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: shortness of breath major surgical or invasive procedure: pericardial drain placement and removal peg placement picc placement intubation/extubation, mechanical ventilation thoracentesis x2 (bilaterally) history of present illness: the patient is a 70 yo man with ho dm2, htn, and recent diagnoses of afib who was transferred from osh on for evaluation of pericardial effusion. around , pt had chf-like symptoms, and he was started on diuretics. four days prior to admission patient had new onset atrial flutter and was started on coumadin. on , the patient was admitted to for a worsening dyspnea over 4 weeks. he was intubated in the ed and transferred to the ccu, where he was started on a dilt gtt and was eventually extubated on . then pt had ams, thought to be metabolic and had a ct-chest showing a large pericardial effusion and bilateral upper lobe and rml air space disease. he started imipenem and continued levofloxacin. tte at that time showed lvef of 25%. he underwent a tee with attempt to cardiovert, but he was found to have an atrial thrombus, so this was not attempted. he was transferred to for further care and possible pericardiocentesis since effusion appears to progress. at osh he also had arf, hematuria, and anemia (hct 24). . on transfer his echo showed tamponade changes and he was transfered to the ccu for pericardial drainage. repeat echo showed no reaccumulation of fluid. due to his garbled speech and dysphagia, neurology was consulted and felt he had a left parietal cardioembolic stroke (h/o a. fib). after failing s&s eval, decision has been made to pursue peg after transfer to the floor. he was also found to have a pneumonia, so is being treated with zosyn. on the floor he has had more agitation and has been given haldol 1mg and zyprexa 5mg. then pt became more somulent and a abg showed 7.19/92/56 on a shovel mask with 2 liters. hr was in the 80s and bp in 120s. he was transfered to micu for airway concern and hypercabic resp failure. . on arrival to the micu he was unresponsive. he did not tolerate placement of a bipap, so was intubated. on intubation he was noted to have a large amount of material in the thorat, possible food. he had some transient runs of bradycarida that quickly recovered to 90s without intervention. . review of systems: unable to obtain due to solmulence and intubation. past medical history: dm2 htn bph congestive heart failure anxiety disorder atrial fibrillation alcohol dependance and abuse social history: per osh medical records, the patient smokes 2 cigars and one cigarette daily. he drinks a six pack of beer daily. he lives with his wife. . family history: non-contributory physical exam: gen: middle aged man, aaox1, in nad vs: 126/70, p 66, r 16, o2 99% on 4l heent: perrl, eomi, mucous membranes dry cv: distant heart sounds. jvd elevated to angle of jaw. pulm: coarse breath sounds throughout lung fields bilaterally abd: +bs, nt, nd limbs: no edema. 5/5 strength bilaterally skin: no rashes or ecchymoses neuro: aaox1, moving all extremities. unable to follow commands. . on transfer to the micu: vitals: t: 96.9 bp: 97/38 p: 53-90 r: 19 o2: 97% on bag mask, then 100% on vent general: responsive to pain, solument heent: sclera anicteric, dry mm, op with debris neck: supple, jvp not elevated, no lad lungs: rhonchi b, decreased left breath sounds, no crackles cv: regular rate and rhythm, no murmurs, 2+ pulses abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley with clear urine ext: warm, well perfused, no clubbing, cyanosis or edema pertinent results: admission labs: 03:49am blood wbc-12.6* rbc-2.82* hgb-8.8* hct-26.6* mcv-95 mch-31.1 mchc-32.9 rdw-16.0* plt ct-751* 03:49am blood neuts-76* bands-1 lymphs-15* monos-7 eos-1 baso-0 atyps-0 metas-0 myelos-0 nrbc-2* 03:49am blood pt-27.8* ptt-36.9* inr(pt)-2.7* 03:49am blood glucose-171* urean-114* creat-2.0* na-143 k-4.1 cl-100 hco3-32 angap-15 03:49am blood alt-32 ast-41* ld(ldh)-288* ck(cpk)-88 alkphos-105 totbili-0.8 03:49am blood albumin-3.4* calcium-8.7 phos-4.8* mg-3.3* iron-43* 03:49am blood caltibc-229* vitb12-862 folate-16.0 ferritn-1190* trf-176* ----------------- discharge labs: ----------------- studies: . pericardial fluid: negative for malignant cells. lymphocytes, monocytes, and mesothelial cells. . rhcath and pericardiocentesis: 1. right heart catheterization prior to pericardiocensis showed elevation and equalization of diastolic filling pressures (20-22mmhg) that were similar to the opening pericardial pressure (19mmhg). pulsus paradoxus recorded via the a-line tracing was approximately 20mmhg. 2. pericardiocentesis was performed with needle entry from the subxiphoid position. the opening pericardial pressure was 19 mmhg. 3. subsequent to removal of 920 cc of blood fluid (all sent for studies) and confirmation by echocardiography of complete fluid removal, the pericardial pressure decreased to -2 to 1 mmhg and ra pressure decreased to 15 mmhg. 4. anesthesia was present during the case to manage the patient's airway given his tenuous respiratory status. he was maintained on 100% oxygen therapy. final diagnosis: 1. pericardial tamponade with improvement in hemodynamics after removal of 920 cc of bloody fluid. 2. pericardial drain in place. . ct head : there is no evidence of hemorrhage, edema, masses, mass effect, or infarction. the -white matter differentiation is preserved. the ventricles and sulci are prominent, most compatible with atrophic change. note is made of bilateral atherosclerotic calcification within the carotid siphons. the visualized portions of the paranasal sinuses and mastoid air cells are well aerated. . echo #1: no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 10-15mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. overall left ventricular systolic function is low normal (lvef 50-55%). with borderline normal free wall function. