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: s/p gunshot wounds to left scapula and left posterior neck major surgical or invasive procedure: exploratroy lap; splenectomy, left nephrectomy, neck exploration; placement of g-j tube; esophageal repair; tracheal reconstruction and placement of tracheostomy history of present illness: 21 yo male s/p gunshot wounds to left scapula/flank region and left posterior neck; gcs 15 at scene, taken to an area hospital, developed stridor and was intubated; a left chest tube was also placed with 800 cc bloody return. he was transferred to for continued trauma care. past medical history: none family history: noncontributory physical exam: vs upon arrival to trauma bay: hr 87 bp 180/palp gen: intubated, paralyzed/sedated heent: ncat neck: + crepitus, c-collar in place chest: equal bs bilaerally, left chest tube cor: s1 s2 abd: soft, nd pelvis: stable extr: no c/c/e, gsw left scapula pertinent results: 10:52pm type-art temp-37.7 rates-12/ tidal vol-700 peep-5 o2-40 po2-167* pco2-42 ph-7.38 total co2-26 base xs-0 intubated-intubated vent-controlled 03:02pm lactate-3.2* 11:32am glucose-107* urea n-12 creat-1.2 sodium-139 potassium-4.5 chloride-110* total co2-18* anion gap-16 11:32am calcium-7.6* phosphate-3.3 magnesium-1.0* 11:32am wbc-18.0* rbc-3.94* hgb-11.4* hct-32.2* mcv-82 mch-28.8 mchc-35.3* rdw-14.2 11:32am plt count-206 11:32am pt-13.9* ptt-27.6 inr(pt)-1.2* c-spine (portable) 3:21 am c-spine (portable) reason: gsw trauma indication: 21-year-old male status post gunshot wound. ap cervical spine: the endotracheal tube is in the right mainstem bronchus. there are two left apical chest tubes. there is extensive subcutaneous emphysema of the neck and a bullet is located just to the right of c6. chest (single view) 1:46 pm chest (single view) reason: ? tip location ** can do cxr downstairs while doing ct* medical condition: 21 year old man with s/p intubation ** can do cxr downstairs while doing ct** reason for this examination: ? tip location ** can do cxr downstairs while doing ct** clinical history: status post intubation. check position. chest: a tracheostomy tube is present. the tip lies 6 cm from the carinal angle, it is in a satisfactory position. some increased opacities are present in the right upper lobe and an infiltrate in this area may be present. there has been marked clearing of the left lung since the prior chest x-ray of 10 hours before. two chest tubes are again seen. there is no evidence of a pneumothorax. impression: tracheostomy tube in satisfactory position, clearing of left lung opacity. cta neck w&w/oc & recons 1:03 pm cta neck w&w/oc & recons; ct 100cc non ionic contrast reason: ? fracture /carotid injury contrast: optiray medical condition: 21 year old man s/p gsw to neck reason for this examination: ? fracture /carotid injury contraindications for iv contrast: none. indication: 21-year-old man status post gunshot wound to neck. evaluate for fracture or carotid injury. comparison: none. technique: contrast-enhanced images of the neck were obtained to image the carotid and vertebral arteries. multiplanar reformations were obtained. findings: no definite evidence of carotid or vertebral artery pathology is seen. no definite evidence of fracture is apparent. patient is status post removal of right- sided bullet seen on prior plain film at the approximate level of c6. patient is status post tracheostomy. there is a marked amount of subcutaneous emphysema extending bilaterally within the sub and supraclavicular regions. there is mediastinal emphysema, as well as in both sides of the neck, more evident on the right side, and which extends into the parapharyngeal spaces, more evident on the right side as well. there is no pneumothorax seen in the limited evaluation of the upper lungs. a left sided chest tube is noted. there are probable bilateral pleural effusions. impression: 1. no definite evidence of carotid or vertebral artery injury. 2. extensive emphysema seen within the supraclavicular region, mediastinum, and neck, as noted above. esophagus 3:02 pm esophagus; -59 distinct procedural servic reason: eval: esophageal anastamosis (use thin barium) medical condition: 21 year old man s/p gsw to the neck now 10d s/p esoph repair reason for this examination: eval: esophageal anastamosis (use thin barium) indication: 21-year-old male status post gunshot wound to neck with esophageal repair. evaluate esophageal anastomosis. comparisons: . limited single contrast esophagram: the patient was imaged in the upright position and thin barium was administered by mouth. barium passes freely through the esophagus into the stomach, without obstruction. there is no evidence of aspiration or significant