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: no known allergies / adverse drug reactions attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: 62m with extensive medical history including recurrent strokes, aspiration pna, recent hospitalization for pneumonia requiring icu care () discharged from rehabilitation this past presenting with acute onset of inability to talk, left-sided weakness per ems and vomiting x 1. patient has residual deficits on the left side including face, arm and leg, unclear how this is different than his baseline. pt's baseline ms confirmed with family and stroke was ruled out. also notes small amount of bleeding from his penis since rehab. admitted from home with complaint of recent vomiting. family that since rehab pt is failing and decided he needed evaluation today. . ed course notable for code stroke called on arrival. ekg noted to be nsr 79, na, t wave inversions 2,3,avf, v3-v6 , no stemi. chest x-ray: no pna, ptx, w mild effusions. fs on arrival 133. covered with vancomycin and zosyn for presumed pna. also given duoneb for wheezing. inr (1.2) was subtherapeutic and pt was placed on heparin gtt @ 900u/hr @12:30pm. pt does not make urine so no foley placed. pt is tremulous at baseline with hx of seizure d/o. labs notable for creat 9.7, anion gap 26, wbc 10 (differential not checked), lactate 2.7, plts 96, serum tox negative. cardiac enzymes showed trop 0.05 and mb 2. ct head was negative for hemorrhage and showed chronic b/l mca territory infarcts. vs prior to transfer:97.6 89 177/80 22 95%/ra. stroke team recs included treating with home aed (administered keppra and lacosamide at 1500), no eeg needed as he has generalized convulsions, treat seizure activity > 3 min with prn ativan mg. neuro confirmed ms baseline: dysarthric, minimal verbal output. access 20g x 2 with dialysis cath. . transfer to the floor was delayed by fever spike to 102 (received tylenol) and tachycardia to hr 130s. hr decreased to 104 and bp 110/57 on transfer. . on the floor, he reports feeling better than in the ed. does have chills. denies pain at dialysis catheter site, fever at home, diarrhea, nausea or pain. . review of systems: unable to obtain full ros given neurological impairment. (+) per hpi - esrd on hd (m/w/f at ) - h/o multiple prior cvas - per last dc summary ambulates at home, has residual left-sided weakness - seizure disorder - chronic hepatitis b - chronic aspiration with failed speech and swallow eval - family wants him to continue eating despite risks - htn - cad - h/o mssa bacteremia after manipulation of fistula - hospitalization in for incarcerated inguinal hernia complicated by esbl klebsiella bacteremia and pna - hyperlipidemia - gerd - s/p sbo - hernia repair - hypoglycemia past medical history: - esrd on hd (m/w/f at ) - h/o multiple prior cvas - per last dc summary ambulates at home, has residual left-sided weakness - seizure disorder - chronic hepatitis b - chronic aspiration with failed speech and swallow eval - family wants him to continue eating despite risks - htn - cad - h/o mssa bacteremia after manipulation of fistula - hospitalization in for incarcerated inguinal hernia complicated by esbl klebsiella bacteremia and pna - hyperlipidemia - gerd - s/p sbo - hernia repair - hypoglycemia social history: patient lives in with his daughter, , who is a former employee. he denies any recent use of alcohol, tobacco, illicit drugs, or herbal medications. he has a distant, but considerable smoking history per his daughter. uses the toilet himself, but needs help cleaning himself, and does not cook or manage his finances. he is at hd on mwf and spends tu and in an adult day program. his daughter does not leave him alone by himself. family history: mother died at 45 with hypertension. father died at 60 of unknown causes. he has eight living siblings, many of whom have hypertension. he has six children who are all healthy. physical exam: admission physical exam: vitals: t: 101.7 po 105/62 96 18 96%/2l nc general: non-toxic appearing, no acute distress, attentive : nc/at, mmm. neck: reduced rom to passive movement, no carotid bruit. pulmonary: b/l crackles auscultated. cardiac: s1,s2 distant sounds. abdomen: soft, distended, hypoactive bowel sounds. extremities: no edema, left ankle contracture. skin: no rashes or lesions