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: citalopram / seroquel attending: chief complaint: altered mental status major surgical or invasive procedure: intubation and mechanical ventilation history of present illness: 77 year old female with h/o copd on 2l nc, hypercarbic resp failure, htn, pulmonary nodules who was found to be unresponsive at her nursing home. . per nh records and ed report, patient found to be at her normal baseline status (a&ox3) around 5pm. approx 15-30min later, she was found to be unresponsive, and ems was called. her vs at the time were: bp 120/60, hr 100, rr 22, 82% on 15l, fs 190. labs from nh : ua neg ket/nit/leuk/wbc/prot, na 145, k 4.5, co2 45, bun 14, cr 0.4, ca 9.3, glu 81, wbc 3.8, hgb 8.5. of note, per nursing home records, she is on xanax standing and trazadone prn for anxiety. . in the ed, initial vs: 92.7 100 86/37 90% 10l. her sbp ranged 70s-200s. per ed report, dropped w/ propofol and fentanyl, improved with holding of sedations. her pupils were thought to be minimally reactive with some weakness on the left, so a code stroke was called. cta head/neck prelim negative. cxr hyperinflated w/o evidence of pna/effusions. she was intubated in the ed given worsening ams. there was question of jaw , she was given ativan for possible seizure. her labs in the ed were notable for na 150, bun/cr 25/0.6, k 5, hco2 >50, wbc 13.6 (85% pmn, 2% bands), trop < 0.01; ua neg wbc/leuk/nit, pos prot, pos granular casts; lactate 2.2. on the vent, her abg was: 7.34/78/501. she has 2piv's, vent settings: fio2 30%, tv 400, r18. . currently, patient is awake and responsive; she denies pain, history of cough, diarrhea, dysuria, fevers. past medical history: vitamin d 50,000 units qmonth amlodipine 5mg daily asa 81mg daily mvi daily alprazolam 0.25mg q6hr trazadone 25mg qid prn anxiety ventolin 90mcg q4hr advair 250-500mcg spiriva 18mcg cap daily clonidine 0.5mg daily omeprazole 20mg daily tums levaquin 500mg daily - since (unclear why started) colace polyethylene glycol social history: currently at rehab since , but did live in . has several children, very involved. family history: unable to obtain on admission physical exam: admission physical exam: heent: sclera anicteric, dry mmm, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: able to elevate hands/feet off bed, hand grip, down going toes, eomi, perrl, alert, responding to commands appropriatly, no rigidity, normal tone . pertinent results: admission labs: 06:35pm wbc-13.7* rbc-3.49* hgb-10.7* hct-36.5 mcv-105* mch-30.7 mchc-29.3* rdw-15.2 06:35pm neuts-85* bands-2 lymphs-8* monos-5 eos-0 basos-0 atyps-0 metas-0 myelos-0 06:35pm calcium-10.2 phosphate-6.4* magnesium-3.2* 06:35pm glucose-208* urea n-25* creat-0.6 sodium-150* potassium-5.0 chloride-96 total co2-greater th 07:15pm urine blood-neg nitrite-neg protein-30 glucose-tr ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-neg 07:15pm urine color-straw appear-clear sp -1.027 07:15pm urine rbc-2 wbc-2 bacteria-none yeast-none epi-<1 07:15pm urine granular-1* hyaline-46* 07:15pm urine mucous-rare 07:45pm lactate-2.2* 07:51pm type-art po2-501* pco2-78* ph-7.34* total co2-44* base xs-12 intubated-intubated 10:33pm freeca-1.14 11:45pm wbc-8.5 rbc-2.93* hgb-8.9* hct-30.2* mcv-103* mch-30.5 mchc-29.6* rdw-15.3 11:45pm calcium-8.4 phosphate-2.4* magnesium-2.4 11:45pm glucose-118* urea n-19 creat-0.5 sodium-147* potassium-4.8 chloride-103 total co2-41* anion gap-8 microbiology: blood culture - no growth x 2 urine culture - no growth, negative for legionella serogroup 1 antigen. sputum culture - gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive cocci. in pairs and clusters. 3+ (5-10 per 1000x field): gram positive rod(s). respiratory culture (final ): moderate growth commensal respiratory flora. sputum culture - gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): sparse growth commensal respiratory flora. urine culture - no growth blood culture - no growth x 2 sputum culture - gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast with pseudohyphae. respiratory culture (final ): commensal respiratory flora absent. yeast. moderate growth. imaging: cxr- endotracheal tube 2.5 cm from the carina. linear parenchymal opacities in the right upper lung, potentially chronic; however, followup of this region recommended on future exams. . cta head and neck- 1. no acute intracranial abnormality. 2. generalized parenchymal atrophy with changes of chronic small vessel ischemic disease. 3. confluent hypodensity in the central pons likely represents additional sequelae of chronic small vessel ischemic disease, given the such findings in other typical locations. however, possiblity of osmotic myelinolysis ("central pontine myelinolysis") cannot be excluded entirely, in the appropriate clinical context. 