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is a large pericardial effusion. the effusion appears circumferential. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there is right ventricular diastolic compression, consistent with impaired fillling/tamponade physiology. impression: large pericardial effusion with echo evidence of impaired filling/tamponade physiology. . echo #2: overall left ventricular systolic function is normal (lvef>55%). rv with borderline normal free wall function. there is no residual pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , pericardial effusion (post tap) has resolved. there is no longer evidence of rv compression. . echo : the left atrium is moderately dilated. the right atrium is moderately dilated. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is mildly dilated. overall left ventricular systolic function is normal (lvef 60-70%). right ventricular chamber size is normal. with depressed free wall contractility. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. . mr head without contrast: there is no acute infarct, hemorrhage, edema, or mass effect. the ventricles and sulci are prominent, consistent with age-related atrophy. scattered t2 hyperintense periventricular and supratentorial white matter abnormalities represent mild chronic small vessel ischemic disease. the patient is intubated. mild mucosal sinus thickening is seen in the bilateral maxillary, ethmoid, and frontal sinuses. the osteomeatal units appear patent bilaterally. there is partial opacification of the bilateral mastoid air cells. impression: no acute intracranial process. . ct chest : 1. massive bilateral pleural effusions, responsible for severe atelectasis of the adjacent lung. 2. severe aortic valvular calcifications, which represent severe aortic stenosis until proven otherwise. 3. enlarged pulmonary arterial trunk, suggestive of pulmonary arterial hypertension. 4. no evidence of aspiration. . ct chest : 1. substantial improvement in previously large bilateral pleural effusions, stable pericardial effusion. no indication of malignant implants in the pleural space or development of tamponade. 2. new predominantly right lower lobe pneumonia or hemorrhage. 3. marked improvement in previous lower lobe collapse. 4. global cardiomegaly, probable pulmonary hypertension, probable calcific aortic stenosis, severe coronary and innominate artery atherosclerosis. 5. mild emphysema. . echo : the left atrium and right atrium are normal in cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. significant pulmonic regurgitation is seen. there is an anterior space which most likely represents a fat pad. there are prominent bilateral pleural effusion. . echo : the left and right atrium are moderately dilated. the estimated right atrial pressure is 0-10mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50%). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size is normal with borderline normal free wall function. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (valve area 1.2cm2). the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , global biventricular systolic function is less vigorous (now low normal), c/w diffuse process. the heart rate is also slightly lower. in the absence of a history of hypertension, an infiltrative process (e.g., amyloid) should be considered. brief hospital course: 70 yo man with h/o htn and recently diagnosed aflutter who presented from osh with pericardial effusion, ams, and arf. he was intubated for 10 days after presentation to osh. a ct showed a pericardial effusion and rml pna. he was transfered to on imipenem and levofloxacin for management of the effusion. the effusion was bloody and large (1l), though he was on anticoagulation. after extubation, he had ams with a notable wernicke's aphasia with preserved repetition and limited but largely intact comprehension and direction following. after failing multiple speech and swallow evaluations, the plan was for the patient to receive a peg (once his inr was within acceptable limits). in the interim, patient was found to have a pneumonia and was started on zosyn. he became more agitated on the medicine floor, and received haldol 1mg and zyprexa 5mg. he then became somnolent, hypercarbic and acidotic and was transferred to the micu where he did not tolerate bipap, so he was intubated. upon intubation, large amounts of tube feeds were found in his throat, so that his acute respiratory failure was felt due to his chronic large bilateral pleural effusions in conjunction with an aspiration event. . # altered mental status/cva/thrombocytosis: the patient has had ams, waxing and delirium, since extubation at osh. eeg was c/w metabolic encephalopathy, but common metabolic causes ruled out (normal folate/b12). an urgent head ct was ordered that did not demonstrate e/o of an acute intracranial process. neurology was consulted and was concerned for cva. carotid u/s demonstrated <40% stenosis on l and 40-60% on r. recommended mri, but patient could not tolerate mri without sedation. neuro recommended anticoagulation, speech therapy, outpatient follow-up. of note, patient was found to have a right atrial thrombus on osh imaging and mri/mra once patient was intubated confirmed periventricular and supratentorial white matter abnormalities suggestive of cerebroembolic event; this was consistent with neurology's findings on physical exam. patient also had markedly