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: respiratory distress major surgical or invasive procedure: intubation history of present illness: mr. is a 57 yo male with h/o ms who presented to osh today with respiratory distress. per friend and notes patient was fine last night. today he was coughing for several hours and at ~ 5 pm he was found vomiting, coughing and aspirating emesis. he was sob, rr was 36-40 and o2 sat was 84 % on ra. he was suctioned and treated with o2. . he was transferred to where hr was 160, bp 140/90,rr 36 and o2 sat was 84% on ra. he was given metronidazole, levofloxacin and ativan. he was paralyzed (etomidate 20 mg iv, succinyl choline 125 mg iv) and intubated. he was given fentanyl 50 iv x2. og tube was placed and brownish material came back. peripheral neosynephrine was started after a failed line attempt for systolics in the 80s. he was transferred to the for further w/u. . in the er here temp was 102, hr 150s (?afib), bp was in the 80s systolic. lactate was 7.4, wbc 1.3 with 58% bands. a central line was placed and patient was started on levophed. his abdomen appeared distended so abd/pelvis ct was done. it showed evidence of bowel obstruction. surgery was consulted and did not see a need for surgical intervention. additionally cxr was done and showed a multifocal pneumonia. ct c-spine did not show an acute fracture. past medical history: multiple sclerosis neurogenic bladder utis anxiety hypercholesterolemia social history: per family he does not drink, smoke or do drugs. he is divorced. his daughter and a friend are the hcps. family history: non-contributory physical exam: vs: t 100.2 hr 130 bp 110/63 rr 33 o2 sat 99% pcv: fio2 0.8 peep 15 inspiratory pressure 28 rr 24 gen: intubated, sedated male in nad heent: intubated, anicteric sclera neck: supple, rij in place cardio: tachy with regular rhythms pulm: cta b/l ant abd: soft, distended, hypoactive bs, nt ext: trace peripheral edema, 2+ dp pulses neuro: sedated, opens eyes to voice, does not respond to commands pupils equal, round, slightly reactive to light pertinent results: ekg: appears to be sinus tachycardia vs. aflutter at a rate of 153 st, q waves in 2, 3 < depressions in v2-v3 . ct head : no acute intracranial pathology including no evidence of intracranial hemorrhage. mild-to-moderate amount of chronic periventricular microvascular ischemic changes with mild prominence of the ventricles and sulci. paranasal sinuses show a minimal amount of mucosal thickening in the medial left maxillary sinus and ethmoid air cells. . cxr : bilateral asymmetric opacities representing either multifocal pneumonia vs asymmetric pulmonary edema with infection more likely given lack of widening of the vascular pedicle. . abd/pelvis ct : bilateral parenchymal consolidations in both lower lobes posteriorly, and there are multiple nodular densities in the right middle lobe. the abdomen contains multiple dilated small bowel loops with air-fluid levels and a transition point in the right lower quadrant, consistent with small bowel obstruction. the colon is relatively decompressed, containing residual air at several locations. there is no ascites or free intra-abdominal air. . c-spine film (prelim): limited exam due to patient motion. no obvious fractures or malalignment. . ruq u/s : no evidence for gallstones. no son signs of acute cholecystitis. sludge within gallbladder. . . speech and swallow evaluation : recommendations: 1. advance diet to ground solids & thin liquids by single cup sip only, no straws!! no mixed consistencies like cold cereal w/milk or chicken soup w/liquid and solids together. 2. medications crushed in puree 3. strict aspiration precautions: a. pt must be fed by staff! b. remind him to eat & drink slowly and c. no talking w/food/liquid in his mouth d. single cup sips of thin liquid, no straws e. hold liquid in mouth & keep head level (don't look up or throw head back when drinking) f. alternate between bites and sips 4. if he coughs while drinking, downgrade his diet to nectar- thick liquids. if he has any signs of coughing or choking on ground solids, downgrade to pureed foods. if he does well w/ground solids, consider upgrading to soft solids while carefully alternating between bites and sips 5. repeat the videoswallow if his mental status or medical status worsens to be sure this diet is still safe prognosis: prognosis for safe swallowing without aspiration is good if he is supervised to take single sips of liquid and alternate between bites and sips. however, if he drinks from a straw or feeds himself, he tends to "gulp & shovel" liquid/food into his mouth, placing him at significant risk to aspirate. also, his level of alertness/attention vary throughout the day. please don't feed him when he is not alert, attentive and appropirately following commands. . . : tte with bubble study: the left atrium is normal in size. