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: penicillins attending: chief complaint: somnolence & respiratory distress major surgical or invasive procedure: intubation, mechanical ventilation history of present illness: patient is a 64 y/o f with a 92 pack-year smoking history, presumed copd, hypertension, hypothyroidism and obesity, who presented to an outside hospital in with shock and respiratory failure secondary to strep pneumoniae pneumonia and is transferred to for further management of her respiratory failure. mrs. initially presented to the hospital with hypoxic/hypercarbic respiratory failure. she was intubated and treated for shock (sbp as low as 80s). she was found to have r sided pna. on , she was transferred to . past medical history: hypertension hypothyroidism obesity social history: lives in , though stays in during summers. works as art dealer. long term smoker: 46yr x 2ppd. married, two grown kids family history: nc physical exam: t 96.8 bp 140/70 (130-170/60-90) hr 94 (60-90s) rr 25 o2 sat 90% 6l (84-92% on 4l nc); length of stay i/o -3.5l; 19hr -2.2l gen: awake, ,ox3, pleasant, nad. heent: perrl, eomi cv: rrr, nl s1/s2, no m/r/g lungs: decreased airflow, mild bibasilar crackles abd: soft, obese, nt, nd, normoactive bs ext: 1+ pitting edema on b/l le. skin: no rashes; marks on abd hep sc shots pertinent results: admission: 06:00pm glucose-163* urea n-33* creat-1.8* sodium-143 potassium-3.9 chloride-107 total co2-27 anion gap-13 06:00pm amylase-1011* 06:00pm lipase-243* 06:00pm calcium-6.2* phosphate-5.0* magnesium-1.5* 06:00pm tsh-1.0 06:00pm wbc-26.2* rbc-4.62 hgb-15.2 hct-49.2* mcv-106* mch-32.9* mchc-31.0 rdw-14.6 01:56pm lactate-6.2* 01:50pm ck-mb-85* mb indx-6.6* ctropnt-0.20* 01:50pm alt(sgpt)-411* ast(sgot)-601* ck(cpk)-1289* vbg 7.45/58/42 discharge labs: wbc 6.1 hgb 10.9 hct 33.2 mcv 97 plt 157 gluc 110 bun 15 crt 0.7 na 141 k 3.9 cl 101 co2 29 ekg: sinus tachycardia. biatrial enlargement. right axis deviation. st segment elevations in leads v3-v4 with tall peaked precordial t waves and an increase in rate compared to the previous tracing of . ct abdomen: absence of intravenous contrast limits evaluation of the abdominal parenchymal organs and vasculature. there is a small amount of ascites around the liver, and throughout the abdomen. the liver itself is grossly unremarkable. small calcified gallstone is seen within the gallbladder lumen. there is a mild amount of gallbladder wall edema, likely secondary to ascites. pancreas is edematous, and there is a minimal amount of peripancreatic stranding. there is no discrete fluid collection or abscess. the spleen is unremarkable. the adrenal glands, kidneys, and ureters are unremarkable. stomach and intra-abdominal loops of bowel are normal. there is no bowel obstruction. there is no free air or abnormal intra-abdominal lymphadenopathy. ct pelvis: pelvic loops of large and small bowel are normal. urinary bladder is decompressed with foley catheter in place. the uterus and adnexa are grossly unremarkable. there is a small amount of free pelvic fluid. there is no abnormal pelvic or inguinal lymphadenopathy. bilateral femoral central venous catheters are in place, tips in the external iliac veins. minor atherosclerotic changes are seen in the distal abdominal aorta. there is no osseous lesion suspicious for malignancy. there is mild dextroconvex lumbar scoliosis, and associated degenerative change. impression: 1. no focal lung consolidation. small right, and trace left pleural effusions, and associated mild bibasilar atelectasis. 2. several small, ill-defined areas of parenchymal nodularity, largest in the right upper lobe is somewhat linear, 11 mm in size. given the background emphysematous change, six-month followup is recommended to determine stability of these nodules. 3. mild pancreatic edema and peripancreatic stranding compatible with pancreatitis. no peripancreatic fluid collection. 4. small volume of ascites throughout the abdomen. 5. cholelithiasis. mild associated gallbladder wall thickening is likely secondary to ascites. cta chest w&w/o: there is no evidence of main, central, or segmental pulmonary embolism. main pulmonary artery measures 3.6 cm, a finding suggestive of underlying pulmonary arterial hypertension. no significant hilar or mediastinal lymphadenopathy is identified. patient is intubated. central airways have a posterior concavity, suggestion tracheomalacia. evaluation of the lung parenchyma does reveal increased patchy areas of consolidation within the right middle lobe. this is a nonspecific finding, but discoid morphology likely reflects atelectasis. mold-moderate emphysema is noted. bilateral moderate pleural effusions are seen, right greater than left. these are slightly increased in size since the prior study. areas of nodularity again seen, the largest of which is again noted within the right upper lobe. six- month followup is again recommended to ensure stability of these findings. the visualized portions of the upper abdomen appear grossly unremarkable, noting small ascites. no suspicious lytic or blastic bony lesions are seen. impression: 1. no evidence of pulmonary embolism. suggestion of pulmonary hypertension. 