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: fever major surgical or invasive procedure: picc line placed: history of present illness: mr. is a 39 year old patient with nhl s/p allosct and dli , in remission but with gvhd-associated bronchiolitis obliterans and severe restrictive lung disease who was recently admitted with fever, hypoxia and respiratory distress and discharged to on . he is readmitted today in the setting of fever and increased cough. . please see discharge summary from and for details of his previous hospitalizations. in brief, the patient has pseudomonal infection of his lungs, he has been treated with 21 day course of colistin and meropenem to treat this, and was on colistin ih for suppression. additionally, he has an upper extremity dvt that, since that admission, is being treated with fondaparinux 2.5 mg subq, lower dose secondary to history of serious gi bleeding. . per rehabilitation notes, the patient spiked temperature to 101.6, and wbc count increased to 25.5. he resports increased coughing. he had some low bloood pressures, 90/53 and 107/73. additionally, given the worsening symptoms, on , he recieved 1 dose of 125mg iv colistin (rehab discussed with outpatient id attg, dr. . . on admission to the icu the patient is comfortable. he denies, abdominal pain, dysurea. reports increased cough and fevers while at rehab. . in the er, initial vitals t101.1, bp 122/79, hr 122, rr 18, vented. he recieved vancomycin 1gm iv, zosyn 4.5mg iv, tylenol 1gm po, morphine 2mg ivx1. past medical history: past oncologic history: - p/w fevers, night sweats, and weight loss in the setting of a left inguinal lymph node. - ct scan: 15x14x10cm mass in the luq. - bx grade ii/iii follicular lymphoma. - treated with six cycles of chop/rituxan with good response, but showed evidence for relapse in and was treated with mine chemotherapy for two cycles. - : underwent stem cell mobilization with cytoxan followed by autologous stem cell transplant in - : noted for disease recurrence. he was initially treated with a course of rituxan without response followed by zevalin with - : noted progression of his disease. he was treated with one cycle of followed by one cycle of eshap. - : nonmyeloablative allogeneic stem cell transplant with a hla-matched unrelated donor with campath conditioning - six-month follow-up ct noted for disease progression. - : received donor lymphocyte infusion in , complicated by acute liver/gi gvhd grade iv, for which required a prolonged hospitalization in the summer of . - multiple gi bleeds requiring icu admissions and multiple transfusions and embolization of his bleeding. - noted to have cns lesions felt consistent with ptld and this was treated with a course of rituxan. no evidence for recurrence of the ptld. - acute liver gvhd, on cellcept, prednisone, and photophoresis. - photophoresis was d/c'd due to episodes of bacteremia and eventual removal of his apheresis catheter. - restarted photopheresis on a weekly basis on , but then discontinued this again on as this was felt not to be making any impact on his liver function tests. - undergone phlebotomy due to iron overload with corresponding drop in his ferritin. he has continued with transient rises in his transaminases and bilirubin and has remained on varying doses of cellcept and prednisone which has been slowly tapered over the time. - cellcept discontinued. - admission due to increasing right hip pain. mri revealed edema and infiltrating process in the psoas muscle bilaterally. after extensive workup, this was felt related to an infection and required several admissions with completion of antibiotics in 03/. - : last scans showed no evidence for lymphom and he has remained in remission. - : uri and treatment with course of levaquin. - completed a 4 week course of rituxan to treat his gvhd. -in , noted to have tiny echogenic nodule on abdominal . mri of the liver also showed this nodule but was not as concerning on review and he is due to have a repeat mri imaging in early . -- gi varices and attempts at banding have been unsuccessful due to difficulty with passing the necessary instruments. he has been on a low dose beta blocker as well as simvastatin, which was started on to help with medical management of his varices. -on , worsening cough and was noted to have a small new pneumothorax in the left apical area. this has essentially resolved over time - issues with weight loss (followed by dr. ); multiple tests done with no etiology found; question malabsorption related to gvhd - has on and off respiratory infections and has been treated with antibiotics (now colistin inhaled and iv) for resistant pseudomonas. question underlying exacerbations of pulmonary gvhd in setting of his uris. - currently receives ivig every month. . other past medical history: 1. non-hodgkin's lymphoma s/p allo sct 2. grade 4 acute gvhd of gi/liver following dli with gi bleed, chronic transaminitis, portal htn with esophageal varices (not able to band) 3. history of intracranial lesions felt consistent with ptld. 4. extensinve chronic gvhd of lung, liver, skin, mucous membranes. 