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: history of present illness: this is a 77-year-old gentleman status post left lower lobe lung lobectomy who was transferred to the medical intensive care unit team from the surgical intensive care unit team on for failure to wean off ventilation. the patient is a 77-year-old gentleman with a history of throat cancer who presented to in for leg claudication and at that time an admission chest x-ray showed right upper lobe and left lower lobe lung masses. at that time he had a right upper lobe wedge resection and pleural biopsy which was negative for malignancy on pathology, and he also had a negative bone scan and head mri for metastatic disease. in of this year he was admitted again for an uncomplicated left femoral peroneal bypass surgery for his leg claudication, and further workup at that time revealed a left lower lobe 3-cm mass. so, he was electively admitted on for a left lower lobectomy. he had no immediate complications post surgery and was easily extubated. however, on postoperative day one he had an episode of atrial fibrillation and hypotension, and he was transferred to the intensive care unit. a swan-ganz catheter was placed with initial of right atrium 4, pulmonary artery pressure of 38/14, cardiac output of 5.9, cardiac index of 3.2, and systemic vascular resistance of 1038. he was aggressively volume resuscitated and then intubated for progressive respiratory distress. a neo-synephrine drip was initiated. he also had several bronchoscopies during this admission which showed multiple mucous plugs and left upper lobe collapse. sputum from the bronchoscopy grew klebsiella and serratia which were pan sensitive, and he was started on ciprofloxacin and ceftazidime. he was briefly extubated between and ; however, he was reintubated for respiratory distress on . his chest x-ray showed progressive bilateral multilobar pneumonia versus acute respiratory distress syndrome. efforts at weaning were limited by secretions, high oxygen requirement, and increased respiratory rate if pressure support was decreased, and he was requested to be transferred to the medical intensive care unit for further management. past medical history: 1. throat cancer, status post radiation therapy complicated by esophageal stricture requiring dilation. 2. bilateral leg claudication, status post left femoral peroneal bypass in . 3. hypertension. 4. hypothyroidism. 5. diverticulitis. 6. cervical spine fusion. 7. status post appendectomy. 8. status post colectomy secondary to diverticulitis. 9. bilateral carotid asymptomatic 60% stenosis. medications on admission: ciprofloxacin 400 mg intravenous q.12h., ceftazidime 2 g intravenously q.8h., lopressor 5 mg intravenously q.6h., nitroglycerin q.h.s., neo-synephrine drip, procainamide drip, ativan drip 2 mg per hour, morphine drip 2 mg to 4 mg per hour, haldol 1 q.2h., sliding-scale regular insulin, synthroid 0.1 mg intravenously q.d., reglan 10 mg intravenously q.8h., albuterol/atrovent meter-dosed inhalers, flovent 2 puffs b.i.d., colace 100 mg p.o. b.i.d., dulcolax 1 p.r. q.d., and nystatin swish-and-swallow. allergies: no known drug allergies. social history: the patient lives in with his wife. has two sons who are actively involved in his life. he has a history of tobacco for 40 years and quit 20 years ago. he is an occasional alcohol drinker. prior to this admission the patient was in a wheelchair with a decreased quality of life that he was unhappy with. physical examination on presentation: vital signs were temperature maximum of 99.5, pulse of 92, blood pressure between systolic 103 to 169 and diastolic 40 to 60. in general, on ventilation at ac with a tidal volume of 550, respiratory rate of 20, fio2 of 0.7, peep of 8; most recent arterial blood gas 7.28/59/78. ins were 1841, outs 1535, net positive 306. length of stay fluid balance -11.9 liters. in general, an elderly gentleman lying in bed, intubated and sedated. heent revealed pinpoint pupils, minimally reactive. neck was supple. no jugular venous distention. cardiovascular revealed distant heart sounds, regular rate and rhythm. normal s1 and s2. lungs revealed left lung with coarse breath sounds, right upper quadrant coarse breath sounds. no wheezes. abdomen was soft, slightly distended, very hypoactive bowel sounds. extremities were thin, muscle wasting. no edema. neurologically, intubated and sedated. pertinent laboratory data on admission: white blood cell count 21.1, hematocrit 32.5, platelets 382. sodium 140, potassium 3.9, chloride 107, bicarbonate 27, bun 42, creatinine 1.2, glucose 129, anion gap 10. calcium 8.1, ionized calcium 1.18, phosphorous 2.7, magnesium 2. urinalysis was negative on . microbiology on bronch growing pan-sensitive klebsiella and serratia. on , sputum growing oropharyngeal flora. on , catheter tip growing vancomycin-sensitive enterococcus. blood cultures negative to date. urine cultures negative to date. pulmonary function tests on revealed fev1 of 1.34 (57% of predicted), fev1:fvc 106% of predicted, tlc 75% of predicted, dsbva 53% of predicted, bl/va 85% of predicted; with conclusion consistent with an interstitial process. radiology/imaging: chest x-ray on revealed extensive left lung consolidation throughout, right upper lobe consolidation, probable left lower lobe effusion. abdominal ultrasound on revealed biliary