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: hypoxia, sob major surgical or invasive procedure: chest tube placement x3 and removal central line placement and removal arterial line placement and removal intubation and mechanical ventilation bronchoscopy picc placement percutaneous gastrostomy-jejunostomy tube placement history of present illness: pt is a 74 yo m with history of copd(on home o2 4l nc) who presented to with sob and productive cough for several weeks. history was obtained from the records as the patient was intubated. at he was noted to have sats in the low 80's. there cxr showed right sided pleural effusion(concerning for an empyema). he was started on azithromycin, ceftriaxone, 125mg solumedrol and transferred to for further care. . per his wife he had been having pain in his right groin for about a week. pain improved with ibuprofen (800mg for 3 days) and heating pad. pain migrated up to his right side of the chest wall. has lost about 15 pounds over the last 2 weeks. no fevers, chills. has been having cough with a small amount of sputum and occasionally blood. he developed worsening sob over last 24 hrs. at baseline is sob/doe and on 4l nc. decrease po's over this time. past medical history: copd/emphysema- on home o2 4l nc exposed to in the military social history: lives with wife. retired from the special forces. traveled abroad while in the service (, , ). started smoking at age 10. quit 4 years ago. normally smoked 3 ppd. drinks about cans per morning and glass of wine at night but drank more at other times of his life. family history: unknown per wife physical exam: t 100.4 bp 88/48 hr 130 rr 16 o2sats 100% vent settings ac 700/16/5/100% gen: agitated, thrashing around. able to nod yes/no to questions heent: perrl, mmm, anicteric, og tube in place with coffee ground like substance neck: no jvd, lad lungs: clear on the left. right side coarse breath sounds, with diminished breath sounds at base heart: tachy, no m/r/g abd: soft, nt, nd + bs liver edge 2 cm below costal angle ext: no edema, 1+ dp/pt bilaterally neuro: sedated but moving all 4 extremities pertinent results: 04:10am plt count-930* 04:10am wbc-37.7* rbc-3.83* hgb-14.0 hct-41.6 mcv-109* mch-36.6* mchc-33.7 rdw-15.3 04:10am neuts-92* bands-5 lymphs-1* monos-2 eos-0 basos-0 atyps-0 metas-0 myelos-0 04:10am ck-mb-notdone ctropnt-<0.01 04:10am ck(cpk)-47 04:10am glucose-83 urea n-28* creat-1.3* sodium-137 potassium-4.7 chloride-97 total co2-20* anion gap-25* 04:24am type-art po2-31* pco2-44 ph-7.36 total co2-26 base xs--1 05:00am urine rbc-0-2 wbc-0-2 bacteria-none yeast-none epi-<1 renal epi- 05:00am urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 05:00am urine color-yellow appear-clear sp -1.016 08:12am lactate-1.2 08:12am type-art temp-38.3 tidal vol-700 po2-248* pco2-41 ph-7.33* total co2-23 base xs--4 intubated-intubated 10:30am pleural wbc-* rbc-1375* polys-95* lymphs-3* monos-2* 10:30am pleural tot prot-3.3 glucose-54 ld(ldh)-1302 amylase-27 albumin-1.5 11:56am pt-15.6* ptt-34.2 inr(pt)-1.4* 11:56am calcium-7.0* phosphate-4.1 magnesium-1.7 11:56am ld(ldh)-234 06:15pm hct-32.4* . cxr: findings: compared with 04/16, allowing for differences in position, the left pleural effusion is probably not significantly changed. . the multifocal infiltrates in the right mid and lower lung fields appear to have become more confluent superiorly. persistent retrocardiac collapse/consolidation. . the visualized portions of the left lung are grossly clear. no chf . ct chest: impression: 1. complex-appearing right pleural effusion, with loculated components. the pleura does not clearly enhance, thus this loculated effusion is not necessarily an empyema. 2. there is dense consolidative change with cystic spaces within the right lower lobe. the finding is concerning for a cavitating pneumonia. however, this lung parenchyma is not evaluated for an underlying mass lesion, and one cannot be excluded. 3. severe emphysematous changes of the lungs. 4. scattered nodular opacities within the left lung. three-month ct followup is recommended. 