5. grade ii esophageal varices, intollerant to beta blockade. 6. hsv in nasal washing (completed course of valtrex) 7. hypothyroidism 8. hx of psoas muscle infection social history: smoke: never etoh: none currently; occassional use prior to nhl dx drugs: never born in and moved to the u.s. for college (). married in and lives in . no children. stays at home and writes (currently writing a book on being diagnosed with cancer at young age). family history: no lymphoma or other cancers in the family. father had cad s/p pci. physical exam: on admission: vitals: t 99, hr 93, bp 91/61, sat 100% on ac 500/18/8/50% gen: cachectic male heent: sclera anicteric nec: trach in place cv: tachycardic, no m/r/g pulm: coarse breath sounds bilaterally, no wheezes, crackles abd: soft, nt, nd, bowel sounds present ext: no peripheral edema pertinent results: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:25 11.1* 2.54* 7.4* 23.6* 93 29.0 31.2 16.3* 344 05:29 58* 70* 640* 0.7 source: line-picc other enzymes & bilirubins lipase 05:30 80* imaging: ct chest findings: the endotracheal tube terminates 1.9 cm above the carina. a right-sided picc line terminates at the cavoatrial junction. an ng tube is identified inferiorly to level of the stomach. there has been interval worsening of multifocal bilateral nodular airspace opacities which are most prominent in the right upper lobe, some of which have air bronchograms. also noted are numerous tiny centrilobular nodules at the lung bases, right greater than left. moderate bilateral pleural effusions and adjacent compressive atelectasis is again identified. secretions are noted within the superior aspect of the trachea. he heart is normal in size. there is no pericardial effusion. no pathologically enlarged mediastinal lymph nodes are identified. the visualized upper abdominal organs are unchanged in appearance with no gross abnormalities identified. no suspicious lytic or sclerotic lesions are identified within the osseous structures. impression: 1. interval worsening of multifocal nodular opacities, most prominent in the right upper lobe compared to prior ct of , which may represent recurrent or residual worsening infection. however, given the possible chronicity of these findings, organizing pneumonia cannot entirely be excluded. 2. stable moderate bilateral pleural effusions and adjacent airspace disease, which is at least in part secondary to atelectasis. 3. redemonstration of secretions within the superior trachea, slightly increased when compared to the prior study. chest x ray: findings: the tracheostomy tube is in place, with its tip 3 to 3.5 cm above the carina. an endogastric tube projects over the antrum of the stomach. additionally, coils projecting over the epigastrium are consistent with embolization coil. the heart and mediastinal contours appear unremarkable. the previously described right upper lobe and retrocardiac opacities persist with increase of the retrocardiac opacity. this likely represents components of atelectasis and consolidation. additionally, in the right lower lobe, at the right cardiophrenic angle, there is developing opacity concerning for additional foci of pneumonia. bilateral effusions persist. there is no pneumothorax. the osseous structures appear intact. impression: multifocal opacities, worse in the retrocardiac and right cardiophrenic regions; unchanged small bilateral pleural effusions. 10:07 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. heavy growth. colistin susceptibility requested by dr. (#) . colistin sensitive at <=2 mcg/ml. pseudomonas aeruginosa. heavy growth. colistin susceptibility requested by dr. (#9/0841) . colistin sensitive at <=2 mcg/ml, sensitivities performed by laboratories. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | pseudomonas aeruginosa | | amikacin-------------- 8 s 16 s cefepime-------------- 8 s 16 i ceftazidime----------- 4 s 8 s ciprofloxacin--------- =>4 r =>4 r gentamicin------------ =>16 r =>16 r meropenem------------- 4 s 8 i piperacillin/tazo----- =>128 r =>128 r tobramycin------------ =>16 r =>16 r brief hospital course: fevers: the patient was admitted from rehab after less than 48 hrs since his discharge for multidrug resistant pseudomonas. he presented with fevers and hypotension. he complained of increased yellow/white sputum, so it was thought that the source of his fevers was recurrent lung infection. a ct chest revealed multifocal nodular opacities, most prominent in the right upper lobe consistent with recurrent pneumonia. he was started on meropenem in addition to iv and inhaled colistin. c diff was initially in the differential and he was started on po vancomycin. however he had two stools that were negative for c diff so this antibiotic was stopped. urine and blood cultures were