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: cephalosporins / penicillins attending: chief complaint: trauma to chest major surgical or invasive procedure: chest tube placement and removal ng tube placement and removal intubation and successful extubation central line placement and removal history of present illness: pt is a 57 yo man with h/o alcohol abuse, copd, schizoaffective d/o, remote h/o seizures, who was transferred from hospital s/p fall on with 3 rib fractures, and hemopneumothorax requiring chest tube. pt fell on his left side while on a 5 foot wall, hitting his left chest. there was no loc. his wife called 911 as he was having trouble. at , he was found to have the broken ribs and hemopneumothorax, and the chest tube was inserted. there were continued problems oxygenating the patient; ct pe protocol was negative and bronchoscopy was done which did not reveal any bronchial obstructing lesions, and only a small amount of mucous. he was then intubated at for respiratory failure. his course was also complicated by hypotension (briefly on levophed), evidence of rv strain (resolved after chest tube), and hct drop to 29 (s/p 3 units of prbcs). sputum micro at osh showed gp and pt was started on linezolid and levaquin (d/cd at ). pt was then transferred to for further management. he was noted to have a large aa gradient while vented. pt was initially started on heparin gtt for a question of ischemic stroke. head ct and mri were negative and this was then d/cd. there was question one night of seizure like activity but the story was unclear and eeg was not consistent with seizure activity. pt was extubated on . after extubation, pt was answering questions unintelligibly, moaning, or looking away. the sicu team has been trying to avoid sedating medications, but he does require morphine for pain. per psychiatry, risperdone and mirtazapine (which the patient is on at home) were discontinued (abilify and effexor had been stopped earlier). chest tube was d/cd on . early am pt had a.fib ~150. he was given diltiazem and metoprolol with little effect. he was loaded with amiodarone and cardioverted. pt continues to be delirious and is transferred to medicine for further work-up. past medical history: etoh abuse in past- sober 10 years hypercholesterolemia copd bipolar vs. schizoaffective d/o-depression and two major overdoses, with previous hospitalizations at the hospital, hospital, and the va h/o seizure disorder- seizures in life, last one was 4 years ago. social history: pcp- . in , ma; neurologist: dr. in () pt is married. he is a former paramedic but has been on disability for 20 years bipolar. 1.5 ppd tobacco x 40 years. +marijuana use. etoh as above. family history: non-contributory. physical exam: on transfer to medicine: t: 98/100.2 bp: 101/53 p: 73 rr: 21 o2: 94%ra; i/o 1760/2256 gen: sitting in bed, nad heent: perrl, eomi. sclera anicteric. op no exudate. cv: rrr s1s2. no m/r/g lungs: +air movement bilaterally. crackles at bases. abd: soft, nd/nt, +bs. ext: no edema. dp 2+. neuro: alert, oriented to "hospital" and "" able to do dowf but not moyb. perseverative. called pen a pencil, able to correctly name stethoscope. occasionally will talk in a nonsensical manner, but redirectable. cn 2-12 intact. strength in all extremities. non focal exam. pertinent results: chemistries on admission to 09:49pm glucose-116* urea n-19 creat-0.7 sodium-147* potassium-3.9 chloride-117* total co2-24 anion gap-10 09:49pm albumin-1.9* calcium-7.7* phosphate-3.1 magnesium-2.0 lfts 09:49pm alt(sgpt)-10 ast(sgot)-13 alk phos-46 amylase-150* tot bili-0.5 09:49pm lipase-31 tfts 09:49pm tsh-3.7 cbc 09:49pm wbc-8.7 rbc-3.28* hgb-10.3* hct-30.4* mcv-93 mch-31.3 mchc-33.8 rdw-15.1 09:49pm plt count-144* coags 09:49pm pt-13.7* ptt-28.8 inr(pt)-1.3 radiology: - ct head without contrast impression: no evidence of intracranial hemorrhage. fluid and opacification of the sinuses and mastoid air cells. there are two small equivocal hypodensities in the medial right temporal lobe, vaguely defined, of unclear significance. - cta chest, abdomen, pelvis 1) rib fractures. 2) bilateral lower lobe collapse with small surrounding effusions. 3) chest tube in left hemithorax. 4) small amount of ascites. 5) some thickening and stranding in the left pararenal fascia of unclear significance, also about the left kidney and pancreas. 6) small abdominal aortic aneurysm. echo- the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. there is no aortic valve stenosis. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is an anterior space which most likely represents a fat pad. mr - no evidence of acute ischemia/infarction,intracranial mass effect, or hemorrhage. - cxr (ap)-1) right sided diffuse patchy and ground glass opacities that likely represent lung contusion but could also be asymmetric fluid overload vs. infection. 