5. small pericardial effusion. 6. 5 cm arterially enhancing mass of the liver at the confluence of hepatic veins, not characterized. when the patient's condition improves, if he is able to breath hold, a contrast enhanced mri is recommended. if he cannot breath hold, multiphase ct is recommended. . ruq u/s: abdominal ultrasound: the liver is normal in echotexture. multiple hepatic cysts are seen, the largest of which is in the right lobe measuring 4.3 x 3.8 x 4.3 cm. additionally, there is a hypoechoic solid lesion in the lateral aspect of the right lobe measuring 5.2 x 5.6 x 4.7 cm. this lesion has a central feeding artery. multiple small stones are seen within the gallbladder and the wall is thickened measuring 3 mm, however this is likely related to hypoalbuminemia as there is a small amount of ascites and large left pleural effusion. the gallbladder is not distended. common hepatic duct measures 1.3 cm and the pancreatic duct is also mildly dilated measuring 0.3 cm. no discrete pancreatic head mass is identified. the portal vein is patent with anterograde flow. limited views of the kidneys demonstrate no hydronephrosis. an additional solid hypoechoic vascular mass is seen above the left kidney measuring 3.3 x 2.6 x 3.4 cm. impression: 1. solid hypoechoic masses are seen in the right lobe of the liver and above the left kidney, concerning for metastases. recommend ct of the abdomen for metastatic work-up, or hepatic mri if there is clinical concern for a primary hepatocellular carcinoma. 2. multiple hepatic cysts. 3. dilatation of the common hepatic duct and pancreatic duct with no discrete mass seen in the pancreatic head. again, this could be evaluated with abdominal ct. 4. cholelithiasis and gallbladder wall edema, likely related to hypoalbuminemia. 5. a small amount of ascites and large left pleural effusion. . echo: ef 75-80% conclusions: no atrial septal defect is seen by 2d or color doppler. left ventricular systolic function is hyperdynamic (ef>75%). the right ventricular cavity is mildly dilated. right ventricular systolic function is normal. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. . pleural fluid negative for malignancy . ct abd/pelvis impression: 1. poorly defined predominantly hyperehancing mass within the medial right hepatic dome just to the right of the ivc surrounding and narrowing the right hepatic vein. ct imaging characteristics are not specific but differential includes hepatocellular carcinoma, hepatic adenoma or even a solitary metastasis. further charactherization of this mass is recommended with mri. 2. complex right lower lobe empyema/parapneumonic effusion. there is an adjacent right lower lobe consolidation. 3. decrease in the more simple-appearing left pleural effusion and left lower lobe atelectasis. 4. gallstones. 5. several left upper quadrant splenules. 6. multiple hepatic and renal cysts. 7. descending and sigmoid colonic diverticula. 8. 2-3 mm lingula nodule. interval follow up is recommended. length of follow up (3-6 months vs 1 year) should be determined based on whether the patients has a primary malignancy . liver biopsy: liver needle biopsy: adenocarcinoma. immunostains of the tumor are strongly positive for cytokeratin ck7, weakly positive for ck20, and negative for ttf-1, with satisfactory controls. iron stain: moderate iron deposition in hepatocytes. trichrome stain is reviewed. note: the tumor histology and immunostains are most consistent with a biliary/pancreatic origin, including both primary cholangiocarcinoma and metastatic disease. dr. was provided a preliminary diagnosis on . . colonoscopy findings: protruding lesions a single sessile 4 mm polyp of benign appearance was found in the ascending colon. a piece-meal polypectomy was performed using a hot snare. the polyp was completely removed. impression: polyp in the ascending colon (polypectomy) otherwise normal colonoscopy to cecum . egd: findings: normal esophagus, stomach, and duodenum. no signs of bleeding. . ct torso: 1. persistent right empyema with adjacent opacities consistent with pneumonia, aspiration or atelectasis. 