obtained and were negative. sputum showed two strains of psuedomonas that were sensitive to amikacin and intermediately sensitive to meropenem. id was closely involved and felt that slow infusion meropenem was appropriate treatment in addition to iv colistin. he did well with only occasional low grade fevers and decreased sputum. he completed 17/28 days of meropenem and colistin by day of discharge. last day of antibiotics will be on . he was discharged on a regimen of meropenem and colistin for 6 more days (to be completed ) and daily prophylaxis of bactrim, acyclovir, voriconazole. he will follow up with id outpatient. leukocytosis: mr. presented with an elevated white count of 28 with left shift. wbc trended down with initiation of meropenem and colistin and was 11 on day of discharge. pt was briefly given flagyl for empiric treatment of presumptive c. diff but stopped treatment when toxins repeatedly returned negative. ventilator dependence: pt has history of bronchiolitis obliterans from allo-sct with tracheostomy. he has history of pseudonomas infections and hospitizations for pneumonias. the patient initially presented on a ventilator with the following settings: assist control 400/18/8/50%. he had been unable to wean off the vent at rehab and during his previous hospitalization due to increased secretions. while in icu, was put on pressure support trials and some days was able to undergo trach collar for a few hours at a time. at night he would request to be put back on assist control and tolerated ps during the day. he was given chest pt. it will be important to continue to encourage trach collar trials and aggressive chest pt for the goal of becoming ventilator independent. there was some discussion of lung transplant and coordinating outpatient meeting with the pulm transplant team at . before meeting with physicians there, he must meet criteria of walking 500 ft in 6 minutes which he has not yet achieved. upper extremity dvt: the patient was found at his previous hospitalizations to have a lue dvt. given his history of massive gi bleed (secondary to gvh of gi)it was decided not to anticoagulate him with theraputiuc doses of heparin. he was eventually switched to fundaparinoux. during the present hospitalization he was continued on low dose fundaparinox, 2.5mg. on there was questionable right upper extremity swelling in the arm with his picc. leni negative. day before discharge he had repeat u/s of left upper extremity and showed no progression of clot in brachial v. decision was made to stop fundaparinox. graft versus host disease: the patient was continued on his regimen of prednisone 15mg, mycophenolate 250mg dialy, and prophylactic bactrim, acyclovir, and voriconazole. nutrition/electrolytes: he lost about 4kg since admission despite appropriate tube feeds and tpn. nutrition was closely involved. pt likely has malabsorption in setting of gvhd of gi. by day of admission, he was getting tpn 42 ml/hr, tube feeds 60ml/hr in addition to 200cc free water boluses every 4 hours through ngt. nhl: mr. is status post allo complicated with gvhd of gi and bronchiolitis obliterans. was closely involved in patient's care. he was given prednisone, mycophenolate, acyclovir, bactrim, and voriconazole. pt also received ivig for low levels of igg. pt has been recieving infusions of ivig every 2-3 weeks. psych: seen by psych who felt that he had adjustment disorder related to medical illness but he declined treatment with ssri at this moment. medications on admission: acyclovir 400mg every 12 hours ascorbic acid 500mg daily colistin 75mg inh qmwf ergocalciferol 50,000 units every saturday ferrous sulfate 300mg liquid daily fluticasone intranasally 1 spray daily fondiparinux 2.5mg sc dailt lansoprazole 20mg daily levothyroxine 125mcg daily mycophenolate mofetil 250mg daily prednisone 15mg daily bactrim ds qmwf voriconazole 200mg every 12 hours zinc sulfate 22mg daily prns: tylenol 650mg ever 4 hours as needed acetylcysteine 10% neb every 4 hours as needed albuterol 6 puffs every 2 hours as needed guaifenesin 200mg every 6 hours as needed lorazepam 1mg every 4 hours as needed morphine 2mg every 2 hours as needed zogran 8mg as needed senna 10mg as needed simethicone 80mg as needed trazdone 25mg as needed nightly insomnia . discharge medications: 1. colistimethate sodium 150 mg recon soln : 75mg recon solns injection days (mo,we,fr) as needed for : continue indefinitely . 2. meropenem 1 gram recon soln : 1000 mg recon solns intravenous q8h (every 8 hours): 6 more days through . 3. colistimethate sodium 150 mg recon soln : 125 mg recon solns injection q12h (every 12 hours): take 6 more days through . 4. acetaminophen 325 mg tablet : 650 mg tablets po q6h (every 6 hours) as needed for pain/fever: indefinitely . 5. acyclovir 400 mg tablet : 400 mg tablets po q12h (every 12 hours): take indefinitely. 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : six (6) puff inhalation q2h (every 2 hours) as needed for sob: take as needed. 