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: the patient is an outside hospital transfer for mixed respiratory failure, neurology work-up. he was initially admitted to osh for lethargy. major surgical or invasive procedure: intubation tracheostomy percutaneous gastrostomy tube history of present illness: mr. is a 77yom with recent h/o hypercarbic respiratory failure asp pna who presented on to for lethargy ( icu ). he was transferred for further management and work-up of his respiratory status. most recently on , he became lethargic at home with sats in the 80's on home dose 3l nc. he reportedly had difficulty answering questions, but denied f/c/cough. per the notes, he was not wearing his home bipap or nc as he was supposed to after d/c from rehab. cxr at the osh showed ? new right effusion and pna, but he was not started on antibiotics. abg at the time was 7.18/104/106/41 on 2lnc; he was started on bipap but later intubated for poor ms developed hypoxemia. per notes, secretions were minimal. chest cta was negative for pe. head ct was negative; mirapex was held due to the lethargy. bp meds were held on . he recieved d5w-1/2ns at 75 cc/hr. prior to transfer on , he was noted to have o2 sats ~92% with pao2's around 50 on fi02 of 80% with a peep of 7.5; tidal volume was set to 450 with a rr 16. past medical history: #) recent hypercarbic resp failure since -- admitted in with aspiration pna; c/b parapneumonic effusion -- was discharged to rehab after hospitalization on bipap at night with 2lnc during the day #) parksinson's disease -- diagnosed 3-4 months ago based on rigidity and withdrawal from adl's, as well as 30 lb weight loss -- did not tolerate sinemet (started in late or early ; had hallucinations) or requip (somnolence); was recently started on mirapex. -- neurologist is dr. #) h/o papillary cell transitional cell bladder ca, #) s/p turp, ? bph #) htn #) hyperlipidemia #) iga gammopathy-- per osh h&p, first "noticed" in #) pancytopenia-- per osh h&p, first "noticed" in #) ? h/o chronic dysphagia-- supposedly prior to pd dx -- had s&s eval prior to d/c on ; no evidence of aspiration on the study #) ? iron overload #) erosive gastritis #) ? asbestiosis-- calcifications c/w per recent chest ct's social history: -- girlfriend has been with him for 25+ years -- originally from , moved here in the 's -- used to play professional soccer for -- an ex-smoker; unclear how much and when he quit -- denied etoh family history: unknown. physical exam: vs on arrival to the icu: t 99.0; 121/46 (cuff), 141/46 (left alin), hr 57; vent settings ac, 450/14, 100/peep 8 general: intubated, sedated; elderly; had og tube heent: op clear but dry lungs: decreased bs on left base; crackles half-way up throughout; no wheezes cardio: rrr, no m.r.g. appreciated abd: +bs, soft, nd extremities: no edema, wwp skin: no rashes, no petechiae neuro: sedated; 2+ reflexes throughout on discharge: vs: t 97.0, bp 102/40, hr 97, rr 22, 94% on air. tm 97.6, 102-138/40-58, 97-117, 18-22 general: nad heent: op clear lungs: decreased bs on bilateral bases; no wheezes, poor air movement in bilateral upper fields, but improved from yesterday. cardio: regular, s1/s2, no murmurs, rubs or gallops appreciated. abd: +bs, soft, nd extremities: no edema, wwp skin: no rashes, no petechiae neuro: a&ox3, normal strength, no tremor. +ve for right foot drop. pertinent results: admission labs: 12:08am blood wbc-8.0 rbc-3.19* hgb-10.7* hct-29.0* mcv-91 mch-33.6* mchc-36.9* rdw-16.5* plt ct-160 12:08am blood neuts-73.8* lymphs-16.1* monos-9.4 eos-0.3 baso-0.4 12:08am blood pt-13.7* ptt-35.2* inr(pt)-1.2* 12:08am blood glucose-92 urean-28* creat-1.3* na-129* k-4.3 cl-89* hco3-38* angap-6* 12:08am blood calcium-9.3 phos-3.3 mg-1.7 microbiology: urine culture: negative blood culture, two sets: ngtd sputum culture: gram stain: >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture: sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | enterobacter cloacae | | cefepime-------------- 8 s <=1 s ceftazidime----------- 4 s 16 i ceftriaxone----------- 16 i ciprofloxacin--------- =>4 r =>4 r gentamicin------------ 4 s <=1 s meropenem------------- 8 i <=0.25 s piperacillin---------- 8 s 64 i piperacillin/tazo----- 8 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s radiology: osh radiology reports: admission cxr: ? loculated effusions b/l l > r, decreased lung volumes on left cxr report from osh: interval decrease in lll consolidation compared to ; reportedly new right pleural effusion head ct: negative for ic bleed and mass effect amdission cxr: flattening of both diaphragms is present consistent with copd. blunting of the right costophrenic angle is present. in the absence of prior films, it is not known whether this is chronic or acute. if acute the degree of failure should be suspected. old rib fractures are noted. impression: copd, right effusion. follow-up cxr: in comparison with the study of , there is more sharp appearance of the left hemidiaphragm, though there is still residual left basilar atelectasis. no evidence of shift of the mediastinum to the left at this time. the degree of right effusion has apparently