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: fatigue major surgical or invasive procedure: central venous line placement (right ij) peg placement midline placement history of present illness: mr. is an 82m with a multiple medical problems including chronic progressive severe copd, complicated by two recent bouts of recurrent pneumonias in the past 4 months (s/p recent courses of levofloxacin, a five day course in , and recently completed a course on ), and failure to thrive. per report from his nh, he was noted at 6:30 pm on to be lethargic, with a t=95.6, hr=62, bp=74/42, rr=18. no o2sats were taken at the time. he was sent to the ed for evaluation. . in the ed, vital signs were t=96.8, bp 74/42, hr=67, rr=22, 96%2l. exam was notable for a severely cachectic elderly man, with clear breath sounds. a right ij was placed given his hypotension, 2lns bolused, and a levophed drip was started and titrated to 0.03 he recieved a dose of ceftriaxone and levofloxacin. . on ros mr. is sitting up in a chair, he states that his breathing is fair. he is complaining that he has been asked to feed himself with some assistance. he denies any headaches, confusion, changes in his vision, chest pain, abdominal pain, nausea, or swelling. he had some heel pain which has improved greatly with the soft boots that were placed on his feet. . in the icu he was started on levophed to maintain his bp which was weaned off by hospital day #2. he was continued on vanc/zosy/levofloxacin. he had permissible hypotension with sbp in the 80s and maps in the 50s. he was continued on a diet of thin liquids and moist soft solids. his code status was advanced to dnr/dni and plans for placement of a peg tube. . past medical history: --copd - fev1 51% predicted, fvc 57%, fev1/fevc 89% predicted; hospitalized for exacerbation in -- in sputum since - untreated, followed by pulmonology --atrial fibrillation - new in , not anticoagulated due to gi bleed at the time, on dilt and dig --echo : ef 55%, mod tr/mr, rv moderate global hypokinesis, borderline pulmonary artery systolic hypertension. --gi bleeding: egd showing multiple small avms in distal duodenum/prox jejunum, 1 large avm in distal duodenum s/p thermal therapy. colonoscopy showed diverticulosis. --anemia, mcv 107, on fe supp --cachexia anorexia, altered taste, needs peg social history: previously lived with wife in home. he has no history of living in nursing or facilities until this admission---> health center for rehab. he has 4 children, 3 in ma, involved in care tob: recently quit smoking, but has history of heavy smoking use. etoh: 2-3 beers/week.. illicits: none. family history: his sister died of lung cancer. no hx of cad, dm or htn. physical exam: t=96 orally... bp=92/54 hr=93s... rr=18... o2= 98% on 2l and rr = 18 . . physical exam general: severely cachectic, elderly man. pleasant, a+ox3, able to converse in detail. heent: normocephalic, atraumatic. +temporal wasting. no + conjuctival pallor. no scleral icterus. perrla/eomi. moist mucous membranes. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . distant heart sounds lungs: dry inspiratory crackles mid lung zones, decreased breath sounds at the bases bilaterally. abdomen: scaphoid abdomen, nabs, nttp. extremities: cachectic, cool, good pulses psych: listens and responds to questions appropriately, pleasant skin: reddened unbroken areas on back and sacrum. pertinent results: 08:00pm blood wbc-2.7*# rbc-2.71* hgb-8.6* hct-27.1* mcv-100* mch-31.7 mchc-31.7 rdw-16.0* plt ct-259# 04:12am blood wbc-3.0* rbc-2.46* hgb-8.1* hct-25.6* mcv-104* mch-33.0* mchc-31.7 rdw-16.6* plt ct-275 04:47am blood wbc-2.5* rbc-2.47* hgb-8.1* hct-25.2* mcv-102* mch-33.0* mchc-32.2 rdw-16.7* plt ct-222 08:00pm blood neuts-88.4* lymphs-8.9* monos-2.2 eos-0.5 baso-0.1 04:12am blood neuts-90.8* lymphs-5.9* monos-3.0 eos-0.3 baso-0 08:00pm blood pt-13.5* ptt-32.5 inr(pt)-1.2* 04:12am blood pt-12.9 ptt-32.7 inr(pt)-1.1 08:00pm blood glucose-157* urean-16 creat-0.7 na-133 k-5.4* cl-93* hco3-35* angap-10 04:47am blood glucose-99 urean-11 creat-0.6 na-131* k-5.0 cl-99 hco3-31 angap-6* 08:00pm blood alt-12 ast-16 ck(cpk)-20* alkphos-75 totbili-0.2 08:00pm blood ctropnt-<0.01 04:12am blood totprot-5.1* calcium-7.5* phos-3.8 mg-1.7 08:00pm blood digoxin-0.8* 01:22pm blood type-art po2-117* pco2-59* ph-7.33* caltco2-33* base xs-3 intubat-not intuba 01:22pm blood lactate-0.8 . 