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: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath, nausea major surgical or invasive procedure: none history of present illness: 65 yo with esrd on hd, copd, and systolic dysfunction (ef 45%), presenting with malaise, nausea, and shortness of breath starting this afternoon after dialysis. dialysis was uneventful, and the patient went home. at around 3:30 p.m., he was sitting in a chair when he became sweaty, nauseas, warm, short of breath. no chest pain or pressure. he lay down for a couple of hours, experiencing orthopnea. then at around 5:30 p.m., he asked his family to call 911 and take him to the hospital. he had clear emesis once at home and once in he er. he also noted a cough. of note, the patient ran out of one of his blood pressure medications a few days ago, but he is not sure which one. . in the ed, initial vital signs were t 99.8 hr 106 bp 183/109 rr 40 sat 78%/ra. ekg showed sinus 104, st depressions in i, v5-6, similar to prior. labs were notable for wbc 13.2, trop 0.05, lactate 3.9. cxr showed patchy basilar opacities, concerning for pneumonia. cta negative for dissection (done due to back pain). the patient was given methylprednisolone 125 mg iv, vancomycin 1 gram iv, levofloxacin 750 mg iv, acetaminophen 1000 mg, albuterol nebs x 1, ipratropium nebs x 1, morphine 4 mg iv, and zofran 4 mg iv. vital signs on transfer afebrile hr 104 bp 117/85 rr 28 sat 94%/4l. has piv x 2. . on review of systems, (+)chills (in ed), +sweats. +fatigue. +lightheadedness. +shortnes of breath. +cough. +nausea/vomiting. +chronic weakness in right hand, otherwise no weakness. (-)no fever. no chest pain or pressure. no loss of consciousness. no diarrhea/constipation. no blood in stool or black stools. no difficulty urinating or pain with urination. no tingling/numbness. no visual changes. past medical history: 1. copd 2. esrd (on hd since ) 3. hypertension 4. hypercholesterolemia 5. peptic ulcer disease 6. colocutaneous fistula status post low anterior resection, colostomy, and a loop ileo-ostomy 7. history of pneumonia 8. bilateral carotid artery stenosis s/p left carotid endartectomy 9. h/o left frontoparietal stroke 10. systolic dysfunction (lvef 45% in ) social history: he lives with his daughter, he is retired from instructing at a driving school. he has a significant smoking history, but quit in . he does not drink alcohol or use drugs. family history: brother is on dialysis as a complication of dmii. mother also had diabetes. physical exam: admission exam: vital signs: t 99.0 bp 143/39 hr 102 rr 25 sat 96%/2l nc heent: anicteric sclerae. moist mucous membranes. neck: supple. no lad. jvp not elevated. resp: mildly tachypneic. bibasilar rales l>r. good air movement. no wheezes. no egophony. cv: tachycardic. regular rhythm. no m/g/r. abdomen: +bs. soft. nt/nd. ext: warm and well-perfused. radial and dp pulses 2+. right hand with pain at distal 5th metacarpal. neuro: a+ox3. cn ii-xii intact. right hand weak. strength otherwise throughout. . discharge exam: vitals: tm 99.3, bp 102-129/50-60, p 80s-90s, r 18, 88-96% on ra at rest and with ambulation general: resting comfortably in nad heent: ncat, eomi, no icterus or pallor, mmm neck: supple, no jvd cardiac: rr, nl s1/s2, no m/r/g lungs: good respiratory effort, some rales throughout, no wheezing extrem: rue in splint, full rom without pain, no le edema neuro: a&ox3, cn ii-xii intact, strength and sensation grossly intact pertinent results: admission labs: 06:55pm blood wbc-13.2*# rbc-3.75* hgb-12.4* hct-36.1* mcv-96# mch-33.1*# mchc-34.4 rdw-15.1 plt ct-284 06:55pm blood neuts-82.1* lymphs-13.6* monos-2.6 eos-1.2 baso-0.6 06:55pm blood pt-10.8 ptt-17.7* inr(pt)-0.9 06:55pm blood glucose-109* urean-20 creat-3.6* na-136 k-4.7 cl-94* hco3-28 angap-19 03:52am blood ld(ldh)-pnd ck(cpk)-35* totbili-pnd 11:41pm blood ck(cpk)-36* 06:55pm blood calcium-9.2 phos-3.5 mg-1.8 06:55pm blood ctropnt-0.05* 11:41pm blood ck-mb-2 ctropnt-0.04* 03:52am blood ck-mb-2 ctropnt-0.04* . discharge labs: 07:15am blood wbc-5.8 rbc-2.64* hgb-8.9* hct-25.7* mcv-98 mch-33.7* mchc-34.5 rdw-15.6* plt ct-226 07:15am blood glucose-124* urean-33* creat-7.2*# na-137 k-3.8 cl-91* hco3-34* angap-16 07:15am blood calcium-8.4 phos-4.7*# mg-2.1 . micro: blood culture x2: no growth to date urine culture: no growth stool c. diff: negative sputum culture: commensal respiratory flora . imaging: portable cxr: small patchy opacities in both lung bases, worrisome for either foci of aspiration or possibly multifocal pneumonia. . cta chest: multifocal pneumonia. . right hand xr (ap/lat/oblique): soft tissue swelling about the small finger metacarpal. there is a transverse fracture through the distal small finger metacarpal with volar displacement, apex dorsal. no other fractures. no dislocation. no degenerative or erosive changes. . right hand xr (ap/lat/oblique): evaluation is limited by an overlying cast. again seen is the boxer's-type fracture of the fifth metacarpal with radial and volar angulation of the distal fracture fragment grossly unchanged compared to the prior examination. no additional fracture is identified. brief hospital course: 65 year old man with esrd on hd, copd, systolic dysfunction, presenting with shortness of breath and nausea and found to have a multifocal pneumonia. . # sob: patient was ruled out for mi. he is euvolemic on exam w/o suggestion of heart failure, and we reviewed the ct chest with radiology and confirmed that there is no evidence of pulmonary edema. no evidence of a copd exacerbation. cxr was suggestive of pneumonia (aspiration vs. multifocal). cta was negative for pe or dissection, and confirmed a multifocal pneumonia. he was observed eating and does not appear to be aspirating. he was initially treated for hcap (considering his dialysis treatments) with cefepime/vanc/levofloxacin, but the cefepime was discontinued due to low suspicion for pseudomonas infection. he makes very little urine and we therefore were unable to check a urine legionella antigen. he will complete a 7-day course of levofloxacin and vancomycin (dosed with hd) from . he was already given his dose of levofloxacin prior to discharge on and will need his last dose on . he will receive his last dose of vancomycin at dialysis on . he remained afebrile with normal wbc and clinical improvement. o2 sats are 88-96% on ra at rest and with ambulation; 92-98% on 1l. he denies any sob, dizziness, or other symptoms with ambulation. . # copd: pfts on showed fvc 2.48, fev1 1.10, fev1/fvc 44. the patient was treated with an inital dose of methylprednisolone 125 mg iv in the ed, but was w/o wheezes on exam and no suggetion of a copd exacerbation. he was continued on his home famotidine, advair, and spiriva, as well as albuterol and ipratropium nebs prn. he was discharged on his home regimen. . # pulmonary nodules: on the ct chest there are a few prominent mediastinal and right hilar nodes which do not meet criteria for pathologic enlargement and may be reactive. these were noted on prior imaging and are being followed by his outpatient pulmonologist dr. . he is scheduled for a repeat ct chest in 8/. . # dizziness/hypotension: the day prior to discharge the patient experienced dizziness and hypotension to the 90s during dialysis. he reported a dry mouth and was found to be orthostatic. his symptoms improved after a 500cc bolus of ns. his symptoms were felt to be secondary to removal of too much fluid in dialysis. in discussion with the renal team, we will adjust his new dry weight to 67kg. his blood pressure has been well controlled despite holding the nifedipine and on a reduced dose of metoprolol. it is unclear why he is requiring fewer anti-hypertensives, but may be due to more aggressive volume removal with dialysis. he was instructed to hold the nifedipine and continue metoprolol succinate 50mg daily (reduced from 100mg daily). . # esrd on hd: the patient received an extra dialysis session on friday for hyperkalemia and possible volume overload, but was then dialyzed per his usual tu/th/sa schedule for the rest of the admission. we continued sevelamer and epo, and started nephrocaps per renal's suggestion. . # anemia: likely multifactorial. baseline hct appears to be ~25-36. normocytic. pt has a h/o anemia of ckd. iron studies in revealed a low iron and low tibc suggesting a mixed picture of iron deficiency anemia as well as anemia of chronic disease. b12 and folate wnl. patient receives epo with outpatient hd. his pcp could consider iron supplementation and to make sure the patient is up to date on colorectal cancer screening. . # systolic dysfunction: echo in revealed mild regional left ventricular systolic dysfunction with anterior and anterolateral hypokinesis, with an lvef=45% (stable from ). he is currently euvolemic on exam, and there is no evidence of pulmonary edema on the cxr or ct chest, however considering his normal blood pressure despite holding the nifedipine and decreasing the metoprolol dose, there is a question of worsening systolic function. the patient is scheduled for an outpatient echo on . . # hyperlipidemia: continued home simvastatin 80mg daily. . # right hand pain: started after the patient punched