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: penicillins / terbutaline / epinephrine / glucocorticoids / alupent / iodine / prednisone attending: chief complaint: shortness of breath major surgical or invasive procedure: intubation and extubation history of present illness: mr. is a 50 y/o gentleman with cad, diastolic chf, self-reported multiple sclerosis, schizoaffective disorder, narcissistic personality disorder, which contribute to his frequent medication noncompliance, and multiple admissions & intubations for copd exacerbations. he presented to the ed with shortness of breath and was admitted to the for respiratory failure which required intubation in the ed. . of note, he has no documented pfts but he is prescribed copd medications. when he is admitted, cxr usually does not show hyperinflation or pulmonary edema, usually does show asymmetric atelectasis (right worse than left). . he was last hospitalized for copd in , and was last intubated in . he came to the ed today complaining of 2 weeks of fever/chills/cough/gradual dyspnea, with acute worsening of his dyspnea over the past day. he was extremely nervous, was tachypneic to the 40's, and had difficulty speaking more than one word at a time. . in the ed, initial vs were: t99 rectal, bp 123/79, hr 132, sao2 low 90s%, rr12. he was diaphoretic and cool, and had expiratory wheezes. no peripheral edema. he was given solumedrol 125mg, abx, and nebs. he was persistently tachycardic despite small fluid bolus. he was tried on bipap and nonrebreather with sao2 100%, but he continued to be tachypneic to the 40s. he became less responsive and was intubated. . in the , the patient is intubated and sedated on propofol, arousable to painful stimulus but not following commands. past medical history: copd s/p multiple intubations: h/o refusal to use prednisone or bipap. not on home o2 due to insurance issues. cad s/p "at least 3" mi's with multiple cardiac catheterizations, per patient report chronic diastolic chf steroid-induced diabetes mellitus type ii, uncontrolled multiple sclerosis per patient: states he was diagnosed 2 years ago, followed by dr. (. however, dr. had no record of patient. diverticulosis s/p bowel resection obesity narcissistic personality disorder schizoaffective personality disorder social history: he is married, but his wife resides in a state psychiatric facility. he currently lives alone in ct although he has been spending time in the past few weeks with friends or family. he has a supportive cousin named . is on disability. history of smoking with unknown # of pack years, currently denies smoking, etoh, or recreational drug use. family history: father had emphysema, died of an mi at age 56. mother died of an mi at age 70. otherwise non-contributory. physical exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: rt sided inspiratory wheezes, transmitted to left side; no rales, no rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley draining yellow, cloudy urine ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: wbc-8.5 rbc-5.46 hgb-14.6 hct-43.6 mcv-80* mch-26.7* mchc-33.5 rdw-18.5* plt ct-632*# neuts-69.5 lymphs-21.0 monos-6.6 eos-1.8 baso-1.0 pt-12.8 ptt-24.7 inr(pt)-1.1 glucose -156* urean-18 creat-0.8 na-142 k-5.3* cl-105 hco3-27 angap-15 alt-37 ast-37 alkphos-70 totbili-0.4, calcium-9.3 phos-3.6 mg-1.8 probnp-57 ctropnt-<0.01 probnp-144* ck-mb-4 ctropnt-0.03* 01:37am blood ck-mb-3 ctropnt-0.01 03:24am blood ck-mb-1 ctropnt-<0.01 03:30am blood type-art rates-12/ tidal v-450 peep-5 fio2-100 po2-100 pco2-78* ph-7.19* caltco2-31* base xs-0 aado2-553 req o2-89 -assist/con intubat-intubated 05:34am blood type-art rates-16/ tidal v-600 peep-10 fio2-100 po2-93 pco2-59* ph-7.29* caltco2-30 base xs-0 aado2-579 req o2-93 intubat-intubated 12:56am blood glucose-127* lactate-2.1* na-142 k-5.3 cl-102 calhco3-27 . cxr : impression: low lung volumes with atelectasis, but no acute cardiopulmonary process. . chest ct : impression: 1. resolution of right upper lobe consolidation since with residual bilateral lower lobe and right middle lobe atelectasis and new superior segment of left lower lobe consolidation. 2. opacification of the pulmonary arteries is suboptimal. there is no evidence of a central pulmonary embolism nor is there evidence of right heart strain but a segmental embolism cannot be excluded on the basis of this study. . micro: gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. legionella culture (preliminary): no legionella isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. . blood culture, routine (preliminary): staphylococcus, coagulase negative isolated from one out of four total sets - sensitivities only performed on request.. aerobic bottle gram stain (final ): reported by phone to dr. on at 0450. gram positive cocci in clusters. . cvl tip cx : negative brief hospital course: summary from the icu: mr. is a 50y/o gentleman w/ little confirmed pmh and underlying psychiatric disorders and substance abuse who was admitted to the after being intubated for respiratory distress. . #. hypoxic/hypercapneic respiratory failure: unclear etiology. pt agitation likely playing a role as he was significantly agitated in the ed before intubation. in the past, he has had similar presentations and improved clinically after treatment for copd, though he has no documented obstructive disease and low lung volumes on cxr convincing for copd. per pt there is diagnosis of chf, but tte showed normal ef and only mild