7:59 am urine source: cvs. **final report ** legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. . final report : computed tomography of the thorax indication: chronic respiratory failure, nonresolving opacities. comparison: the examination is compared to a previous ct from . technique: volumetric ct acquisitions over the entire thorax in inspiration, no administration of intravenous contrast material, multiplanar reconstructions. findings: there is generalized severe pulmonary emphysema. the emphysematous lesions are mainly panlobular. in addition, severe airway wall thickening and airway wall irregularities are seen. these are combined with bronchial plugs and secretions in the trachea. the dorsal parts of both lower lobes, the dorsal parts of the middle lobe, the lateral dorsal parts of the upper lobe and the right lung apex are occupied by a partly consolidated, partly semitransparent opacity. in the areas of opacity, multiple air bronchograms as well as the underlying emphysematous changes are seen. on the soft tissue windows, these opacities are relatively hypodense and homogeneous. hypodensity would favor pneumonia over atelectasis. the pre-described small and stable lung parenchymal nodules are not all visible. new lung nodules have not occurred. there are numerically increased borderline-sized hilar and mediastinal lymph nodes. small bilateral pleural effusions, no evidence of pericardial effusions. extensive coronary calcifications, the size of the heart is slightly increased as compared to the previous examination. the pre-existing mild compression deformity of the mid thoracic vertebral body is unchanged. impression: severe multifocal pneumonia. severe pulmonary emphysema and chronic airways disease. small bilateral pleural effusions, reactive numerical increase of lymph nodes number in the hilus and the mediastinum. no newly appeared lung nodules. . cxr indication: pneumonia, evaluation for interval change. comparison: . findings: as compared to the previous radiograph, there is no relevant change. bilateral predominantly reticular opacities accompanied by areas of consolidation. bilateral pleural effusion. unchanged extent of retrocardiac atelectasis. the findings have also been described in a ct examination from . the size of the cardiac silhouette is unchanged. also unchanged is the position of the right-sided central venous access . video swallow evaluation : summary: pt presented w/ a moderate dysphagia characterized by silent aspiration of nectar thick liquid after triggering a timely pharyngeal swallow, but prior to reaching the height of the swallow and obtaining full vf closure. a delay in vocal fold closure may be indicated. pureed solids and honey thick liquids are recommended. recommend meds crushed in puree or via peg. alternate sips of honey w/ bites of puree. recommend nutrition consult to monitor pt's po intake along with tubefeeds. pt may benefit from ensure or boost supplements. pt was exceptionally compliant during today's evaluation, and would benefit from speech and swallow tx at rehab. his family was also in favor of speech tx services. this swallowing pattern correlates to a dysphagia outcome severity scale (doss) rating of 3, moderate dysphagia. recommendations: 1. diet: pureed solids and honey thick liquids 2. meds: crushed in puree or via peg 3. alternate sips of honey w/ bites of puree 4. recommend nutrition consult to monitor pt's po intake and tube feed requirements for adequate nutrition 5. pt may benefit from ensure or boost supplements 6. pt would benefit from speech and swallow tx at rehab brief hospital course: this is an 82m with a multiple medical problems including chronic progressive severe copd, complicated by two recent bouts of recurrent pneumonias in the past 4 months (s/p two recent levofloxacin courses), atrial fibrillation, and failure to thrive, who presented with hypotension and multifocal pneumonia. initially admitted to the icu and then transferred to the medical floor on hd#3 for ongoing care. . #. hypotension/sepsis: thought secondary to hypovolemia, as the patient was having several days of diarrhea prior to presentation with poor po intake secondary to dysphagia, and septic shock from pneumonia. he was tachypneic and hypothermic, and his cxr showed a persistent pulmonary infiltrate. urine culture was negative. urine legionella negative. given his baseline severe copd and recent hospitalizations for pneumonia, the patient was treated with broad spectrum antibiotics of vancomycin, zosyn, and levofloxacin. he was bolused 2l of ns in the ed, and placed on levophed. by hospital day #2 he was weaned off levophed, and his blood pressures remained stable at his baseline 80-90s/30-40s. he was transferred to the medical floor by hospital day #3. sbp still in 90s on the floor, and his diltiazem was retitrated in for rate control. sbp ran in the 90s-110s prior to discharge. . #. hcap: bilateral, multifocal infiltrates