pooling of contrast in the valleculae or piriform sinuses. no contrast extravasation is identified. scout images demonstrate a tracheostomy tube, numerous surgical skin clips and a drain projecting over the right thoracic inlet. impression: limited study. no evidence of contrast extravasation or esophageal stricture. video oropharyngeal swallow 3:02 pm video oropharyngeal swallow reason: eval: swallow medical condition: 21 year old man s/p gsw to the neck now 10d s/p esoph repair reason for this examination: eval: swallow indication: 21-year-old male with gunshot wound to neck status post esophageal repair. video oropharyngeal swallow examination: an oral and pharyngeal swallowing video fluoroscopy study was performed in collaboration with the speech and language pathology division. various consistencies of barium including thin, barium, nectar thickened liquid, puree and a half cookie coated with barium were administered. findings: the oral phase demonstrates normal oral transit time and bolus formation. premature spillover was initiated. the pharyngeal phase was notable for mild delay in swallow initiation. there was moderately reduced laryngeal elevation, normal hyoid movement and epiglottic deflection. decreased laryngeal elevation contributes to reduced bolus propulsion and moderate residue in the valleculae and piriform sinuses. edema was appreciated within the epiglottis posterior pharyngeal wall. trace aspiration was noted following multiple sips of thin liquid. impression: mild pharyngeal dysphagia with pharyngeal edema resulting in moderate pharyngeal residue, which was trace aspirated. for a greater detail and for treatment recommendations, please see the dedicated speech and language pathology division report of the same date. date: signed by , ccc-slp on affiliation: oropharyngeal videofluoroscopic swallowing evaluation evaluation: an oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with radiology. thin liquid, nectar-thick liquid, pureed consistency barium, and one-half of a cookie coated with barium were administered. results follow: oral phase: the oral phase was judged to be wfl overall for bolus control and formation with adequate ap tongue movement and oral transit time. no premature spillover was appreciated. pharyngeal phase: the pharyngeal phase was noted for overall mild deficits with regards to a mild delay in swallow initiation. there was moderately reduced laryngeal elevation though hyoid movement anteriorly was entirely adequate and epiglottic deflection was complete. decreased laryngeal elevation contributed to reduced bolus propulsion and moderate residue in the valleculae and pyriform sinuses. residue was greatest with thick liquids and the cookie in comparison to residue with thin liquids. there was also edema appreciated of the epiglottis, posterior pharyngeal wall and at the level of the pyriform sinuses. edema also contributed to decreased bolus propulsion. anterior to posterior position: the ap view revealed absent movement of the right vocal fold. aspiration/penetration: trace aspiration occurred over time after the swallow of multiple sips of thin liquid/high density barium that was administered for the esophageal portion of the examination. aspiration occurred as a result of spillover of residue into the airway over time. a cued cough was not effective at eliminating all subglottic aspirate material, though some was expectorated via the trach. treatment techniques: the use of consistent repeat swallows, averaging 4 swallows per bite/sip was effective at clearing the majority of residue remaining in the pharynx. in clearing the residue out of the pharynx, the pt significantly decreased his aspiration risk as material was no longer available to be aspirated. summary: mr. presents with a mild pharyngeal dysphagia at this time characterized by pharyngeal edema and also likely presence of tracheostomy tube which impede laryngeal elevation and bolus propulsion. this results in moderate pharyngeal residue which was trace aspirated over time. aspiration can be reduced/prevented by consistently performing repeat swallows which cleared the residue from the pharynx. ap view also revealed evidence for decreased right vocal fold movement, which also appreciated on the bronch. would suggest ent consult to examine vocal fold function. spoke to md re: results of evaluation and re: absence of evidence for leak. further examination of the esophagus was completed by the radiologist, and per discussion with radiologist,did not reveal evidence for leak as well. spoke to md who reported team will confirm these results by examining the films prior to initiating a po diet. once cleared to begin a po diet, would recommend that the pt be advanced to soft solids and thin liquids. soft solids are recommended primarily due to the edema remaining in the pharynx. please note the 13 mm barium tablet was not administered due to concern it may lodge in the pharynx given the edema and residue that had already been appreciated. as such, po meds should be given either in liquid form or crushed. recommendations: liquids. 