2) ng tube in stomach. -eeg- consistent with diffuse, mild encephalopathy. brief hospital course: impression: 57 yo male with history of etoh abuse (sober), copd, bipolar disorder, transferred from osh with hemopneumothorax s/p chest tube, respiratory distress s/p intubation. chest trauma the patient had a mechanical fall of off a 5 foot ladder landing on his left side. he was taken to hospital where he was noted to have three rib fractures and left sided hemopneumothorax. he was also in respiratory distress. his cervical spine was stabilized, he was intubated and a left-sided chest tube was placed. he was transferred to for further management. the patient was admitted to the sicu, and did well from a trauma standpoint: he was extubated, the chest tube was removed, and his pain was well controlled. his cervical, lumbar and thoracic spine was cleared clinically and his collar was then removed. radiographs of his full spine did not show any evidence of fracture of dislocation. he was then transferred to the medicine service on for further management of delirium. delirium after extubation the patient was confused and disoriented, though his neurological exam was non focal. the differential included infection, a toxic-metabolic cause, stroke, or seizure. he had been febrile at hospital and had been started on broad spectrum coverage (linezolid and levaquin), but these was stopped on transfer to . cxr did not show a clear pneumonia. urine was positive for a pan sensitive enterococcus, and he was started on a 7 day course of antibiotics (initially levofloxacin and then vanco given the reinitiation of amiodarone). his mri and ct scans were negative for stroke. an eeg was done and was not consistent with seizure. the patient had been receiving ativan and morphine, and had become hypernatremic since admission to 152, all of which could have contributed to his delirium. neurology and psychiatry consults were obtained, and medications that could be contrubuting to his change in mental status were discontinued. he was found to have a free water deficit of ~2 liters and was given d5w boluses with improvement in his sodium. he was given haldol prn for agitation with qt interval monitoring by ekg, and briefly required a 1:1 sitter and restraints to prevent him from pulling out tubes/lines. his outpatient psychiatric medications (effexor, mirtazapine, and risperidol) were initially held. (of note, risperdal was later added back). his mental status improved slowly with these interventions and he became increasingly less agitated and more oriented. by discharge he was attentive and oriented x3. his serum sodium on discharge was 142. he should follow up with psychiatry regarding reinitiation of effexor and mirtazapine. bipolar he was continued on depakote and lamictal. on investigation, it appears that the patient was on these for his bipolar disorder, likely not for his seizures. psychiatry recommended some dosage changes in the setting of his delirium. he was discharged on depakote 250 and lamictal 25 . hypoxia the patient was intubated for hypoxia in the setting of a hemopneumothorax. he was weaned off of the ventilator without difficulty. the patient had cxr evidence of a left sided lung contusion. his pain was controlled and he used an incentive spirometer to prevent atelectatic changes. by discharge, the patient was breathing room air with adequate oxygen saturations. cv a. ischemia: the patient had no known history of cad. hre was formally ruled out with enzymes and was continued on asa. b. pump: the patient also had no known history of chf. he did get some lasix doses while intubated. serial cxrs did not demonstrate gross volume overload. i/os and daily weights were obtained. c. rhythm: the patient had evidence of a conduction system disorder. while in the sicu he went into atrial fibrillation with rvr to the 150s (no history of af prior to this). his rate was immediately controlled and he underwent amiodarone loading and successful cardioversion (<24 hours after onset of af). he was continued on amiodarone and oral metoprolol. subsequently, he was monitored on telemetry and was noted to have episodes of asymptomatic sinus bradycardia to the 20-30s during sleep as well as an 8 second pause. the amiodarone and metoprolol were held. ep was consulted and the patient had a pacemaker placed. the amiodarone taper was restarted. he will follow up in device clinic next week, and with dr. in follow up. etoh abuse the patient does have a history of etoh abuse, but had been sober for many years. he was briefly on benzos for a question of delirium withdrawl but these were discontinued, and his delirium improved. he was given mvi, thiamine, and folate supplementation. copd the patient had a history of smoking. he received nebulizer