have been present since first dx of pna in 10/. he underwent chest ct which showed severe multifocal pneumonia, along with severe emphysema and chronic airways disease. he was initially started on vanc/zosyn/levofloxacin on for 3 days, and then narrowed to just zosyn/levofloxacin to complete an 8 day course (vanc stopped as no evidence of necrosis or sputum data to support staph pna). he received mucomyst nebs, oral care, and albuterol nebs as needed. as per below, pt was started on a prednisone taper as well in the setting of his copd. . #. failure to thrive: chronic problem, thought caused by catabolic state of copd and chronic infection. colonoscopy in showed 1 polyp, no malignancy. egd/sbft showed avms, no malignancy. ct chest shows no clear evidence of lung cancer. even if pt were harboring some malignancy, pt would not be candidate for chemo/surgery at this point given his severe malnutrition, prior to admission, patient was planning on peg tube placement by gastroenterology service at for his chronic cachexia. he was continued on a pureed diet with multivitamins. upon discussion between patient, pt daughter, pcp . , and gi dr. , decision was made for peg placement. peg was placed on . tubefeeding recommendations were given by nutrition, and tubefeeding can be initiated once pt gets to his rehab. would check daily potassium, phosphate, and magnesium with initiation of tube feeds as pt is at high risk of refeeding syndrome. . # peg site bleeding: peg sited noted to be oozing blood prior to discharge. ercp re-examined the site prior to discharge and recommended holding aspirin for 5 days, dressing changes, sc heparin only twice daily. they feel bleeding should stop on its own; no necessary interventions . #. copd: at baseline pt is on 2 l o2 at home. he was continued on his home flovent, albuterol, and tioptropium. a prednisone taper was initiated in the setting of pna/copd flare and he will require a 2 week taper. . #. chronic anemia: recent iron studies more consistent with anemia of chronic disease. he does have a known history of avm/gi bleeds. hct drifting down to 24 here on . noted to have ob+ brown stool on admission. he was given 1 u prbc on with hct rising to 26 .iron supplements were held peri-peg placement and can be resumed on . #. atrial fibrillation/rapid ventricular rate: given his hypotension, diltiazem and digoxin were initially held. his digoxin was restarted by hospital day #3. hr in 110s on . his diltiazem was retitrated back in, with hr coming down into the 60s. he continues on asa and not coumadin given his history of gi bleeding and avms. asa however was held on day of discharge due to midline site bleeding/peg site bleeding and should not be resumed until . # sinus bradycardia: following peg placement, on the floor pts hr was noted to be in the 20s for several seconds at a time, asymptomatic. ekg showed afib. discussed with ep over the phone, and pts bradycardia was presumed to be due to vasovagal episodes. he had no further episodes of bradycardia after the afternoon of post peg placement. pt safe to continue diltiazem at this time. . # acute on chronic diastolic chf: ef 55%: pt was given lasix 20 mg iv on for elevated jvp, increased sob. his acute decompensation was presumed to be due to his recent afib/rvr, fluid resuscitation in the icu, and prbc received the day prior. he was continued on diltiazem for rate control. would monitor pts i/o closely, jvp, etc and assess for need for further diuresis. . # delirium: pts family and pt had admitted to confusion on admission. likely was multifactorial, including infection/pna, changing environments, steroids, lines, etc. currently alert and oriented x 3, but at times is mildly confused. would frequently reorient, avoid lines/sedating medications. . # aspiration: pt noted to be aspirating on in the setting of drinking thin liquids. this was however after peg/sedation. diet of ground solids and nectar thickened liquids was advised by speech and swallow initially. video swallow evaluation on did show the patient has aspiration with possible delay in cord closure prior to pt reaching height of swallow. it was recommended he have a diet of pureed, honey thickened liquids. meds crushed in puree or through peg. aspiration precautions. also recommended for pt to have speech and swallow therapy at rehab. . # metabolic alkalosis: bicarb was 40 on day of discharge, up from baseline of 34-37 and likely due to lasix received the day prior. would continue to trend bicarb. some chronic elevation is likely due to compensation for copd/resp. acidosis. . # fen: pureed, honey thickened diet; ensure supplements . #.dnr/dni: discussion was held