2. po meds given in liquid form or crushed. 3. aspiration precautions, including: a. for each bite & sip: swallow 4 times in a row. b. take small bites. d. alternate each bite with a sip to wash it down. e. avoid straws & take only one sip at a time. these recommendations were shared with the patient, the nurse and the medical team. date: signed by on affiliation: cosigned by , ccc-slp on repeat passy-muir valve attempt history: we returned again today to attempt a pmv for this 21 yo male admitted with multiple gsw with posterior tracheal injury/disruption and esophageal perforation. - bronch which revealed swelling of the epiglottis, arytenoids, decreased motion of the right vocal fold in comparison to the left, and patent subglottic airway/region. the pt previously was unable to tolerate the pmv due to edema and a lower than typical trach position, which was likely causing increased airflow resistance around this trach site. upon our last eval, it was recommended that pt have a trach downsize to reduce the airflow resistance. pt's trach was downsized yesterday. therefore, we have returned today to re-evaluate the pt to see if pt can tolerate the pmv after trach downsize. trach type:portex #6, dic, cuffless, trach tube secretions / ability to handle cuff deflation: pt has a cuffless trach. pmv tolerance / vocal quality / o2 sats: pmv placement was difficult due to protrusion of the inner cannula. the inner cannula was removed, however placement continued to be difficult due to ? variation of the standard 15mm hub. the valve was placed for approximately ~1-2 minutes with tracheal pressure measurements obtained throughout the evaluation. tracheal pressures measured at -1to+ 1 cm h20 (normal pressure ranges are between +/-10cmh20). this is an improvement from previous tracheal pressures, which ranged from +15 to +20 possibly due to increased pressure in the trachea created by the larger trach. prior to the evaluation, pt was able to talk without the pmv with a clear voice. he noted that he did not feel the tightness that he previously felt when trying to speak with the valve or finger occlusion. with the valve in place, pt's vocal quality is clear. after the evaluation, pt requested to have the pmv removed due to a slight tightness that he felt and because he preferred to communicate without the valve. the pmv was removed and inner cannula replaced. per discussion with the team, decannulation was mentioned for the pt. therefore, a trach cap was obtained and placed on the pt's trach. pt had no c/o discomfort with the cap in place. if the cap is kept on the trach for 24 hours without removal, pt will be ready for decannulation. summary: pt is able to tolerate the pmv at this time without o2 desaturation, respiratory distress, or c/o discomfort/tightness. pt is able to achieve adequate voicing without using the pmv at this time, and therefore, it is recommended that the cap remain on the trach for the next 24 hours and valve not be used to ensure that pt does not require use of the trach and that he is appropriate for decannulation. recommendations: 1. recommend keeping the cap on the trach for the next 24 hours operative report , m. signed electronically by , on tue 6:43 am name: , unit no: service: tra date: date of birth: sex: m surgeon: , m.d. preoperative diagnosis: multiple gunshot wounds to the neck and back. postoperative diagnosis: multiple gunshot wounds to the neck and back. procedures: 1. exploratory laparotomy, trauma splenectomy, trauma left nephrectomy and repair of left diaphragmatic injury. 2. neck exploration and repair of left-sided esophageal injury. 