7. ascorbic acid 500 mg/5 ml syrup : 500 mg po daily (daily): take indefinitely. 8. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup : 5ml mls po q6h (every 6 hours) as needed for cough: take as needed. 9. ergocalciferol (vitamin d2) 50,000 unit capsule : 50,000 u capsules po 1x/week (sa): take once a week. 10. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : 300 mg po daily (daily). 11. fluticasone 50 mcg/actuation spray, suspension : one (1) spray nasal daily (daily). 12. lansoprazole 30 mg tablet,rapid dissolve, dr : 30 mg tablet,rapid dissolve, drs (daily). 13. levothyroxine 125 mcg tablet : 125 mcg tablets po days (mo,tu,we,th,fr,sa). 14. ondansetron 8 mg tablet, rapid dissolve : 8mg tablet, rapid dissolves po q8h (every 8 hours) as needed for nausea. 15. prednisone 5 mg tablet : 15 mg tablets po daily (daily): take indefinitely. 16. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 17. simethicone 80 mg tablet, chewable : 40-80mg tablet, chewables po qid (4 times a day) as needed for indigestion. 18. sulfamethoxazole-trimethoprim 800-160 mg tablet : 1 tab tablet po days (mo,we,fr): take indefinitely. 19. trazodone 50 mg tablet : 25 mg tablets po hs (at bedtime) as needed for insomnia. 20. voriconazole 200 mg tablet : 200 mg tablets po q12h (every 12 hours): take indefinitely. 21. zinc sulfate 220 mg capsule : 220 mg capsules po daily (daily). 22. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q2h (every 2 hours) as needed for sob/wheezing. 23. acetylcysteine 20 % (200 mg/ml) solution : 20% 6-10 ml neb mls miscellaneous q2h (every 2 hours) as needed for secretion. 24. cyanocobalamin 250 mcg tablet : 250mcg tablets po daily (daily). 25. insulin regular human 100 unit/ml solution : one (1) injection asdir (as directed): please follow attached sliding scale. 26. heparin, porcine (pf) 10 unit/ml syringe : 10 u mls intravenous prn (as needed) as needed for line flush: prn to flush picc line. flush 10 ml ns followed by heparin (10u/ml) 2 ml iv daily and prn per lumen. 27. lorazepam 2 mg/ml syringe : 0.5-2.0mg injection q4h (every 4 hours) as needed for anxiety. 28. morphine 2 mg/ml syringe : 2mg injection q2h (every 2 hours) as needed for pain. 29. mycophenolate mofetil hcl 500 mg recon soln : 250 mg recon solns intravenous (2 times a day): take indefinitely. 30. ondansetron hcl (pf) 4 mg/2 ml solution : 4mg injection q8h (every 8 hours) as needed for nausea. 31. diphenhydramine hcl 50 mg/ml solution : 25 mg injection q6h (every 6 hours) as needed for pre-medication for ivig: take before ivig. 32. heparin, porcine (pf) 10 unit/ml syringe : 2ml (10u/ml) mls intravenous prn (as needed) as needed for line flush: flush picc with ns followed by heparin. discharge disposition: extended care facility: - discharge diagnosis: ventilator associated pneumonia deep vein thrombosis acute on chronic hypoxemic respiratory failure malnutrition non hodgkins lymphoma status post bone marrow transplant acute renal failure graft versus host disease bronchiolitis obliterans hypothyroidism discharge condition: level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital with fever and high white blood cells possibly indicating infection. your infection was partially treated with antibiotics. please continue taking meropenem and colistin antibiotics for total course of 28 days through . you have 6 more days left at the day of discharge. please continue your tpn (42ml/hr) and tube feeds (60ml>hr) to ensure appropriate nutritional status. continue to take your prophylactic bone marrow transplant medications each day: bactrim, acyclovir, voriconazole to prevent infections in an immunocompromised state. you made great progress with walking toward the end of your hospitization. please continue to walk each day with a goal of 500 ft in 6 minutes. followup instructions: provider: , md phone: date/time: 2:00 provider: , md at 11:30 am. on . phone: provider: , m.d. phone: date/time: 2:30 provider: , md and pulmonary transplant group at . clinic number . pt's family to call to set up appt. provider: , phone: date/time: 11:30 md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances diagnoses: acute kidney failure, unspecified hyposmolality and/or hyponatremia portal hypertension unspecified acquired hypothyroidism acute and chronic respiratory failure complications of transplanted bone marrow accidents occurring in other specified places hypoxemia diarrhea esophageal varices in diseases classified elsewhere, without mention of bleeding surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation ventilator associated pneumonia pseudomonas infection in conditions classified elsewhere and of unspecified site tracheostomy status other specified alveolar and parietoalveolar pneumonopathies nodular lymphoma, unspecified site, extranodal and solid organ sites acute on chronic graft-versus-host disease 

Answer: The patient is high likely exposed to