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). the aortic valve leaflets appear structurally normal with good leaflet excursion. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. brief hospital course: a/p: 57 yo male with h/o ms who presents with hypoxia, hypotension, neutropenia, fevers, ileus with likely pna and uti, intubated for respiratory failure & sepsis. . # pulmonary: on arrival to the micu, mr. was hypoxic, hypotensive, neutropenic, febrile and was intubated for hypoxic respiratory failure. source of his respiratory failure was likely aspiration in the setting of sepsis. he was initially treated with treated with meropenem x 7 days given concern for aspiration pneumonia in this man who is chronic resident of an extended care facility. a bal was performed which showed 1+ gm pos cocci in pairs and negative cultures. on , a sbt was performed and patient was successfully extubated. following extubation, he continued to have copious secretions with diminished gag, requiring vigorous chest pt. on , cxr appeared markedly worsened consolidation representing aspiration. patient has weak gag and is not completely clearing copious secretions. due to leukocytosis, ? consolidation, pt was started on zosyn as empiric therapy for hospital acquired vs recurrent aspiration pneumonia. . pt was called out to medical floor on . a cta was obtained persistent tachycardia and oxygen requirement (2-3l), which revealed bilateral pe. pt was started on heparin, then transitioned to lovenox and coumadin. he was weaned off of oxygen, and breathing comfortably on ra on . pt discharged on with instructions to continue coumadin, and lovenox injections twice daily, and to have daily inrs checked and faxed to his pcp ( , fax ) with goal inr . he may discontinue his lovenox injections once his inr is therapeutic (inr ) or as instructed by his pcp. his pneumonia, pt will complete a 14 day course of zosyn and vancomycin (via picc) for hospital acquired pneumonia (day 1 , last day ). pt may benefit from ongoing chest pt to help mobilize his secretions. . . # altered mental status: pt with h/o multiple sclerosis. at times, pt noted to be talking out loud with no one in room but was easily redirectable. in the icu, this was attributed to icu delirium after intubation/sedation, acute illness, lack of sleep vs. ms . thiamine deficiency. of note, per family, patient's ms has been known to flare in the setting of infection and has caused paralysis. pt's mental status improved gradually at time of callout to medical service, and per disucssion on with pt's pcp and with his daughter on , pt's mental status appeared close to baseline (he was a&ox3, mumbling, and somewhat distractable, but aware of current events, and of his recent medical history). while in the icu, pt developed acute onset of weakeness in hiw upper extremities, whichw as felt to his ms. demonstrated marked improvement over the course of his stay on the medical floor, and had bilateral strength of biceps, triceps, and delts at the time of discharge. pt does not currently have a neurologist, discussion with pt's previous neurologist (dr. , , last saw pt ), suggest that pt lacks some insight at baseline, but is generally a&ox3, and understands some current events and some of his pmh. . . # hypotension/sepsis: sources of infection considered included pneumonia (aspiration) and uti. hypotension could also be fluid losses in the setting of pancreatitis, cardiac causes such as ami or inadequate co in the setting of rapid heart rate. pt had a history of urosepsis, with mrsa and multidrug resistant proteus. he was initially maintained on single pressor titrated to goal map 70. his basal cortisol level was 35.3 and did not elevate with cosyntropin stimulation; he was treated with a course of hydrocort and fludrocort. in the setting of profound septic shock, he was initially started on meropenem & linezolid given concern for aspiration pna and h/o vre in urine. he completed a 7-day course of meropenem; linezolid was d/c'd on day 6 as it may have been trigger for pancreatitis. pt subsequently started treatment for a hospital acquired pneumonia on given +bal for gpcs, worsening sputum producing, and new leukocytosis. surveillance