2. increased pleural effusions. 3. increased areas of discoid atelectasis in the right middle lobe. 4. pulmonary nodules again seen, recommend six-month followup to ensure stability. 5. small ascites. transthoracic echo: the left atrium is moderately dilated. the right atrium is moderately dilated. no intracardiac shunt is identified after intravenous saline microbubbles at rest. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality. preserved global biventricular cavity sizes and global systolic function. no intracardiac shunt identified. right and left lateral decubitus films: there is no significant change in the left-sided effusion. however, the right-sided pleural effusion is slightly decreased in volume. there are no other interval changes noted. impression: stable left-sided pleural effusion with slight decrease in volume of right-sided pleural effusion. brief hospital course: this is a 64 yo f with htn, hypothyroidism, obesity, presumed copd who presented to an osh with respiratory failure in setting of strep pneumo pneumonia and sepsis, and was transferred to for further evaluation and management. # septic shock: mrs. was initially hypotensive to the 80s and with evidence of end-organ damage: elevated lfts, arf and cardiac enzymes. this resolved with aggressive ivf as well as temporary treatment with pressors. she was treated for strep pneumo pneumonia (sputum cx positive for the organism; bld cx negative) with a 14 day course of levofloxacin, which was completed on . # hypoxic/hypercarbic respiratory failure: mrs. presented with both hypoxic and hypercarbic respiratory failure in setting of strep pneumo pneumonia with sepsis. she required 14 days of mechanical ventilation. she was extubated successfully on . following extubation the patient required bipap for a period, and eventually only required bipap at night for treatment of newly diagnosed obstructive sleep apnea. despite treatment of her pneumonia, mrs. had a persistent oxygen requirement, initiall as high as 6-7l via nc. she underwent cta of chest, which was negative for pe, though did show bilateral pleural effusions. based on this, her hypoxia was attributed primarily to volume overload from the aggressive volume resuscitation when she presented with shock. however, it was also thought that she had some component of copd (emphysema seen on chest ct) and possibly obesity hypoventilation syndrome as well. with aggressive diuresis, her oxgyen requirement was weaned to 2-3l via nasal cannula. of note, the requires continuous oxygen at present to keep her oxygen at a goal of 90-95%. as she diureses further, she may be able to be weaned further off of oxygen. prior to admission, she was not on supplemental oxygen, though she may require low level at home, depending on how she responds to continued diuresis at rehab. # volume overload/pleural effusions: the patient was grossly overloaded on transfer to the medical from the micu, following volume resuscitation. she required aggressive diuresis and diuresed over 10liter. she is being discharged on 60mg lasix po daily--she was on 60mg twice daily for the few days prior to discharge, but this was dose decreased as pt seems to be nearing her dry wieght. she still has bilateral pleural effusions, which are thought to be from her volume overload and which are improving on cxr with diuresis. because of this, the effusions were not tapped during this hospital stay. she should have a follow-up chest x-ray if her oxygen requirement increases to assess the size of her pleural effusions. she should be on a 1.5l fluid restriction. it is suspected that her lasix dose may be able to be further decreased as she gets closer to her dry weight, though this will need to be monitored closely, particularly via measurement of her creatinine (crt 1.7 on day of discharge). at present, we are aiming for a fluid balance (i/o goal) of approximately 500cc to 1liter negative daily. if her creatinine increases, this goal should be adjusted. # presumed copd: the patient has a 92 pack year history of smoking. she smoked up until current admission. she has never had a formal evaluation for copd (ie, no pfts in past). however, given her smoking history and ct chest showing evidence of emphysema, she was treated for a copd exacerbation with inhalers/nebulizers (see med list) and prednisone taper. she should continue the inhalers started during the hospitalization as an outpatient. she will need formal pft evaluation as an outpatient as well. # obstructive sleep apnea/query obesity hypoventilation syndrome: mrs. showed evidence of desaturating while sleeping. she was seen by the pulmonary consult service and sleep consult services. she was started on bipap at night at a setting of and 3l of 02 for presumed obstructive sleep apnea. she has an appointment