4. tiny, 2 mm aneurysm arising from the proximal portion of the right posterior inferior cerebellar artery. 5. unremarkable cta of the neck. 6. prominence of superior ophthalmic veins in both orbits, likely varices. 7. severe emphysematous changes in the visualized lung apices with ill-defined nodular opacities in the right upper lobe. comparison with previous (outside) cross-sectional studies, if available, is advised. . cta chest- 1. no evidence for pulmonary embolus with suboptimal opacification of the left lower lobe subsegmental arteries where there is scarring; therefore, pulmonary embolus cannot be excluded in this region. 2. severe emphysema. 3. trace bilateral pleural effusions. . tte - the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef 65%). the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. tricuspid valve prolapse is present. moderate tricuspid regurgitation is seen. there is a small to moderate sized pericardial effusion. there are no echocardiographic signs of tamponade. echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. . cxr - as compared to the previous radiograph, there is no relevant change. large lung volumes, moderate cardiomegaly without pulmonary edema. no evidence of pneumothorax or pleural effusions. no newly appeared focal parenchymal opacities. brief hospital course: 77 year old female with h/o copd on 2l nc, hypercarbic resp failure, htn, pulmonary nodules who was found to be unresponsive at her nursing home, intubated for hypercarbic respiratory distress, found to be hypothermic in ed, hyperna, and w/ fluctuating bps. . # hypercarbic respiratory distress: patient with copd on 2l home o2, w/ elevated bicarb from nursing home a week ago and likely co2 retainer. her ph suggests compensated process and elevated bicarb suggest that her respiratory status likely has deteriorated over a chronic period of time due to worsening copd. although cxr was not notable for pna, cta showed some suggestion of retrocardiac opacities and sputum w/ gram positive cocci on gram stain. pe was ruled out w/ cta. patient was treated for hcap (vancomycin, levofloxacin and cefepime), along with standing nebulizers. there was difficulty controlling her anxiety with recurrent hyperventilation on pressure support. initial extubation attempt on failed due to tachypnea, low minute ventilation and eventually hypercarbic respiratory failure. patient was continued on hcap coverage and started on steroids for copd exacerbation and marked bronchospasm on examination. tte showed a moderate pericardial effusion w/o signs of tamponade with diastolic dysfunction. patient underwent iv diuresis. a major barrier to her extubation was felt to be anxiety leading to tachypnea, in addition to above factors. she was tried on multiple sedative and antipsychotics and best regiment was felt to be clonazepam 0.5mg (prior attempted medications w/o significant improvement - xanax, ativan, zydis, seroquel). per records, baseline abg was confirmed to be 7.33-37/70-80/39/80-100. patient was extubated on . she tolerated this well, however was noted to be very sensitive to hyperoxia (as during nebulizer treatments or increased supplemental oxygen) with resultant hypercarbia, resp. distress (requiring return to icu though no intubation). this improved w/ reduction of supplemental o2. she was restarted on antibiotics with vancomycin, levofloxacin, cefepime though there was no cxr evidence of recurrent pneumonia. she was narrowed to levofloxacin and remained afebrile and stable. her goal o2 sat should be 88-92 to prevent resultant hypercarbia and acidosis. patient's advair dosing was increased to 500/50 and tiotropium was restarted w/ albuterol inhalers. nebulizers were discontinued seondary to hyperoxia as above. patient was stable on 1.5l nc at the time of discharge, sat'ing 88-96%. patient will continue levofloxacin through for total 8 days treatment. # altered mental status: patient recieved number of sedating medications per nursing home records, which in addition to hypercarbia could have contributed to her mental status changes. patient w/ leukocytosis and hypothermia on admission, though infectious w/o negative. labs also notable for hyperna, and appeared volume depleted by exam. cta head/neck unremarkable, and neuro exam in non-focal. seizure seemed unlikely given the above factors. no meningeal signs on exam. urine and blood cultures were negative; sputum culture positive as above. sodium was corrected. much of this was felt to be due to transient hypercarbia and benzodiazapines. at time of discharge, patient was alert and oriented x 3. she was tolerated clonazepam 0.5mg qam and qhs. # bacterial pneumonia: hypothermic in ed 92.5 and patient w/ leukocytosis. lactate mildly elevated. hypotensive in the ed, but normotensive in icu. see above for further