sludge, no obstruction, fatty liver. most recent electrocardiogram on revealed sinus at 90, normal axis, intervals 0.2/0.12/0.36, diffuse t wave flattening in limb leads which were new compared to preoperative electrocardiogram on . no acute st-t wave changes. echocardiogram stress in showed an ejection fraction of 60% to 70%, no wall motion abnormalities, no ischemia. left lower lobe pathology revealed squamous cell carcinoma with no lymph node involvement. impression: a 77-year-old gentleman status post left lower lobectomy on postoperative day 15 with diffuse alveolar infiltrates and consolidations suggestive of pneumonia bilaterally; now with difficulty weaning from mechanical ventilation. hospital course: 1. pulmonary: the patient was status post left lower lobectomy. this fact, and his diffuse pneumonia would cause a decrease in ventilation. the patient was hypoxic on an fio2 of 5.55. he also had a decreased compliance suggestive of possible acute respiratory distress syndrome. his hypercarbia was secondary to poorly ventilated areas of his lungs. he was followed on arterial blood gas and was on assist control ventilation while in the medical intensive care unit. he became progressively acidotic by his followed arterial blood gas, and his set respiratory rate was increased to compensate for his metabolic acidosis. he was continued on ciprofloxacin and ceftazidime for his serratia/klebsiella pneumonia. a repeat chest x-ray showed continuation of diffuse alveolar infiltrations bilaterally, left greater than right. his metabolic acidosis was most likely secondary to his progressive renal failure. on the night of , he was started on a bicarbonate drip given his worsening acidosis. his lactate was 1.5. it was decided to increase his sedation by increasing the amount of ativan he was receiving and morphine he was receiving. on , his morphine was changed to fentanyl. with increased sedation his arterial blood gas results remained steady, and he seemed to be more in synchronization with the ventilation. 2. cardiovascular: (a) rhythm: his of atrial fibrillation during this hospitalization with rapid ventricular rate. he was started on procainamide drip by the surgical team; however, since postoperative day one he had normal runs of atrial fibrillation and once he was transferred to the medical intensive care unit, the procainamide drip stopped. he had no more runs of atrial fibrillation under the medical intensive care unit's care. the patient was hypotensive; thought to be secondary to possible sepsis. however, in order to rule out cardiogenic shock, and echocardiogram was done on which was within normal limits. the neo-synephrine drip was unable to be weaned off; and in fact, because of his progressive hypotension, vasopressin drip was added on . he was also given intravenous fluids boluses which only helped temporarily to support his blood pressure. on , his neo-synephrine drip was changed to levophed drip for more beta agonist effects. cortisol was added to his laboratories to check for adrenal insufficiency as an etiology for his hypotension. 3. infectious disease: the patient with multilobar pneumonia with sputum growing klebsiella and serratia pan sensitive. he was continued on ciprofloxacin and ceftazidime. his subclavian tip grew vancomycin-sensitive enterococcus and was removed. he was given one dose of vancomycin for this at 1 g. blood cultures did not grow anything to date. on , two more blood cultures were checked as they were on given his rising temperature. urine cultures were also negative to date. his white blood cell count continued to rise despite his antibiotic treatment, and with his hypotension this was consistent with a septic picture. a sputum culture was sent on . 4. renal: the patient developed progressive acute renal failure. this was thought to be secondary to acute tubular necrosis from his hypotension. his kidneys did not seem to respond well to intravenous fluids boluses. urine electrolytes were checked, and his fena was calculated at 1.3; not consistent with a prerenal etiology. free water was restricted and all intravenous medications were placed in normal saline. all of his medications were renally doses on , and his urine output progressively decreased and became darker in coloration. 5. oncology: squamous cell carcinoma of the lung; staging unclear. lymph node involvement. 6. gastrointestinal: the patient was on total parenteral nutrition. he had a dobbhoff feeding tube in place situated correctly in post pyloric; however, because of his increasing liver function tests tube feeds were held off, and then they were never started because of his lack of bowel sounds and lack of peristalsis. he was continued on total parenteral nutrition. the patient's liver function tests were also noted to be increasing, particularly his ast, alkaline phosphatase, and direct bilirubin. this was thought to be secondary to mixed picture of shocked liver versus obstructive due to total parenteral nutrition versus ceftazidime or other medications causing hepatic obstruction. enzyme elevation: a right upper quadrant ultrasound was done on which revealed no gallbladder wall thickening or pericholecystic fluid, no biliary obstruction. coarse hypoechoic appearance to the liver which was suggestive of fatty liver versus other forms of liver disease including significant hepatic fibrosis/cirrhosis; unchanged from his previous right upper quadrant. because of his increasing blood glucose levels the amount of insulin in his total parenteral nutrition was increased accordingly. 