scheduled at the outpatient sleep clinic on (see appointment list). # hypertension: patient has a history of hypertension treated with hydrochlorothiazide. her hctz was held on admission because of her hypotension. she was then started lisinopril as she became hypertensive later in her hospital. her sbp on discharge was in the 100s-110s. # anemia/guaiac + stool: her admission hematocrit was elevated in the setting of dehyration--49. it dropped into the low 40s with ivf. however, on , her hematocrit dropped to 35.7. she was guaiac was positive on and . she was hemodynamically stable and did not require transfusion. her hematocrit has remained stable between 33-35 since that time. repeat guaiacs were negative. she will need outpatient evaluation, including colonoscopy. # glucose intolerance: mrs. required insulin while on prednisone (for her copd exacerbation). however, even off of the steroids, she still had elevated fasting gluose levels >110. she will need additional outpatient evaluation and treatment for this. # pulmonary nodules: see ct report. will need 6mo repeat chest ct. # fen: pt has required regular potassium repletion while on lasix. please monitor her potassium and replete as necessary. she had a k of 2.9 on , likely due to the combination of contraction alkalosis # nstemi: in setting of septic shock (likely not plaque rupture). tte w/ normal systolic function following resuscitation. should be started on aspirin as outpatient once she undergoes eval of anemia. # hypothyroidism: she as continued on home synthroid regimen. # arf: elevated cr at presentation (2.6), which resolved with ivf, suggesting pre-renal etiology in setting of sepsis. normal crt on discharge. # ppx: sc heparin # social - full code status, communication with son ,son and husband medications on admission: hctz 50 mg daily atenolol 25 mg daily levoxyl 200 mcg daily prempro 0.45-1.5 mg daily otc allergy med chlorpheniramine discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 6. albuterol 90 mcg/actuation aerosol sig: inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: one (1) inhalation every six (6) hours. 8. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): dvt prophylaxis--not a home med. 10. furosemide 20 mg tablet sig: three (3) tablet po once a day: 60mg. 11. potassium chloride 20 meq tab sust.rel. particle/crystal sig: two (2) tab sust.rel. particle/crystal po once (once) for 1 doses: 40meq/day (to be adjusted per serum potassium level). discharge disposition: extended care facility: - discharge diagnosis: primary: strep pneumoniae pneumonia septic shock respiratory failure pleural effusions guaiac postive stools obstructive sleep apnea copd/emphysema pulmonary (lung) nodules glucose intolerance (pre-diabetes) obesity/deconditioning hypertension secondary: hypothyroidism discharge condition: good, 02 sat 91-96% on 2l nc, sbp 100-110s, hr 60-80s, weight 243lb discharge instructions: you were admitted with sepsis from pneumonia. during your hospital stay you were newly diagnosed with the following: 1. obstructive sleep apnea 2. copd/emphysema 3. pulmonary (lung) nodules 4. glucose intolerance (pre-diabetes) 5. guaiac positive stool (small amount of blood in your stool) you will need close follow-up for those issues. - you will need to see a sleep specialist--see appointments--regarding your sleep apnea. you should continue to use your bipap machine as instructed. - you were started on a number of new inhalers (see list) for your presumed emphysema. you will need to undergo lung function tests after discharge. this can be arranged by your pcp. will need to have a ct scan of your chest within 6months to follow-up the lung nodules found. - you will need to have formal testing for diabetes wit your pcp. should adhere to a low-sugar/low carbohydrate diet. - you should have a colonoscopy within 6months to evaluate for an episode of blood in your stool, as well as for routine colon cancer screening. you were started on a new blood pressure medication called lisinopril, which is to take the place of hydrochlorothiazide. you should continue your other medications. followup instructions: you have an appointment with the sleep specialist , md, on at 8:00am on the of on the of the building. please call and reschedule if you cannot make this appointment. phone: please see your primary care doctor within 1-2 weeks of discharge from rehab. md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung enteral infusion of concentrated nutritional substances diagnoses: obstructive sleep apnea (adult)(pediatric) subendocardial infarction, initial episode of care unspecified pleural effusion unspecified essential hypertension acute posthemorrhagic anemia acute kidney failure, unspecified unspecified septicemia severe sepsis unspecified acquired hypothyroidism obstructive chronic bronchitis with (acute) exacerbation acute respiratory failure septic shock pneumococcal pneumonia [streptococcus pneumoniae pneumonia] 

Answer: The patient is high likely exposed to