noted. dry skin. gu: uncircumcised, retraction of foreskin reveal small amount of dark clotted blood, no active bleeding or drainage, no ulcers or skin breakdown, area is nontender neuro: aox2, able to give me his first name, place of birth (), unable to relay date. exhibited delayed reaction to commands and verbal responses. pertinent results: 11:00am blood wbc-10.2 rbc-4.22* hgb-12.7* hct-40.8 mcv-97 mch-30.2 mchc-31.2 rdw-17.4* plt ct-96* 04:13am blood wbc-12.8* rbc-3.29* hgb-10.0* hct-31.2* mcv-95 mch-30.3 mchc-32.0 rdw-17.2* plt ct-92* 07:30am blood wbc-7.4 rbc-3.22* hgb-9.6* hct-30.3* mcv-94 mch-29.9 mchc-31.9 rdw-16.6* plt ct-119* 06:30am blood wbc-7.3 rbc-3.14* hgb-9.5* hct-29.4* mcv-94 mch-30.1 mchc-32.2 rdw-16.7* plt ct-119* 03:35am blood wbc-5.4# rbc-3.59* hgb-10.8* hct-33.5* mcv-93 mch-30.0 mchc-32.1 rdw-17.0* plt ct-97* 04:13am blood wbc-12.8* rbc-3.29* hgb-10.0* hct-31.2* mcv-95 mch-30.3 mchc-32.0 rdw-17.2* plt ct-92* 11:00am blood wbc-10.2 rbc-4.22* hgb-12.7* hct-40.8 mcv-97 mch-30.2 mchc-31.2 rdw-17.4* plt ct-96* 11:00am blood neuts-86* bands-0 lymphs-9* monos-3 eos-2 baso-0 atyps-0 metas-0 myelos-0 06:30am blood pt-18.2* ptt-57.5* inr(pt)-1.7* 11:00am blood pt-12.9* ptt-35.2 inr(pt)-1.2* 07:30am blood glucose-67* urean-39* creat-7.9* na-142 k-4.2 cl-95* hco3-34* angap-17 06:30am blood glucose-63* urean-41* creat-7.9*# na-139 k-4.2 cl-94* hco3-33* angap-16 03:35am blood glucose-106* urean-23* creat-6.0*# na-139 k-3.9 cl-91* hco3-33* angap-19 04:13am blood glucose-77 urean-41* creat-9.5* na-135 k-6.5* cl-100 hco3-22 angap-20 10:43am blood creat-9.7* 12:45pm blood alt-15 ast-22 alkphos-113 totbili-0.4 04:13am blood alt-15 ast-19 ck(cpk)-58 alkphos-105 totbili-0.3 11:00am blood alt-14 ast-38 alkphos-168* totbili-0.3 11:00am blood lipase-69* 04:13am blood ck-mb-2 ctropnt-0.05* 11:00am blood ck-mb-2 ctropnt-0.05* 07:30am blood calcium-8.8 phos-5.0* mg-2.2 06:30am blood calcium-8.6 phos-5.3* mg-2.1 03:35am blood calcium-8.8 phos-4.2 mg-1.5* 04:13am blood calcium-8.4 phos-3.5# mg-1.8 06:36am blood vanco-16.1 06:30am blood vanco-14.7 04:13am blood vanco-18.1 07:38am blood lactate-1.0 04:24am blood lactate-1.8 10:31pm blood lactate-2.8* 10:44am blood glucose-137* lactate-2.7* na-139 k-5.4* cl-95* calhco3-21 c-peptide test result reference range/units c-peptide 8.23 h 0.80-3.10 ng/ml insulin test result reference range/units insulin 6 <17 uiu/ml insulin analogues may demonstrate non-linear cross-reactivity in this assay. interpret results accordingly. beta-hydroxybutyrate test name flag results units reference value --------- ---- ------- ----- --------------- beta-hydroxybutyrate, s 0.1 mmol/l <0.4 labs: 07:00am blood wbc-4.8 rbc-3.43* hgb-10.4* hct-32.7* mcv-95 mch-30.4 mchc-31.9 rdw-18.5* plt ct-155 07:00am blood pt-27.5* ptt-143.8* inr(pt)-2.6* 07:00am blood glucose-72 urean-34* creat-8.8* na-135 k-4.9 cl-91* hco3-32 angap-17 micro (final = negative for growth) all cultures negative blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient stool clostridium difficile toxin a & b test-final inpatient mrsa screen mrsa screen-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final emergency blood culture blood culture, routine-final emergency imaging chest xray findings: dialysis catheter over the left internal jugular vein, the tip projects over the right atrium. no evidence of pneumonia. mild interstitial fluid overload. no pleural effusions. borderline size of the cardiac silhouette. old right clavicular fracture. no pneumothorax. ct head unchanged encephalomalacic changes from bilateral right mca territory infarct. no evidence of new acute infarct. kub findings: suboptimal positioning, please note diaphragms and inferior pelvis and part of the right abdomen not included in the radiograph. there are markedly distended loops of bowel measuring up to 6.5 cm concerning for small-bowel obstruction. evaluation for free air is suboptimal. impression: small-bowel obstruction. kub study date of 4:34 pm impression: non-obstructive bowel gas pattern. rue duplex impression: 1. patent left-sided upper extremity vasculature. 