d and calcium, senokot discharge medications: 1. midodrine 2.5 mg tablet sig: one (1) tablet po tid (3 times a day). 2. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) for 7 days. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shorness of breath for 7 days. 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. senna 8.6 mg tablet sig: one (1) tablet po daily (daily): hold for loose stools. 7. levofloxacin 750 mg tablet sig: one (1) tablet po once a day for 2 days: start . 8. vitamin d oral 9. calcium oral 10. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. discharge disposition: extended care facility: nursing & rehab center - discharge diagnosis: primary diagnosis: pneumonia delirium secondary diagnosis: dementia discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital for difficult breathing and problems clearing your secretions and as this was severe when you presented to the ed you were intubated (a breathing tube was placed) and spent a brief stay on the medical icu on a breathing machine. a chest x-ray was performed and this showed evidence of a pneumonia and you were treated with intravenous antibiotics for this. your inr was also found to be very high (8.6) and you were given a medication to lower this and reduce the risk of bleeding (called vitamin k which reduces blood tinning by warfarin). following removal of the breathing tube, you were found to have a poor swallow and you were assessed by the speech and swallow specialists. you had a video swallow which showed evidence that your swallow was not normal and that during the trial, some of the liquid went into your lung (called aspiration). you were then put on a modified diet. you were initially drowsy and confused with you being disorientated and you initially received some sedative medications for significant agitation for your safety. you quickly iproved in this regard and you became more oriented. you responded well to antibiotics and your oxygen requirement decreased quickly overtime. you still have problems with your swallowing and secretions and this will be a longstanding problem which could predispose you to chest infections. we will continue the antibiotics for a total 7 day course. you will be seen in teh commmunity by gerontology who were looking after you during your hospital stay. you were discharged to rehab on and you looked much improved. changes to medications: 1) regular sodium docusate and senna for laxatives 2) levofoxacin to continue for total 7 days (last day ) 3) warfarin 1mg daily - will need to monitor inr followup instructions: department: gerontology when: thursday at 11:00 am with: , md building: lm campus: west best parking: garage department: cardiac services when: thursday at 12:00 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube arterial catheterization diagnoses: pneumonia, organism unspecified anemia, unspecified atrial fibrillation paralysis agitans acute respiratory failure long-term (current) use of anticoagulants orthostatic hypotension microscopic hematuria 

Answer: The patient is high likely exposed to