2. increased intra- and extrahepatic biliary ductal dilatation, as well as somewhat increased prominence of the pancreatic duct. this could suggest an obstructive process near the ampulla, and although no stone or clot is directly observed there, the presence of a stone or blood clot would often not be observable on ct. 4. cholelithiasis. 5. satisfactory position of gastrojejunostomy tube. 6. stable l2 compression fracture. . labs on discharge: na 140 cl 104 bun 16 glc 99 k 3.7 co2 30 cr 0.5 phos: 2.0 wbc 12.1 hgb 8.6/hct 26.1 plts 711 brief hospital course: pt is a 74 yo male with a history of copd admitted with strep milleri empyema, now s/p ct tube removal and full course abx, with intercurrent diagnosis of adenocarcinoma of likely biliary primary, course complicated by recurrent aspiration pna and blood loss anemia . # blood loss anemia- patient has chronic, macrocytic anemia likely due to alcohol use; b12 and folate were within normal limits. however, hct acutely dropped from 25.5 on to 19.1 on ; egd, , ct torso all negative for source of bleeding and hct responded appropriately to 2units prbcs and remained stable at 26-27. then, after peg placement, patient had maroon, guaiac positive stool x1, remained hemodynamically stable. lavage from peg was clear/yellow, no blood seen. patient has not had further melena although loose brown bowel movement yesterday was guaiac positive. ct abd/pelvis did not reveal any bleeding around peg site. discussed with gi briefly possible additional work-up for unexplained hct drops; ercp or push enteroscopy with side view scope could identify hematobilia if present, although this is unlikely as explanation of bleeding requiring transfusion since hematobilia would be more chronic; they could perform procedure diagnostically but there would not be endoscopic therapeutic options. therefore, monitor hct and transfusing supportively may be best option for this patient. continue ppi, iron. . # recurrent/aspiration pna: after completing full course (5 weeks) antibiotics for strep milleri pneumonia with empyema drained with chest tubes, patient had increasing rhonchi, leukocytosis, low grade fevers. given his known aspiration risk and prolonged hospital stay, treating empirically with zosyn/vanc for total 3 weeks, which will be through . continue pulmonary toilet, supplemental o2 . # persistent leukocytosis: wbc remains thousand despite long course of antibiotics directed at empyema; afebrile. continue antibiotics. . # copd- long time smoker, 4l o2 at home. received pulse dose steroids in icu in early . atrovent/alb inhalers. continue oxygen by nasal cannula. . # l2 vertebral body fracture: seen incidentally on ct torso, patient complained only of same chronic/intermittent lbp. neurosurg/spine saw patient and reviewed films, recommended tlso brace only if patient having pain that limits ambulation. . # etoh use- pt drinks 3-4 beers daily in morning and glass of wine at night. no signs/sx of withdrawal this admission and out of time window. continue mvi, thiamine, folate, b12 . # adenocarcinoma: per pathology prelim read, biopsy specimen c/w adenocarcinoma (not hepatocellular), unlikely lung or colon based on immunohistochemical staining so most likely cholangiocarcinoma. cea <1; afp 8.8 (0-8.7, ref range); ca19-9 26 (0-37, ref range). hep serologies neg. no h/o prostate ca and psa wnl. + strong smoking history so possibility of lung ca w/ met but no obvious lesion on ct chest. ? could be a lesion hiding in his rll pna/empyema. colonoscopy w/ one small polyp but no other concerning lesions. egd normal. remainder of staging will be completed as outpatient (arranged with dr by heme-onc consult team). . # thrombocytosis- multifactorial, from alcohol, iron deficiency, and inflammation. . # s/p percutaneous gastrostomy-jejunal feeding tube: patient required feeding tube for aspiration risk; speech and swallow therapists optimistic that patient will be able to regain swallow function with exercise. pain meds for tenderness at insertion site. per ir, sutures used to