3. placement of a feeding gastrostomy tube and feeding jejunostomy tube. assistant: dr. , res dr. , int anesthesia: general endotracheal. iv fluids: 7000 cc of crystalloid. estimated blood loss: 1500 cc. urine output: 1000 cc. indications for procedure: mr. is a 21-year-old gentleman who sustained gunshot wounds to his neck and back. he was emergently taken to where he was intubated and then transferred to the emergency trauma. on arrival, he was noted to have decreased breath sounds on the left, and a chest x-ray confirmed a presumed hemothorax. a left chest tube was placed. he had 2 wounds in the subcutaneous tissue. the first subcutaneous wound was 6 cm posterior and 6 cm inferior to the mastoid process and the second wound was 2 cm inferior to the most distal point of the left scapula. there was no active hemorrhage from either subcutaneous wound. there was a significant amount of crepitus in both sides of his neck. plain films demonstrated 2 radiopaque objects. one was within the abdominal field and one was within zone 2 of the neck. the patient was requiring fluids in the emergency room bay and, after the placement of the chest tubes, he was taken to the operating room for an exploration of both his peritoneal cavity and his neck. procedure in detail: the patient was brought to the operating room. identify was confirmed to be , . he was placed on the operating room table in the supine position with the arms extended 90 degrees on arm boards. anesthesia ensured adequate sedation, paralysis and iv access. the patient was warmed. he was continued to receive resuscitation while he was prepped from his chin to his midthigh. he was draped to include his neck, chest, abdomen and thighs within the operative field. given that he at this point and in conference with anesthesia he appeared to be hemodynamically normal and did not require massive resuscitation, we opted to proceed with the abdominal exploration first. we made a midline incision from xiphoid to just inferior to the umbilicus. we sharply cut own to the fascia which was incised at the linea and this was taken through its entire length, leaving the peritoneum intact. once we were sure that anesthesia was ready, we entered the peritoneal cavity and packed the 4 quadrants expeditiously. there was no a massive hemorrhage within the abdominal cavity, but there was blood in the right and left upper quadrant. we began by examining the bilateral lower quadrants and we did not note any injuries. we then retracted the small bowel at its mesentery towards the patient's right and we noted that there was a significant hematoma in the retroperitoneum in the area of the kidney and, as we further examined the left upper quadrant, we noted an injury to the left diaphragm which was evident and it was in communication with the pleural space. we packed this area. we ran the small bowel and there was no small bowel injury. we examined the liver and there was no injury to the liver. we examined the right upper quadrant and there was no injury that we were able to note. there was no right-sided retroperitoneal hematoma. we then proceeded with maneuver. we mobilized the left colon medially and the descending colon medially. we continued to mobilize the spleen medially, taking its lateral attachments with the cautery, and we insinuated in the plane between the peritoneal attachments to gerota fascia and we elevated the spleen, the tail of the pancreas and the small bowel mesentery to the midline. this gave us excellent exposure to the left upper quadrant space. we were able to visualize the diaphragmatic injury and better evaluate the hematoma. when we mobilized the spleen to the midline, there was a significant laceration to the most lateral aspect of the spleen, and it was nearly split in 2. the decision was made to take the spleen. at this point, we were able to clamp the hilar vessels and the short gastric vessels and cut between kellys and tie them individually. due to the fact that the hemorrhage was well controlled with hilar pressure, we were able to meticulously dissect the tail of the pancreas away from the hilum and we were able to take the hilar vessels between clamps and ties individually. with the spleen removed, we then paid attention to the diaphragmatic injury. this was approximately 2 x 2 cm. we placed two 0 silk figure- of-eight stitches to reapproximate the muscle, and this provided a good result. we then irrigated the left upper quadrant. we then began to explore the retroperitoneal hematoma. we mobilized the left kidney medially and, upon doing so, it was apparent the kidney had sustained an injury from its superior pole down through its middle and essentially had bivalved the kidney. given the extent of the injury and the ongoing bleeding, the decision was made to perform an emergent left nephrectomy. since the kidney had been mobilized midline, we were able to isolate the hilar vessels, take them with right angles, divide them, and tie them individually. we tied the artery with a 2-0 silk and then we suture ligated the renal vein. with the kidney removed, we irrigated the left pericolic gutter and left upper quadrant again. there appeared to be excellent hemostasis. once we had excellent hemostasis, we ran the small bowel once again. we examined the colon closely. we entered the lesser sac through the gastrocolic ligament, and there was no hematoma in the lesser sac. at this point, we