treatments as needed. f/e/n after extubation the patient was seen by speech and swallow, initially while he was still in a c-collar. he was found to have overt aspiration of thin liquids but tolerated purees. his ng tube was initially kept in place to augment his oral intake, but he self-dc'd this on . once his c-collar was removed and his mental status cleared, he was re-evaluated by s/s who still felt that the patient was aspirating thin liquids. this can be re-evaluated at rehab. access the patient had a right internal jugular central line but this was removed without complications prior to transfer out of the sicu. on discharge, he had a midline in place for 4 days of vancomycin. ppx the patient was kept on a ppi and sq heparin for dvt prophylaxis. he was evaluated by pt and ot prior to discharge. he was able to ambulate with assist, but would benefit from rehab. medications on admission: outpatient medications: lipitor 10', effexorxr 150', depakote 1000", risperidal 0.5", abilify 10', mirtaxone 30', lamictal 150", asa 81', mvi medications on transfer to medicine: lansoprazole oral suspension 30 mg ng daily albuterol 0.083% neb soln 1 neb ih q6h:prn lamotrigine 75 mg po bid amiodarone hcl 200 mg po tid duration: 7 days start: aspirin 325 mg po daily metoprolol 25 mg po bid bisacodyl 10 mg pr hs:prn folic acid 1 mg iv daily miconazole powder 2% 1 appl tp qid haloperidol 2.5-5 mg iv q2h agitation morphine sulfate 2-4 mg iv q4h:prn heparin 5000 unit sc tid thiamine hcl 100 mg po daily insulin sliding scale valproic acid 500 mg po q12h discharge medications: 1. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. lansoprazole 30 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 4. valproate sodium 250 mg/5 ml syrup sig: one (1) po q12h (every 12 hours). 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 8. lamotrigine 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 12. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. 13. insulin lispro (human) 100 unit/ml solution sig: one (1) per sliding scale subcutaneous four times a day: qid fingersticks. 14. risperidone 0.5 mg tablet sig: one (1) tablet po hs (at bedtime). 15. amiodarone 200 mg tablet sig: one (1) tablet po three times a day: 200mg po tid x1 week; then 200mg po bid x 2 weeks; then 200mg po daily ongoing. 16. vancomycin hcl 1000 mg iv q 12h duration: 4 days 17. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain for 10 days. 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. discharge disposition: extended care facility: hospital of & islands - discharge diagnosis: traumatic hemopneumothorax s/p chest tube placement delirium, likely toxic-metabolic in nature tachy-brady syndrome s/p pacemaker placement schizoaffective disorder vs. bipolar disorder history of seizure disorder copd hypercholesterolemia history of etoh abuse >10 years ago discharge condition: stable, ambulatory, mental status improving (alert and oriented x3 on discharge), afebrile, breathing room air. discharge instructions: you were treated for rib fractures and trauma to your lung, and for a urinary tract infection. you also had a pacemaker placed. 1. please follow up with your primary care physician weeks of discharge, in the "device clinic" to check on the pacemaker and with dr. as scheduled. 2. please continue to take medications as prescribed. finish a course of antibiotics for your urinary tract infection. 3. call your doctor or return to the emergency department if you notice fevers, chills, confusion, dizzyness, lightheadedness, chest pain, difficulty breathing, or any other concerning symptoms. followup instructions: please see dr. () within 1-2 weeks of discharge. provider: clinic where: cardiac services phone: date/time: 1:00 provider: , m.d. where: cardiac services phone: date/time: 11:00 please see a psychiatrist at rehab regarding restarting effexor and mirtazapine. md, procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances other electric countershock of heart initial insertion of dual-chamber device initial insertion of transvenous leads [electrodes] into atrium and ventricle transfusion of platelets infusion of vasopressor agent diagnoses: tobacco use disorder urinary tract infection, site not specified chronic airway obstruction, not elsewhere classified atrial fibrillation other convulsions acute respiratory failure traumatic pneumohemothorax without mention of open wound into thorax streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] metabolic encephalopathy sinoatrial node dysfunction hyperosmolality and/or hypernatremia bipolar i disorder, most recent episode (or current) unspecified contusion of lung without mention of open wound into thorax closed fracture of three ribs other accidental fall from one level to another 

Answer: The patient is high likely exposed to