blood cultures on have shown ngtd. surveillance urine cultures on showed ngtd. . . # cardiac: no cardiac history, pt denies chest pain or shortness of breath upon admission to the medical service. mild elevation in trop during icu admission felt demand in setting of hypotension and sepsis. trop/ck trending down at time of transfer to medical floor, repeat cardiac enzymes unremarkable. tte showed ef>55%, e/a 0.75 on . regarding rythym, pt with increased ventricular ectopy starting , and noted to have transient self-limited episodes of bradycardia to the 30's. tte performed which was unremarkable, sinus tachycardia was attributed to pt's pes, and ep consult was obtained to evaluate bradycardia, which were felt to be vagal (gradual slowing observed on telemetry), and not requiring intervention as they were asymptomatic. regarding pump function, pt initially frankly volume overloaded, however he autodiuresed without intervention, and was felt to be euvolemic upon discharge. pt discharged on aspirin and zocor for hyperlipidemia. . . # htn: pt without history of htn, but intermittently noted to have elevated sbps (150's) after extubation, possibly related to mobilization of fluid. upon arrival to the medical floor, his sbps were well controlled without initiation of antihypertensive meds. . . # ileus vs sbo: on admission, ct abd showed large amt of stool in colon. surgery was consulted but no surgical intervention indicated. pt arrived on the medical service without abdominal complants, and +bm, with normoactive bowel sounds. . . # arf/uti: pt presented with cre 2.2 on admission, felt likely to be pre-renal in the setting of hypotension. pt with h/o recurrent urosepsis, s/p course of cefepime which would have covered enterococcus uti, surveillance culture ngtd. creatinine stable s/p cta (1.2->1.0, pt received mucomyst and hydration). pt was aggressively autodiuresing s/p cta, likely mobilizing fluid given during initial resuscitation, and on was felt to be euvolemic. he was encouraged to remain well hydrated upon discharge and to match his urinary losses with oral hydration. pt has a chronic indwelling foley catheter which was last changed 1 month earlier per nh, as such, his foley was replaced on . . . # fen: given pt's acute presentation s/p aspiration event, there was considerable concern regarding his ability to eat unsupervised upon discharge. pt initially fed via post-pyloric feeding tube which pt removed on . pt evaluated by the speech & swallow service who recommended: "ground solids & thin liquids diet by single cup sip only, no straws!! no mixed consistencies like cold cereal w/milk or chicken soup w/liquid and solids together. medications crushed in puree. strict aspiration precautions. pt must be fed by staff. remind him to eat & drink slowly and no talking w/food/liquid in his mouth. single cup sips of thin liquid, no straws. hold liquid in mouth & keep head level (don't look up or throw head back when drinking) alternate between bites and sips. if he coughs while drinking, downgrade his diet to nectar-thick liquids. if he has any signs of coughing or choking on ground solids, downgrade to pureed foods. if he does well w/ground solids, consider upgrading to soft solids while carefully alternating between bites and sips." pt discharged home with instructions to follow above instructions. should he develop recurrent coughing with meals, he will follow-up with his pcp. . . # dispo: pt discharged to his nursing home on , with instructions to complete a course of vanco/zosyn (last day ) via picc line. on , he will contact his pcp regarding removal of picc line. he was instructed to take lovenox injections twice daily, and have his inr checked daily and sent to his pcp, will adjust his inr as appropriate. he was instructed to discontinue lovenox injections once his inr was at goal (inr ) or as instructed by his pcp. plan was discussed with pt's pcp (dr. ) who is aware and amenable to this plan. . . # communcation: hcp is daily (), daughter is (). pt lives at windgate nh, (), pcp is , neurologist is () . medications on admission: vitamin c 500 mg qd prilosec 20 mg qd citalopram 40 mg qd zocor 40 mg qd senna 2 tabs cranberry cap 2 caps tid colace 200 mg qhs baclofen 30 mg qhs asa 81 mg qd mvi ativan 0.5 mg qhs tylenol prn discharge medications: 1. vitamin c 500 mg tablet sig: one (1) tablet po once a day. 2. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 3. citalopram 40 mg tablet sig: one (1) tablet po once a day. 4. zocor 40 mg tablet sig: one (1) tablet po once a day. 5. colace 100 mg capsule sig: capsules po at bedtime as needed for constipation. 