with patient, patient's wife, and patient's daughter, and decision was made to not resuscitate or intubate the patient. . # access: midline; noted oozing prior to discharge . # long term prognosis: pt appears very cachectic with multiple medical comorbidities, severe malnutrition, and progressive decline-->poor prognosis overall. pt would be a good candidate for palliative services in the future if he fails to make progress with peg/nutrition. medications on admission: -ferrous sulfate 325 mg daily -aspirin 325 mg daily -fluticasone 220mcg -docusate sodium 100 mg -senna 8.6 mg prn -multivitamin daily -albuterol nebs q6h prn -tiotropium bromide 18 mcg daily -guaifenesin prn -mirtazapine 15mg qhs -sodium chloride nasal spray prn -diltiazem hcl 140 mg sustained release daily -digoxin 125 mcg daily -ascorbic acid 500 mg -omeprazole 40 mg daily -strawberry ensure , mechanical soft diet with ground meat discharge medications: 1. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 2. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 4. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 6. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 7. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 8. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 9. multivitamin tablet sig: one (1) tablet po daily (daily). 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 11. sodium chloride 0.65 % aerosol, spray sig: sprays nasal prn (as needed). 12. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 13. tube feeding fibersource hn at 10 cc/hr; advance every 8 hrs by 10 cc/hr with goal of 55 cc/hr (1584 kcal; 70 gram protein); check residual every 4 hours and hold if greater then 150 cc 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours). 15. levofloxacin 25 mg/ml solution sig: seven y (750) mg intravenous once a day: through . 16. zosyn 4.5 gram recon soln sig: 4.5 grams intravenous every eight (8) hours: through . 17. acetylcysteine 20 % (200 mg/ml) solution sig: 1-10 mls miscellaneous q6h (every 6 hours). 18. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day): hold for sbp less than 90, hr less than 55. 19. prednisone 10 mg tablet sig: one (1) tablet po as instructed: starting : take 40 mg from through ; take 20 mg through ; take 10 mg through . this will complete a 2 week course. 20. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day: can resume on . 21. heparin (porcine) 5,000 unit/ml syringe sig: 5000 (5000) units injection twice a day. 22. aspirin 325 mg tablet sig: one (1) tablet po once a day: do not give until . discharge disposition: extended care facility: for the aged - macu discharge diagnosis: hypotension sepsis health care associated pneumonia atrial fibrillation with rapid ventricular rate copd cachexia/severe malnutrition discharge condition: stable discharge instructions: you were admitted with sepsis, low blood pressure, and multifocal pneumonia. you were initially admitted into the icu, and you received iv fluids, antibiotics, and medications to keep your blood pressure up. you were then transferred to the general medicine floor for further care. we continued your antibiotics. . you had a peg placed while here so that you could receive nutrition through tubefeeds. you will start tubefeeds at rehab. you were noted to have some bleeding at the peg tube site prior to discharge. this was examined by gi and no interventions need to be taken--it should stop on its own. your aspirin should be held for 5 days. . medication changes: diltiazem was restarted at 30 mg four times a day. your iron will be held until . you were started on a prednisone taper. you will need to complete your antibiotics. your aspirin will need to be held for 5 days. . . call your doctor or return to the er for any worsening shortness of breath, increased cough/sputum production, fever, chest pain, increasing confusion, or any other concerning symptoms followup instructions: please follow up with dr. within the week after your discharge from rehab procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified other endoscopy of small intestine percutaneous [endoscopic] gastrostomy [peg] diagnoses: pneumonia, organism unspecified congestive heart failure, unspecified unspecified septicemia iron deficiency anemia secondary to blood loss (chronic) severe sepsis atrial fibrillation obstructive chronic bronchitis with (acute) exacerbation acute on chronic diastolic heart failure alkalosis septic shock hypovolemia angiodysplasia of stomach and duodenum without mention of hemorrhage chronic respiratory failure nutritional marasmus other gastrostomy complications 

Answer: The patient is high likely exposed to