decreased, though some of this could relate to the more upright position of the patient on this image. no evidence of acute focal pneumonia. video swallow : trace penetration was noted to occur during the swallow nectar thick liquids and cleared independently. the penetration was noted to occur consistently during the swallow on thin liquids and did not clear, increasing the risk of trace aspiration after the swallow. one episode of overt aspiration was noted to occur during the swallow on thin liquids. cough was ineffective in clearing aspirated material. : torso ct: impression: 1. trace pleural effusions, right lung atelectasis and left lower lobe collapse. although no mass is identified, given the calcified pleural plaques (implying asbestos exposure), differential consideration for the etiology of collapse must include a bronchogenic carcinoma. further evaluation with bronchoscopy is recommended. 2. scattered, sub-5-mm pulmonary nodules as detailed above, recommend follow- up in 6-12months with cross-sectional imaging. 3. subcentimeter hypoattenuating pancreatic tail lesion, differential includes side- branch ipmn and recommend attention to this area on subsequent imaging. : mri head: impression: normal brain mri. : tte: impression: bicuspid aortic valve with minimal aortic stenosis. normal regional and globa biventricular systolic function. dilated aortic root. biatrial enlargement. : carotid u/s: impression: there is less than 40% stenosis within the right internal carotid artery. there is 60 to 69% stenosis within the left internal carotid artery. : emg: impression: abnormal study. the electrophysiologic findings are highly suggestive of a disorder of motor neurons or their axons; however, multilevel radicular abnormalities or meningeal infiltrative/inflammatory process might produce a similar electrophysiologic picture. clinical correlation is required. spine mri : conclusion: degenerative disc disease as discussed above. no evidence of spinal cord or cauda equina compression. cxr tracheostomy tube is in standard position. improving bibasilar atelectasis and persistent pleural effusions. otherwise, no change from recent study. discharge labs: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 03:26am 7.0 2.64* 8.7* 24.8* 94 32.8* 35.0 17.3* 166 renal & glucose glucose urean creat na k cl hco3 angap 03:26am 145* 17 0.9 138 3.8 99 37* 6* calcium phos mg 8.8 2.6* 1.8 brief hospital course: mixed respiratory failure: mr. was admitted with respiratory failure, worse ventillatory than hypoxic, thought to be due to an aspiration/hospital-acquired pneumonia. his hypoxia rapidly corrected with significant improvement in lung volumes (recruitment) on cxr. his ventillatory failure was gradually improved with bronchodilators and antibiotics, and he was extubated without complication on . he was initially started on vancomycin and zosyn on admission on ; vancomycin was discontinued on when sputum cultures returned pseudomonas. speciation return enterococcus and pseudomonas on and the patient was started on cefepime to finish on . there was concern that neuromuscular weakness may be contributing to his poor respiratory status, though it was unclear whether this was a primary problem or secondary to deconditioning from being on the ventillatory (he was also on a vent for two weeks earlier in at with aspiration pna; he had difficulty weaning at the time). at , negative inspiratory forces were recorded at -11, -20 and -23 on prior to extubation. of note, the patient has a history of pancytopenia and was noted to have a relative leukocytosis of 8.0 on admission. wbc had decreased to 2.8 upon discharge. after discussion with the family, the patient underwent a trach/peg placement without complications. on the second day post operatively, the patient developed repeated desaturations while on the vent to the mid 80s, but was asymptomatic. a bronchoscopy revealed multiple mucus plugs which were extracted. however, overnight the patient spiked a fever to 101. the patient's cultures became positive for pseudomonas, which was sensitive to ceftazidime which was started on to be continued until . (of note, the patient's previous pneumonia was pseudomonas treated with cefepime). please call to follow up microbiology sensitivites on the sputum cultures. hypertension: mr. has baseline hypertension on home doses of amlodipine and lisinopril. blood pressures were initially in the 140's systolic on admission, but climbed after he was extubated. prior to speech and swallow evaluation, he was maintained on iv metoprolol and hydralazine. he was later changed to his prior medciation amlodipine when he was cleared to take po's. his linisopril was not resumed as his blood pressure was well controlled on amlodipine. lethargy: mr. initially presented to for lethargy. his pramipexole for parkinson's disease had been held by the osh for concern that medication side effects could be contributing; head ct and etoh level were negative. it is likely his ventillatory resp failure upon admission to the osh was also contributing to his somnolence. while at , he did not have problems with somnolence once off sedation