2. nonocclusive thrombus of the right internal jugular vein, and occlusive thrombus of the right axillary vein, right cephalic vein, one of the right brachial veins, and the right av fistula. kub wet read: sjbj 10:11 pm dilated small bowel loop up to 5.5cm. degree of distention has improved since yesterday. air in rectum indicates likely partial obstruction. no pneumoperitoneum. brief hospital course: mr. is a 63 year-old man with a pmh notable for esrd on hd (mwf), chronic aspiration, seizure disorder, history of cva with residual left-sided weakness and dysarthria, who presented to the ed with ams and dehydration. active issues # aspiration pneumonia: pt required transfer to the micu from - for management of aspiration. pt was noted to be in respiratory distress and hypoxia but did not require intubation. pt has a documented history of chronic aspiration likely secondary to his cva, and has been evaluated by speech and swallow multiple times in the past with increased risk for aspiration. family in the past had insisted on continued feeding, regardless of aspiration risk with preference for quality of life to be considered to be the number one priority by the family. also hx of mucus plugging responsive to chest pt and suction. he was treated with vancomycin and zosyn initially for his febrile illness but this was switched to vancomycin and meropenem given concern for zosyn related rash on his abdomen. when the rash worsened, he was switched to ceftaz and completed an 8 day course with vanc and ceftaz given qhd which ended on . the patient had no further aspiration events. #) chronic aspiration: palliative care and ethics was consulted to assist in facilitating the discussion about code status and chronic aspiration. ethics was consulted because of concerns that the hcp may not be able to effectively make decisions as the hcp. this discussion resulted in the family keeping the patient full code knowing full-well the high aspiration risk the patient poses by continuing to eat. they are aware of this high risk and deferred other nutrition options. the patient's hcp expressed a philosophical agreement with dnr/dni but could not come to decide to change his code status from full code to dnr/dni. after discussion with the patient's pcp . , the decision was made to respect the family's wishes and to continue to remind the family that the patient's code status will routinely be brought up at future hospitalizations as a part of hospital policy. support was also provided to the family. # sbo: pt developed vomiting and aspiration symptoms on and a kub showed small bowel obstruction, most likely to an adhesion. his ngt was placed to suction. he was kept npo. he denied persistent nausea, abd pain or distension. repeat kub on suggested resolution of the sbo and he tolerated his diet without any further obstructive symtptoms. # hypoglycemia: patient presented with hypoglycemia of unknown etiology. the hypoglyemia would appear only when he was npo despite normal liver function and no administration of insulin. he had an extensive work up for this last admission without clear etiology. this admission, c-peptide levels, insulin, beta-hydroxybuturate, and proinsulin levels were sent off but were unfortunately nondiagnostic. the timing of the tests did not capture a moment of true hypoglyemia (bg <40 or <60 with symptoms) and therefore could not rule out an endocrinopathy. work up was interrupted by resolution of his hypoglyecmia after advancing his dysphagia diet. caution is advised the next time patient is made npo to monitor his finger sticks carefully. # access: he was admitted with 2 piv: one in his r axilla and the other in the r chest wall. prior cvls placed under fluoro. transplant surgery and the iv team were regarding assistance with short and long term plans for his access issues (see below on transitional issues for details). upper extremity ultrasound showed clots in multiple rue deep veins and the r ij. it was decided to heparinze the patient and bridge the patient to coumadin. the patient's last 3 inrs were within goal range and the heparin gtt was discontinued on . # ams: appears to be at baseline currently. per history pt appears to have been doing poorly at home and noted to be more unresponsive. neuro evaluated patient and did not feel that ams was cva or active seizing. felt to have ams metabolic derangement. not likely acute intracranial process as no changed on ct head w/o. there was a delay in med administration as pt hasn't had aeds since yesterday. he was continued on keppra 1500mg