lv dilatation and did not appear grossly volume overloaded on exam. pt was started on oral prednisone and albuterol/ipratropium inhalers and azithromycin for presumed copd flare. there was low suspicioin for pna. tox screen negative except for benzos/opiates in urine on sample taken after pt given both for vent sedation. bnp was 57 and 144 on repeat. cta showed resolution of right upper lobe consolidation since with residual bilateral lower lobe and right middle lobe atelectasis and new superior segment of left lower lobe consolidation. no evidence of central pe. concern for increased shunt fraction and so echo with bubble study was done. poor study with no evidence of shunt on bubble portion with echo showing mild symmetric lvh. lv cavity is mildly dilated. there is mild global lv hypokinesis (lvef = 30-40%). bronchoscopy showed mild mucous plugging and yielded negative culture data. initial attempt made to taper oral steroids but stopped at 40mg due to worsening wheezing. then pt stated that oral steroids did not help him and refused to take them, so iv methylprednisolone was started and then tapered. pt very agitated on vent but showed improvement in lung status. there was concern for volume overload to resuscitation contributing to hypoxia, and iv lasix was started on with good response. extubated on and transitioned to po lasix on . still requiring large amounts of o2 via nasal cannula once extubated and lungs still very congested but able to maintain o2 sats. . #. cad with sinus tachycardia: intial question of intravascular volume depletion. pt also with past history of tachycardia and was on diltiazem at some point in the past for this. pt reporting 3 past mis but no documentation available. asa started on admit. ekg showed st depressions with t wave inversions and signs of old ischemia. cardiac enzymes negative x 3. ekg did not change during icu stay except prolongation of qt interval with haldol as noted below. continued to be tachycardic, worsen in setting of frequent agitation and activity. did not report increased chest pain during these episodes. . #. agitation/psych disorder: pt with unclear psych history but multiple social work and psychiatry notes in omr describing interactions consistent with personality/psych disorder. pt very agitated while on vent, questionably delirious. given haldol 5mg initially for delirium but qtc interval abruptly widened to 493ms from 458ms. pt switched to seroquel with further qtc prolongation, up to 505ms before it came back down. after pt extubated he was agitated and was trying to leave. psych consult obtained and they deemed that the patient does not have the capacity to make this decision. they recommended switching anti-psychotic to risperidone (so that both po and im forms would be available in one antipsychotic for fear that multiple antipsychotics would have additive impact on qtc). this was done and pt agreed to stay. . #. hypertension: pt was initially hypotensive (sbp 60) peri-intubation per the ed, but this had stabilized with fluid boluses by time he came to the icu. bp meds were held. fentanyl/midazolam used for sedation to help with bp. arterial line was placed and bp monitored. on pt briefly hypotensive and map transiently below 60. pressors were briefly started in context of some concern for infection at the time but then peeled back as bp stabilized. bp stayed on the low end of normal for the rest of the icu admission. . #. positive blood cx: one out of four of initial ed blood cx turned positive for gpc on . vancomycin started over concerns that gpc sepsis contributing to presentation. vanco stopped after 2-3 days when cx results came back cons in bottles which was thought to be a contaminant in light of overal clinical picture. . #. vascular access: initially pt with r ij placed in ed. this site was contaminated during bubble study echo and new cvl was placed with contaminated line removed. pt later had new ij removed and then lost peripheral access requiring ir fellow to place piv for access for meds. . #. social: when pt presented there was no contact information available in the chart. multiple past sw notes indicated some episodes of behavioral outbursts and questionable reports of medical issues per pt. sw was able to find some contact information and pt was discussed with brother ( who is next of . he expressed concern about illicit drug use. another cousin, ( who is the "hcp" was contact and she said she would be in to the hospital shortly but never presented during the icu stay. a friend was also contact who stated that the patient had some psychiatric issues and also raised the question of drug abuse. course on the floor: patient was transferred to the hospital medicine service on . mr. is a 50 year old man with chronic mental illness/ narcissistic personality disorder/ schizoaffective disorder, long history of schf and copd, and self-reported multiple sclerosis. his current presentation seems most consistent with a copd and chf exacerbation. he was intubated in micu. of note, he had a new decline in his lvef while critically ill, with global hypokinesis. . # chronic mental illness negatively impacting his medical care: his course has been notable for a challenging personality style with frequent demands to guide his care and refusals of recommended medical care and treatments. on , a code purple was called when he became very upset with nursing and physician staff about his care, though was not able to be specific about what