for the ventillator. pramipexole remained held. weakness: mr. was recently diagnosed 3-4 months ago with parkinson's disease. neurology evaluation here showed dementia and right foot drop. he was felt to likely have what have arteriosclerotic disease which is chronic small vessel changes in the brain with white matter abnormalities and lacunes. while the patient was on the floor, he had acute respiratory distress and hypercapnia in the ct scanner while evaluating for possible stroke. the patient was intubated and transferred to the icu, and doing well when he was weaned from the vent. he tolerated approximately 6 hours extubated before needing to be reintubated for work of breathing. of note, the patient's nifs were ranging from -8 to -13 on minimal vent settings. patient was further evaluated by the neuromuscular service where an emg was performed, indicating the patient has the diagnosis of als. a spinal mri was obtained revealing no evidence of cord compression or cauda equina that could be causing his weakness. weight loss: he has had a 30 pound weight loss in the last 3-4 months. it is unclear whether this has been secondary to behavioral/pd-related problems or malignancy, a more likely possibility is als as discussed above. history of bph: he had as foley on admission and was continued on his home tamsulosin dose once he was taking po's, restarted on discharge pending issues for follow-up: follow up pseudomonas cultures/sensitivities medications on admission: medications on transfer: combivent inhalers omeprazole pramipexole-- on list, though reportedly held due to delta ms terazosin 10 mg qhs lisinopril 20 mg qd amlodipine 5 mg qd enoxaparin 40 mg sqd acetaminophen 650 mg po q4 hours prn medications at home (doses not listed): flomax lisiopril amlodipine omeprazole mirapex discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 2. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 3. saline flush 0.9 % syringe sig: one (1) injection q8h:prn: peripheral line: flush with 3 ml normal saline every 8 hours and prn. . 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: six (6) puff inhalation q4h (every 4 hours) as needed for wheezing. 8. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation qid (4 times a day). 9. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 10. ceftazidime 2 gram recon soln sig: one (1) recon soln injection q8h (every 8 hours) for 14 days: until . 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 13. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed. discharge disposition: extended care facility: - - discharge diagnosis: primary diagnoses: - amylotrophic lateral sclerosis - ventilator associated pneumonia-pseudomonas secondary: -hypertension discharge condition: stable, afebrile, a&ox3 (baseline). patient with known right foot drop and dementia nos (at baseline), tracheostomy & percutaneous gastric tube in place. discharge instructions: you were admitted to for evaluation of shortness of breath. you were found to have an infection in your airways which required iv antibiotics. a breathing tube was placed because you were unable to breath on your own. because you were having such difficulty coming off the breathing tube, a neurological evaluation was completed. the neurologists determined that you most likely have amylotrophic lateral sclerosis, or als. it was necessary to undergo a procedure to place a permanent breathing tube in your neck, a tracheostomy, to help you breath. you also had a feeding tube placed to undergo tube feeds. you have been given a picc line (central iv line) for continuation of iv antibiotics. while you were here, you were seen by neurology who felt that you did not display signs of parkinson's and more likely carry the diagnosis of als. this diagnosis was made by mri's of your spine and head, and an emg of the muscles of your chest. thus, your parkinson's medication mirapex was discontinued. you were started on the medication aggrenox which can help to prevent strokes. you will follow up with the neuromuscular specialist, dr. , in approximately one month. her office will contact you to set up the appointment. if you do not hear from them, the phone number is (. your mirapex was discontinued. your lisinopril was discontinued. you were started on aggrenox (1 capsule twice a day). you are also being given ceftazidime iv (2g every 8hours) for an additional 14 days. please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. followup instructions: please see your pcp, , as needed. please follow up with dr. in the next month. you will be contact for the appointment date. please follow up in neuromuscular clinic in 1 month by calling to schedule an appointment procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy closed [endoscopic] biopsy of bronchus diagnoses: unspecified essential hypertension acute kidney failure, unspecified acute respiratory failure amyotrophic lateral sclerosis pneumonitis due to inhalation of food or vomitus alkalosis ventilator associated pneumonia pseudomonas infection in conditions classified elsewhere and of unspecified site 

Answer: The patient is high likely exposed to