tack stomach to abd wall should be removed on ; sutures can be cut externally and internal/gastric portion will resorb/pass. . # fen- placed peg-j in ir. tf recs from nutrition: nutren pulm. goal 95ml/hr; will cycle over 14 hours at night when tolerating goal rate. . # ppx- heparin sc, bowel regimen, ppi . # access- picc (placed ) . # code- full . # communication- ( . # dispo- needs rehab bed medications on admission: 1. advair --patient unsure of dose 2. aspirin 81mg po daily 3. ipratropium bromide neb neb ih q6h 4. multivitamin 5. niaspan 750mg po daily 6. tiotropium bromide 1 cap ih daily discharge medications: 1. acetaminophen 325 mg tablet : 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 2. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection tid (3 times a day): until ambulatory. ml 3. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day) as needed for constipation. 4. bisacodyl 10 mg suppository : one (1) suppository rectal hs (at bedtime) as needed for constipation. 5. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 6. ferrous sulfate 325 (65) mg tablet : one (1) tablet po daily (daily). 7. tiotropium bromide 18 mcg capsule, w/inhalation device : one (1) cap inhalation daily (daily). 8. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 9. folic acid 1 mg tablet : one (1) tablet po daily (daily). 10. albuterol sulfate 0.083 % solution : one (1) neb inhalation q4-6h (every 4 to 6 hours) as needed for wheezing. 11. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours). 12. sertraline 50 mg tablet : one (1) tablet po daily (daily). 13. fluticasone-salmeterol 250-50 mcg/dose disk with device : one (1) disk with device inhalation (2 times a day). 14. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 15. piperacillin-tazobactam 4.5 g recon soln : one (1) recon soln intravenous q8h (every 8 hours) for 2 weeks. 16. vancomycin 1,000 mg recon soln : one (1) gm intravenous twice a day for 2 weeks. 17. morphine 2 mg/ml syringe : two (2) mg injection q4h (every 4 hours) as needed for pain. 18. picc line care picc line care per protocol discharge disposition: extended care facility: center discharge diagnosis: pneumonia empyema copd delirium macrocytic anemia adenocarcinoma in the liver discharge condition: hemodynamically stable. ambulatory. discharge instructions: you were admitted for pneumonia with an empyema (abscess next to the lung) and had chest tubes to drain your lung. you will need to be on antibiotics for a total of 30 days. . seek medical attention immediately if you develop fever, chills, increased shortness of breath or chest pain. . several of your medications were changed. followup instructions: an appointment has already been made for you with your new pcp, . for at 12:45 pm. tel (. . please call either dr. () or dr. () to make a follow-up appointment to pursue further work-up and treatment of your liver cancer. they are both based at and will have access to all of the results from your hospitalization. procedure: insertion of intercostal catheter for drainage insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more other endoscopy of small intestine insertion of endotracheal tube enteral infusion of concentrated nutritional substances closed (percutaneous) [needle] biopsy of liver thoracentesis arterial catheterization closed [endoscopic] biopsy of bronchus other incision of pleura endoscopic polypectomy of large intestine transfusion of packed cells percutaneous (endoscopic) jejunostomy [pej] infusion of vasopressor agent diagnoses: iron deficiency anemia secondary to blood loss (chronic) severe sepsis chronic airway obstruction, not elsewhere classified acute respiratory failure septic shock malignant neoplasm of liver, not specified as primary or secondary streptococcal septicemia benign neoplasm of colon other and unspecified alcohol dependence, unspecified empyema without mention of fistula delirium due to conditions classified elsewhere alcohol withdrawal essential thrombocythemia pneumonia due to other streptococcus 

Answer: The patient is high likely exposed to