7. hematology: the patient's hematocrit remained stable while in the medical intensive care unit, although he did require 2 units of packed red blood cells transfusion on under the surgical team's care. hemolysis laboratories were negative and reticulocyte count was 4, indicating an appropriate bone marrow response to anemia. rectal examination was empty of stool, and therefore could not be guaiaced. however, he did have diarrhea on which was guaiac-negative. clostridium difficile toxin was sent on his diarrhea. 8. fluids/electrolytes/nutrition: the patient was on total parenteral nutrition. his phosphorous was climbing with his renal insufficiency, and therefore it was not added to his total parenteral nutrition. tube feeds were not initiated. his blood glucose did increase, most likely secondary to the total parenteral nutrition and insulin was added to the total parenteral nutrition. an insulin drip was considered but never started, although his insulin sliding-scale was adjusted accordingly. 9. lines: right subclavian line, left arterial line placed on . peripheral access, protonix, and subcutaneous heparin. 10. code status: when the patient was transferred from the surgical intensive care unit to the medical intensive care unit his code was reported as full. however, on a family meeting was called given his progressive multiorgan failure. i, , and the pulmonary critical care fellow, dr. , met with the patient's wife and two sons at 4 p.m. on to discuss his medical status. dr. was present for the first portion of the discussion. it was explained to the family that mr. was in multisystem failure; namely: 1. pulmonary: he was ventilator dependent, increasingly so, requiring increased sedation to passively ventilate him. his respiratory status was complicated by his underlying lung cancer. his recent left lower lobectomy which reduced his lung volumes, his multilobar pneumonia, and acute respiratory distress syndrome. he was approaching intubation for 10 days, and therefore if aggressive care was continued a tracheostomy would be considered; however, in his current status he may not tolerate a tracheostomy placement especially given his underlying throat cancer. 2. renal: the patient was in worsening renal failure and worsening acidosis as a result with decreased urine output, and the next therapeutic step would be to involve the renal team and initiate hemodialysis. they were also told that a bicarbonate drip was started for his acidosis. 3. hemodynamics: hemodynamic wise, he was hypotensive and dependent on two pressors; namely, levophed and vasopressin drip to maintain his blood pressure. he also had the history of atrial fibrillation during his hospital stay. 4. gastrointestinal: gastrointestinal wise, the patient would not be able to be tubed fed yet and was dependent on total parenteral nutrition which is not an ideal form of nutrition. 5. liver: the patient has having increasing liver function tests and was in moderate liver dysfunction. it was discussed that his prognosis was very grave given this multisystem failure and that there was a small chance of survival and recovery from this. his wife brought with her the patient's living will which was signed by him in in which he states that if he is in no position to speak for himself and in a state from which there was no hope of recovery he would desire no means of life-sustaining methods including no artifical ventilation, antibiotics or hemodialysis. his wife reiterated that he has verbally expressed this opinion to her in the recent past. the patient was recently in acute acidotic coma, and when he recovered expressed regret at surviving through hit. prior to this admission he was handicapped in a wheelchair and would not want to go back to his prior or worse quality of life. her sons were in agreement of this and confirmed that his status was do not resuscitate. after leaving his wife and sons on their own to discuss their father for 20 minutes they came to the decision to stop his two pressors and leave everything else going. his levophed drip and vasopressin drips were stopped at 6 p.m. on in his family's presence. dr. discussed the family discussion with the attending, dr. , and he was in full agreement with the plan. the patient's blood pressure and heart rate continued to decline off of the pressors, and at approximately 7:30 p.m. his monitor showed a flat line. the intern, was called to pronounce him. the patient was not breathing. he had no pulse. pupils were unreactive to light. he did not respond to noxious stimuli. he had no breath sounds, and he was pronounced dead at 7:30 p.m. the family declined an autopsy and were informed of his death. , m.d. dictated by: medquist36 d: 17:20 t: 13:03 job#: procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances other bronchoscopy closed [endoscopic] biopsy of bronchus diagnoses: acute kidney failure with lesion of tubular necrosis cardiac complications, not elsewhere classified atrial fibrillation urinary complications, not elsewhere classified malignant neoplasm of lower lobe, bronchus or lung pneumonia due to klebsiella pneumoniae 

Answer: The patient is high likely exposed to