daily, lacosamide 50mg wo incident. as his infection cleared, he returned to his baseline of aox2-3. in general, he seems the most drowsy upon waking and after hd, and this usually clears with time/meals. inactive issues # penile bleeding: very mild. does not appear to be worsening despite heparin gtt. apparently persistent on/off since last week in rehab. no issues in the week prior to . # fistula thrombosis/access: following his stay in the icu the patient had a thrombosed rue avg in (the lue avg was removed infectin). has been on coumadin but was subtherapeutic on arrival and started on a heparin gtt until his coumadin was therapeutic. access was a very challenging problem as his vasculature was either thrombosed on the right or being salvaged for a future fistula on the left for new fistula creation. he will follow up with transplant surgery as an outpatient. # esrd on hd: mwf, received dialysis on schedule. access is now a tunneled line, given avg thrombosis. he was continued on home dose sevelamer, which was switched to lanthanum and nephrocaps. # thrombocytopenia: pt with macroycytic anemia and thrombocytopenia prior. this was stable during his stay. # cad/cva history: ecg unchanged from prior. hx of recent rp bleed on hospitalization related to anticoagulation. he was continued on home dose aspirin, statin, metoprolol, and coumadin (which was titrated up for therapeutic inr). # depression: was formerly on fluoxetine as listed med but held on as it causes hypoglycemia and it can lower the seizure threshold. issues of transitions in care: his left arm needs a fistula creation he needs a better access issue next time he is hospitalized, but unfortunately this is temporarily impossible. after consultation with and the tranplant surgeons, his tunneled line cannot be converted to a vip port, and he has no other veins available for central access given his multiple clots and left arm reserved for fistulization. best options are to use antibiotics that use hd dosing such as vanc and ceftaz in order to forgo iv access. the iv team can occasionally place peripherals and re lab draws, art sticks can be used as a last resort. unfortunately, his anatomy does not allow for a better access plan. the only other options would be to reevaluate his goals of care, but the family is adamantly against this as well. very challenging situation as he will likely return to the hospital for future aspiration events and the family is aware of this. # code: full - confirmed hcp daughter # contact: patient; / daughter's cell: (h) . adult day care program is house in medications on admission: 1. acetaminophen 325 mg tablet sig: one (1) tablet po every six (6) hours as needed for fever or pain. 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) capsule po once a day. 3. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 4. levetiracetam 500 mg/5 ml solution sig: 1500 (1500) mg intravenous twice a day. 5. levetiracetam 500 mg iv mwf dose after hd 6. metoprolol tartrate 50 mg tablet sig: one (1) tablet po twice a day: hold if sbp<90, hr<55. 7. polyethylene glycol 3350 17 gram powder in packet sig: one (1) po once a day as needed for constipation. 8. senna 8.6 mg capsule sig: one (1) capsule po twice a day. 9. sevelamer carbonate 800 mg tablet sig: one (1) tablet po three times a day. 10. simvastatin 40 mg tablet sig: one (1) tablet po once a day. 11. heparin (porcine) 1,000 unit/ml solution sig: see below injection prn (as needed) as needed for line flush: 4000- unit dwell prn line flush dialysis catheter (temporary 3-lumen): dialysis lumens/ dialysis nurse only: withdraw 4 ml prior to flushing with 10 ml ns followed by heparin as above according to volume per lumen. 12. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: please titrate to inr, goal . 13. heparin (porcine) 1,000 unit/ml solution sig: see below injection prn (as needed) as needed for dialysis: heparin dwell (1000 units/ml) -8000 unit dwell prn dialysis dwell to catheter volume 14. lacosamide 200 mg/20 ml solution sig: fifty (50) mg intravenous (2 times a day). 15. heparin (porcine) in ns intravenous 16. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. . medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 4. b-complex with vitamin c tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 6. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). 7. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 8. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 9. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 11. heparin (porcine) 1,000 unit/ml solution sig: one (1) injection prn (as needed) as needed for line flush. 12. levetiracetam 500 mg tablet sig: one (1) tablet po 3x/week (mo,we,fr): dose after hd. 13. lacosamide 10 mg/ml solution sig: fifty (50) mg po bid (2 times a day). 14. lanthanum 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 15. warfarin 5 mg tablet sig: one (1) tablet po once a day. 16. warfarin 2 mg tablet sig: three (3) tablet po once a day. disposition: extended care facility: livingcenter - heathwood - diagnosis: aspiration pneumonia chronic aspiration encephalopathy hypoglycemia deep venous thrombosis condition: mental status: confused - sometimes. level of consciousness: and interactive. activity status: bedbound. instructions: you were admitted to the hospital for fever and vomiting thought to be related to an infection from aspiration. you were treated with iv antibiotics. your cultures were negative. you has an episode of aspiration/choking that required admission to the medical icu. you had an nasal tube placed for medication administration and drainage of your stomach fluids as you were found to have a small bowel obstruction as well. this was treated with bowel rest until the obstruction resolved. a discussion was held between your daughter, palliative care services, and the medical team about the safety of eating. the likelihood that you will continue to choke is very high. the decision was made to continue to allow you to eat, despite the high risk of choking on foods. your family was made aware of the risks of choking on food, respiratory failure, infection, and rehospitalization but still prefer you to be full code (meaning undergo cpr and use of breathing machine if your heart would stop). fortunately, you ate your meals without difficulty for the remainder of your hospitalization. we also addressed your long term intravenous access needs. with the help of the iv team and the transplant surgeons who have evaluated you before, it was decided to try to avoid placing ivs in the left arm for future fistula placements. also, in the future, using antibiotics only to be given at dialysis would also benefit. we restarted you on coumadin for your recent blood clot but we had to increase your dose. this will likely fluctuate so you should continue to have your inr monitored. your current dose of coumadin is 11 mg a day. we also changed your sevelamer to lanthanum. we have not made any other significant changes to your medications this hospitalization. you are being discharged to rehab and should follow up with your primary care doctor to home. followup instructions: please follow up with your primary care doctor after your from rehab. the rehab doctors help arrange this. procedure: hemodialysis diagnoses: thrombocytopenia, unspecified end stage renal disease renal dialysis status coronary atherosclerosis of native coronary artery esophageal reflux toxic encephalopathy depressive disorder, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease acute respiratory failure pneumonitis due to inhalation of food or vomitus surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation other late effects of cerebrovascular disease long-term (current) use of anticoagulants late effects of cerebrovascular disease, hemiplegia affecting unspecified side dehydration systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction chronic viral hepatitis b without mention of hepatic coma without mention of hepatitis delta delirium due to conditions classified elsewhere other complications due to renal dialysis device, implant, and graft unspecified deficiency anemia intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) other late effects of cerebrovascular disease, facial weakness vascular disorders of penis generalized convulsive epilepsy, without mention of intractable epilepsy hypoglycemia, unspecified unspecified disorder of metabolism late effects of cerebrovascular disease, dysarthria vascular dementia, with delirium chronic venous embolism and thrombosis of internal jugular veins 

Answer: The patient is high likely exposed to