decided to close the abdomen and proceed with the neck exploration. we closed the abdomen with a #1 looped pds and stapled the skin. we proceeded with the neck exploration. the neck was extended with shoulder bolster. given the trajectory of the bullet which was left zone 2, left posterior and we predict would be moving in an anterior fashion, we opted to explore the left side of the neck first. we made an incision along the anterior border of the sternocleidomastoid. we used dissection through the subcutaneous tissue. we mobilized the sternocleidomastoid laterally. we initially mobilized the carotid sheath towards the medial aspect, and we did not really see any tract or any injured tissue. the carotid and the internal jugular were intact. we then mobilized the carotid sheath and its contents laterally, and we found some subcutaneous air. when we exposed the lateral aspect of the left lateral aspect of the esophagus, it was apparent that there was mucosa pouching out and that he had sustained an esophageal injury on this side. we freshened the edges of the wound. we performed a myomectomy inferiorly and superiorly to ensure that we could see the extent of the mucosal injury. we used interrupted 4-0 vicryl sutures to reapproximate the mucosa and then we used 3- 0 silk simple sutures to reapproximate the muscle layers over the mucosal repair. the repair seemed quite adequate. at this point, knowing the trajectory of the bullet, we were worried that there may be a missed injury on the right. we extended the lateral neck and cervical incision to a collar incision. we elevated a platysmal flap and we mobilized the sternocleidomastoid on the right laterally. we were able to mobilize the carotid sheath laterally. we mobilized the esophagus posteriorly. the esophagus was intact down into the thoracic inlet. we then examined the esophagus further superiorly at the portion of the cricopharyngeus muscle and, on palpitation, we could feel a foreign body in the right lateral aspect of the laryngeal complex. we incised right over the foreign body and we removed what appeared to be a bullet. on doing so, we exposed an injury to both the esophagus and the trachea at the level of the cricoid cartilage. the trachea appear to have been lacerated in half on the right side and there was some mucosal exposure from the right lateral edge of the esophagus. at this point, we asked for an intraoperative consultation by dr. from thoracic surgery who promptly responded and came to the operating room. he performed a further dissection and repair of the tracheal injury and the right esophageal injury which will be detailed in an operative report by dr. . once the tracheal injury and esophageal injury were in the process of being repaired, we came to a decision point that, due to the extensive cervical injuries and the combined tracheal and esophageal injury, we felt it would be quite prudent to place a gastrostomy and a feeding jejunostomy tube in the patient at this current setting. we reconfirmed that his hemodynamic status had been unchanged and been normal throughout the case. he had required no blood products up to this point. we decided to reenter the abdominal cavity to perform a gastrostomy tube and feeding jejunostomy tube. we removed the skin staples that had been placed and we cut the #1 pds suture and we opened the abdominal cavity. we began with the gastrostomy tube. we placed 2 rows of pursestring with 3-0 silks and then we made a gastrostomy with the cautery. we used a #18 foley which we had brought in through a stab incision in the left upper quadrant. we placed that and secured the pursestrings. we then secured the stomach to the peritoneal lining with interrupted silk sutures. next, we found the ligament of treitz and, approximately 20 cm distal, we placed a pursestring suture. then we made an enterotomy in the middle of the pursestring and placed a #12 whistle-tip catheter as a feeding jejunostomy. we tied the pursestring and then we placed lembert silks in a witzel fashion to secure it to a tunneled tube and then we secured the jejunum to the abdominal wall with silks. we secured both the gastrostomy and the jejunostomy tubes with nylons to the skin and then we proceeded to close the abdominal cavity with a #1 looped pds suture and closed the skin with skin clips. after this repair, the tracheal and esophageal repair were completed by the thoracic surgery team. they then proceeded to create a tracheostomy which will be detailed in their operative report. once the repairs were done and the tracheostomy was completed through a separate incision, we placed 2 lateral neck drains brought out through separate stab incisions on the left and the right neck. we reapproximated the platysma with vicryl sutures and then we placed some dermal sutures and we used skin clips to close the skin. lastly, we placed two #1 ethibond chin stitches to ensure 20-degree flexion of the neck status post partial tracheal resection and repair per thoracic surgery. at the end of the case, x-rays were taken and confirmed there were no instruments, needles or sponges within the abdominal cavity or within any of the wounds. dr. was present for the entire case. findings: 1. two subcutaneous wounds as described above. 