his major concern was. psychiatry consult attending dr. felt that mr. had the capacity to understand his situation and was able to decide to leave the hospital against medical advice. however, mr. ultimately decided to stay in the hospital. his clonazepem and oxycontin were re-started at lower doses than his discharge, since he had been without them for 7 days. . # steroid-induced diabetes mellitus type ii: his course has also been complicated by marked hyperglycemia. glargine was started as well as an insulin sliding scale and has been titrated up. he refuses a diabetic diet, sometimes refuses insulin, and he adamantly requests ensure shakes with each meal despite their high carbohydrate load. he eats whatever he wants. . # persistent hypoxemia and dyspnea: on his breathing was more labored, and he was diaphoretic with persistent cough and hypoxia. solumedrol was increased to 125 mg. cxr showed possible rml infiltrate so he was started empirically on levofloxacin for nosocomial pneumonia. on his respiratory status was unchanged but he was more emotionally labile and acutely agitated, particularly after the solumedrol 125mg doses were administered. the dose was therefore decreased back to 80mg. as he was not clinically improving, sometimes on the verge of returning to the icu, pulmonary was consulted on . they recommended adding vancomycin for the nosocomial pneumonia as well as substituting tiotropium for the ipratropium. in addition, they recommended a chest cta to r/o pe, but we were unable to obtain this due to lack of peripheral iv. he had a picc line, and he adamantly refused any further attempts at a piv due to his prior difficult experiences with vascular access. in addition, the pulmonary team recommended a tracheal ct to look for tracheal stenosis or tracheobronchomalacia, and the study showed no tbm. . # acute systolic and diastolic chf: he was diuresed in the and in the early part of his floor course, then he was switched back to his outpatient oral lasix dose. he then had significant osmotic diuresis due to his marked hyperglycemia (300-400s), so no further iv lasix was thought to be necessary. . # self-reported multiple sclerosis: patient reports he previously had a neurologist in but hasn't seen one in two years. he had been tried on different therapies but didn't know details. he felt that his had tremors were getting worse, and he wanted neurology consultation during this hospitalization. given his tenuous respiratory status, this was deferred. . remainder of hospital course: for the final week of hospitalization, which ended after mr. left ama on , is as follows: he was treated with vancomycin and cefepime for possible nosocomial pneumonia. cxr on showed no infiltrates. he continued to have lower extremity edema, with no response to massive diuresis. he was seen by the for resistant steroid induced hyperglycemia, and started on an aggressive sliding scale with improvement. . ultimately on - he was suspected of not taking his oxycontin and pocketing them. he on that day also lowered himself to the ground with jerking movements in the presence of the nurse, similar to prior episodes. he was then confronted by security due to concern for his behavior with the oxycontin. he was found to have 2 oxycontin in his pocket which he gave to the nurse. he subsequently demanded to leave ama. his picc was removed. the risks of leaving against medical device were detailed for mr. , and he expressed understanding that he faced the risk of death, respiratory failure, or significantly worse health outcomes. he had previously been seen by psychiatry and evaluated for his understanding of these risks at that time as well. he ultimately left the building with security. on future admissions, his oxycontin and klonopin usage should be carefully monitored. medications on admission: **unclear if pt taking any of these medications at time of admission: -diltiazem hcl sr 120 mg daily -furosemide 40 mg daily -clonazepam 1 mg tid -lisinopril 20 mg daily -montelukast 10 mg daily -xopenex hfa 45 mcg/actuation hfa 2 puffs q6h -xopenex hfa 45 mcg/actuation hfa 1-2 puffs q4h:prn sob/wheeze -ipratropium bromide 17 mcg/actuation hfa 2 puffs q6h -aspirin 325 mg daily -oxycodone 30 mg q8h -nitroglycerin 0.3 mg sl prn -calcium carbonate 500 mg tid -cholecalciferol (vitamin d3) 400 unit daily discharge disposition: home discharge diagnosis: ## acute on chronic systolic chf ## copd exacerbation ## steroid-induced diabetes, very poorly controlled due to diet ## h/o atrial fibrillation not on chronic anticoagulation ## schizoaffective disorder/ narcissistic personality disorder ## self-reported multiple sclerosis with chronic pain on chronic narcotics discharge condition: left ama discharge instructions: left ama followup instructions: left ama procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube closed [endoscopic] biopsy of bronchus central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: coronary atherosclerosis of native coronary artery congestive heart failure, unspecified adrenal cortical steroids causing adverse effects in therapeutic use obstructive chronic bronchitis with (acute) exacerbation acute respiratory failure other specified cardiac dysrhythmias multiple sclerosis acute on chronic systolic heart failure schizophrenic disorders, residual type, chronic secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified narcissistic personality disorder 

Answer: The patient is high likely exposed to