6. baclofen 10 mg tablet sig: three (3) tablet po qhs (once a day (at bedtime)). 7. aspirin 81 mg tablet sig: one (1) tablet po once a day. 8. bisacodyl 5 mg tablet sig: one (1) tablet po bid prn as needed for constipation. 9. ativan 0.5 mg tablet sig: one (1) tablet po at bedtime as needed. 10. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 11. enoxaparin 100 mg/ml syringe sig: one (1) subcutaneous q12h (every 12 hours) for 2 weeks: please take twice daily. please also take coumadin daily, and have inr checked daily and sent to your pcp (), you may discontinue lovenox injections once inr= or instructed by your primary care physician. . disp:*qs * refills:*0* 12. piperacillin-tazobactam 4.5 g recon soln sig: one (1) recon soln intravenous q6h (every 6 hours) for 6 days: please take total 14 day course (day 1 was , last day ). disp:*24 recon soln(s)* refills:*0* 13. warfarin 5 mg tablet sig: one (1) tablet po daily (daily): please have your inr checked daily and sent to your primary care physician (dr. ), who will adjust your coumadin dose accordingly. your goal inr is . you will likely be on coumadin for 3 months for pe, or as instructed by your pcp> . disp:*30 tablet(s)* refills:*1* 14. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 12h (every 12 hours) for 6 days: please take total of 14 day course (day 1 was , last day ). disp:*12 * refills:*0* 15. heparin lock flush (porcine) 100 unit/ml syringe sig: two (2) ml intravenous daily (daily) as needed for 6 days: please flush picc with 2ml's of solution once daily, and prn. . disp:*qs ml(s)* refills:*0* 16. outpatient lab work please have your inr drawn daily for until , and sent to your primary care physician (dr. , , fax ), who will adjust your coumadin dosing appropriately, and instruct you as to how to monitor your inr in the future. your goal inr is . 17. picc line care please provide picc line care per protocol. 18. picc removal please call pt's pcp (dr. , , fax ) on regarding removal of picc, once pt has completed his course of antibiotics. 19. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day). 20. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 21. zolpidem 5 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed. 22. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. discharge disposition: extended care facility: of discharge diagnosis: sepsis uti respiratory failure aspiration pneumonia altered mental status multiple sclerosis pancreatitis acute renal failure discharge condition: stable discharge instructions: please continue to take all of your medications as prescribed. . you were started on a 14 day course of antibiotics for pneumonia (zosyn, vancomycin last day ). . you were started on a 14 day course of lovenox injections for you pulmonary embolism. you will be transitioned to coumadin therapy while on lovenox. you should have your inr checked daily for the next week (until ) until you reach a stable inr (goal inr ), at which time you will have your inr monitored routinely as per your primary care physician, is aware of this plan. you should continue to take lovenox twice daily until your inr is between , or until instructed to stop by your primary care physician (dr. , ). . you should be fed in a supervised fashion, with aspiration precautions, given that you were admitted for aspiration pneumonia, please see feeding instructions on page 1 sheet for more details. . if you develop chest pain, shortness of breath, difficulty breathing, worsening lower extremity swelling, fevers, chills, or other worrisome symptoms please contact your primary care physician or the emergency department. followup instructions: upon arriving to rehab please contact your primary care physician and arrange to be seen within 2-3 weeks. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus injection or infusion of oxazolidinone class of antibiotics infusion of vasopressor agent diagnoses: anemia of other chronic disease urinary tract infection, site not specified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified septicemia severe sepsis other specified forms of chronic ischemic heart disease other and unspecified hyperlipidemia acute respiratory failure other specified cardiac dysrhythmias pneumonitis due to inhalation of food or vomitus septic shock paralytic ileus multiple sclerosis other pulmonary embolism and infarction acute pancreatitis paraplegia neurogenic bladder nos 

Answer: The patient is high likely exposed to