2. intraabdominal findings included a left diaphragmatic injury which was repaired primarily, a massive splenic laceration resulting in splenectomy, massive left kidney laceration which resulted in a left nephrectomy, and placement of a feeding jejunostomy and a gastrostomy tube. 3. in the cervical region, findings included esophageal injury status post primary repair and a tracheal injury status post primary repair and a tracheostomy placement. brief hospital course: patient admitted to the trauma service: he was immediately taken to the operating room for exploratory lap; neck exploration; left nephrectomy; esophageal repair, placement of tracheostomy and g-tube (see operative report on pertinent results section). thoracic surgery was also consulted for intraoperative evaluation of his tracheal injury and esophageal perforation which was repaired. he remained in the trauma icu for several days. a bronchoscopy was performed which basically revealed epiglottis edema and decreased right vocal cord movement. later during his hospital stay a limited contrast esophagram was performed to rule out extravasation following repair of his tear; there was none noted. he was eventually weaned from the ventilator and was then transferred to the regular nursing unit. his 2 right chest tubes were removed as well as the jp drain that was placed in his neck during the surgery. speech and swallow was consulted; a blue dye study and passy muir valve bedside evaluation was performed; because of laryngeal edema he was kept npo, a video swallow was eventually weaned from the ventilator and was then transferred to the regular nursing unit. a bronchoscopy was performed and he was advanced to a soft diet with aspiration precautions. he remained on cycled tube feedings at night; calorie counts were performed; his tube feedings were stopped once determined that he was meeting his caloric needs orally. he is currently tolerating a regular diet. his most recent weight is 185 lbs as of . his tracheostomy was downsized on hd #16; he was decannulated on without any difficulty. the g-j tube should be removed in another 1-2 weeks. social work/center for violence prevention and recovery were also consulted and followed patient closely throughout his hospital stay, providing support for patient and his family. he was evaluated by physical therapy and is functioning independently. medications on admission: none discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed. disp:*60 tablet(s)* refills:*0* 2. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*20 tablet(s)* refills:*0* discharge disposition: home with service facility: gentiva discharge diagnosis: s/p gunshot wounds to left scapula and left posterior neck esophageal tear ruptured spleen ruptured left kidney ruptured diaphragm discharge condition: good discharge instructions: follow up with dr. , trauma surgeon in in 2 weeks; your g-j tube should be removed at that time. go to the nearest emergency room if you develop any increased shortness of breath, fevers, severe headaches or any other symptoms that are concerning to you. followup instructions: call for an appointment in 2 weeks time with dr. in . procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for less than 96 consecutive hours other enterostomy fiber-optic bronchoscopy fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances temporary tracheostomy nephroureterectomy total splenectomy other gastrostomy suture of laceration of esophagus local excision or destruction of lesion or tissue of trachea suture of laceration of trachea suture of laceration of diaphragm other incision of larynx or trachea diagnoses: edema of larynx traumatic hemothorax with open wound into thorax accident caused by unspecified firearm missile open wound of pharynx, without mention of complication injury to spleen with open wound into cavity, massive parenchyma disruption open wound of trachea, complicated injury to diaphragm, with open wound into cavity injury to kidney with open wound into cavity, complete disruption of kidney parenchyma open wound of larynx, complicated open wound of back, complicated 

Answer: The patient is high likely exposed to