a wall several weeks prior to admission. x-rays revealed a transverse fracture through the distal small finger metacarpal. orthopedics evaluated the patient and placed a temporary splint. occupational therapy later provided the patient with a permanent splint. he has a f/u appt with ortho on . . # eyes: mr. occasionally reported "heavy eyes," but no blurry vision or vision changes, and no eye pain. eomi and his vision and visual fields are grossly intact, although he wears glasses, but did not have them with him during this admission. recommend outpatient optometry f/u. . # cognitive impairment: mr. was often inconsistent with his history and symptims, and appeared depressed. in speaking with his daughter, it seems that he has been this way for some time and there is concern that he may have mild cognitive impairment and/or depression. we recommend that his pcp consider neuropsychiatric evaluation to screen for depression and dementia. . # disposition: he will be discharged to rehab and we will arrange for home services on dialysis days, once he returns home. the patient and his daughter are in agreement. he has a f/u appt with his pcp . on . . **a copy of this discharge summary was faxed to the patient's pcp . ** medications on admission: 1. albuterol nebs prn 2. albuterol sulfate hfa 90mcg, 2 puffs q4-6h prn 3. plavix 75 mg daily 4. famotidine 20 mg daily 5. advair 250/50 one puff 6. metoprolol succinate 100 mg daily 7. nifedipine 60 mg daily 8. sevelamer 800mg, 3 tabs tid with meals 9. simvastatin 80 mg daily 10. spiriva 18 mcg inhaled daily 11. aspirin 325 mg daily discharge medications: 1. levofloxacin 250 mg tablet sig: one (1) tablet po daily (daily): (started and last day is ). disp:*1 tablet(s)* refills:*0* 2. vancomycin 500 mg recon soln sig: five hundred (500) mg intravenous hd protocol for 1 doses: to be given at dialysis; (started and last day is ). 3. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*0* 4. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*0* 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation twice a day as needed for sob, wheezing. 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 8. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 9. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 10. sevelamer carbonate 800 mg tablet sig: three (3) tablet po tid w/meals (3 times a day with meals). 11. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 12. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 13. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: healthcare center - discharge diagnosis: primary: multifocal pneumonia secondary: fifth right metatarsal displaced fracture discharge condition: mental status: clear and coherent (though inconsistent story at times) level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , . you were admitted because you were feeling poorly and had shortness of breath. you were found to have a pneumonia which we are treating with antibiotics. . you were found to have a fracture in your hand from punching a wall. the fracture is being managed with a splint and you need to follow up with orthopedics (appointment listed below). . you are being discharged to a rehab facility to regain your strength prior to going home. . we made the following changes to your medications: - start levofloxacin (last day is ) - start vancomycin (given at dialysis; last day is ) - start nephrocaps (b complex - vitamin c - folic acid) for your kidneys - stop nifedipine because your blood pressure has been low - decrease metoprolol from 100mg daily to 50mg daily - you can take tylenol as needed for pain in your right hand followup instructions: department: internal medicine when: monday at 10:00 am with: , md building: (, ma) campus: off campus best parking: free parking on site . department: orthopedics when: tuesday at 2:10 pm with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage . department: orthopedics when: tuesday at 2:30 pm with: , md building: campus: east best parking: garage . department: cardiology - echocardiogram when: at 10:00 am campus: east best parking: garage **an interpretor will be present** procedure: hemodialysis diagnoses: pneumonia, organism unspecified acidosis hyperpotassemia anemia in chronic kidney disease end stage renal disease chronic airway obstruction, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia other diseases of lung, not elsewhere classified kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure hypotension of hemodialysis closed fracture of base of other metacarpal bone(s) 

Answer: The patient is high likely exposed to