discussion. patient completed vancomycin and zosyn course for hcap. on return to the icu, concern for rll pneumonia, so patient was restarted on antibiotics, vancomycin and levofloxacin. patient was narrowed to levofloxacin and is now day , should be dosed through . # copd with exacerbation: discontinued nebulizers secondary to respiratory distress in setting of hyperoxia. albuterol inhaler as needed and daily tioptrium restarted per home regimen. patient is on a long steroid taper, currently 30mg po daily, with plan to decrease weekly by 10mg (next decrease saturday ). # pericardial effusion: noted on prior osh records. tte here showed moderate effusion that seemed unchanged on repeat tte. # htn: blood pressure controlled with home amlodipine and addition of lisinopril 2.5mg po daily. # transitional issues: - discontinue levofloxacin after (8 day course started ) - goal o2 sat 88-92% (patient has been reaching this goal with 1.5l nc) - avoid nebulizers as high flow oxygen has worsened respiratory distress, patient is stable on albuterol inhalers and tiotropium - patient was full code throughout admission; several family meetings confirmed her wishes for cardiopulmonary resuscitation if necessary medications on admission: vitamin d 50,000 units qmonth amlodipine 5mg daily asa 81mg daily mvi daily alprazolam 0.25mg q6hr trazadone 25mg qid prn anxiety ventolin 90mcg q4hr advair 250-500mcg spiriva 18mcg cap daily clonidine 0.5mg daily omeprazole 20mg daily tums levaquin 500mg daily - since (unclear why started) colace polyethylene glycol discharge medications: 1. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 2. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 3. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. 4. amlodipine 10 mg tablet sig: one (1) tablet po once a day. 5. levofloxacin 750 mg tablet sig: one (1) tablet po daily (daily) for 2 days: ending . 6. prednisone 10 mg tablet sig: three (3) tablet po daily (daily) for 3 days: then taper to 20mg x 1week, then 10mg x 1week, then 5mg x 1week, then stop. 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 9. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation: please hold for loose stools. 10. miralax 17 gram powder in packet sig: one (1) po once a day as needed for constipation. 11. simethicone 80 mg tablet sig: one (1) tablet po four times a day as needed for gas. 12. clonazepam 0.5 mg tablet sig: one (1) tablet po twice a day. 13. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po mwf (monday-wednesday-friday). 14. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 15. cholecalciferol (vitamin d3) 1,000 unit tablet sig: one (1) tablet po daily (daily). 16. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: # hypercarbic respiratory failure # health care associated pneumonia # chronic obstructive pulmonary disease, exacerbation discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure taking care of you during your recent admission to . you were admitted with rspiratory distress likely due to an exacerbation of your copd. you were in the icu and intubated for a period of time, then stabilized and transferred to the floor. you were treated for pneumonia. the following changes were made to your medication regimen: - start lisinopril for your blood pressure - stop clonidine - start prednisone 30mg, continue this through , then decrease to 20mg for an one week, then decrease to 10mg for one week, then decrease to 5mg for one week, then stop - start bactrim every monday, wednesday and friday to prevent infection while you are taking prednisone - stop trazodone for anxiety - start clonazepam 0.5mg every morning and before bedtime for anxiety followup instructions: name: , md location: dept of pulmonary address: , , phone: when: thursday, , 2:00 pm please follow-up with your primary care doctor, dr. , after discharge from the hospital. location: geriatric services address: , acc bldg 3rd fl, , phone: fax: procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances diagnoses: acidosis thrombocytopenia, unspecified congestive heart failure, unspecified long-term (current) use of steroids adrenal cortical steroids causing adverse effects in therapeutic use obstructive chronic bronchitis with (acute) exacerbation other opiates and related narcotics causing adverse effects in therapeutic use anxiety state, unspecified unspecified disease of pericardium acute and chronic respiratory failure acute diastolic heart failure hyperosmolality and/or hypernatremia drug-induced delirium unspecified deficiency anemia other drugs and medicinal substances causing adverse effects in therapeutic use other dependence on machines, supplemental oxygen benign essential hypertension bacterial pneumonia, unspecified solitary pulmonary nodule 

Answer: The patient is high likely exposed to