elevated platelets, which in the setting of pneumonia can result in a hypercoagulable state (arch neurol. ;67(1):33-38) resulting in a thrombotic, small vessel cva. at the same time, he has thrombocytosis (platelets between 760-960), possibly myelodysplastic in origin, which could also cause a thrombo/embolic cva. the workup of essential thrombocytosis was not pursued inpatient since it is very low yield (jak2 mutations being positive in no more than 50% of et cases) and the damage (stroke) had already been wrought. the patient was continued on a heparin drip in the micu and started on bridge to coumadin on , upon transfer back to the regular floors. at the time of discharge, the patient was taking 6mg of coumadin with a subtherapeutic inr, compensated by heparin gtt. . # respiratory distress/pleural effusions: patient's initial hypercarbic, respiratory acidotic episode was felt likely due to the exacerbation of his pulmonary status with the large pleural effusions by aspiration of food contents. haldol and zyprexa may have also slightly contributed. patient was trialed on bipap on admission to the micu without significant improvement and was shortly intubated. diagnostic thoracentesis showed exudative processes. patient was extubated on after lasix diuresis but developed hypercarbic, respiratory acidosis 10 hours later. etiology unclear - ?flash pulmonary edema as patient was hypertensive to sbp190s during this vs. tiring off the ventilator vs. continued significant pleural effusions. ultimately, thoracenteses were done bilaterally, removing 3.5-4 liters total. all the fluid studies came back suggestive of exudative processes. rheumatology was consulted in the setting of significantly elevated esr and crp but did not feel the patient had an underlying rheumatologic processes. repeat ct chest & a cxr performed on the day of discharge did not show signs of infection, malignancy or reaccumulation of fluid. etiology for patient's large pleural effusions remains unclear but the patient may benefit from anti-histone serology or cardiac mri for further work-up if his effusions recur. . patient also noted to have multiple apneic episodes as long as 20 seconds at a time. pulmonology was consulted and felt that the patient's apnea was likely secondary to both a central and obstructive process. they felt that he was safe for discharge, but felt he would benefit from a sleep study to further evaluate the etiology of his apnea and determine whether he could benefit from cpap once his delirium improved. . #. pericardial effusion: patient was transferred to for pericardial effusion and tamponade physiology. pericardial drain was placed, and bloody effusion was noted. pericardial fluid is negative for malignant cells. no microorganism was isolated. repeat tte demonstrated no reaccumulation of the effusion, so drain was pulled on . repeat echos showed no reaccumulation of pericardial effusion and patient's physical exam remained benign. the etiology of his pericardial effusion remained unclear, possibly due to a viral syndrome given his concurrent pleural effusions. repeat echo on , after removal of large pleural effusions (and pericardial effusion), showed global biventricular systolic function was less vigorous (now low normal), consistent with a diffuse process. if patient's hypertension has not been long-standing, amyloidosis is on the differential and may explain both the pericardial and pleural effusions (per cardiology). given the patient's functional baseline, however, myocardial biopsy was not pursued as an inpatient. a cxr on did not demonstrate evidence of pericardial or pleural effusions. . #. multifocal pneumonia: the patient was found to have a suggestion of multifocal pna on a ct dated . he was transferred on imipenem and levofloxacin. given the fact that the patient was intubated for 10 days, he may have had a hap, but sputum cultures from osh taken on were negative. cxr demonstrated bilateral pleural effusions consistent with overload, but no obvious consolidation. patient did not spike during this admission, but temperatures and wbc remained mildly elevated before normalizing. upon admission to , he was treated with zosyn for 8 day course from , last day (given aspiration found when intubated). a peg was ultimately placed with good effect while patient was intubated. of note, multiple blood, urine and sputum cultures were drawn which were all no growth to date for an infectious etiology to his symptoms. patient's ebv/cmv were also negative for acute infection. . #. atrial flutter/atrial fibrillation: patient was initially in atrial flutter, but later during this hospital stay, he was in and out of atrial fibrillation. his ra thrombus noted at osh is a contraindication to cardioversion. digoxin & cardizem were held and metoprolol was continued. he was anticoagulated with coumadin after pericardial drain was pulled. patient had a number of bradycardic episodes initially while in the micu that cardiology felt was due to a vasovagal response to ett placement. these episodes resolved, but he also had intermittent episodes of af with rvr that responded to iv metoprolol. patient may benefit from discussions with ep as an outpatient regarding need for ablation for his afib or pacer placement if he has recurrent episodes of bradycardia. . # hypernatremia: patient's na was 143 on admission, which went up to 153 the next day. urine osm??????s and electrolytes supported a hypovolemic hyponatremia. patient was given free water flushes with tf. his na improved on this regimen. once the peg tube was placed, the patient was continued on small volumes of free water flushes with good effect. his sodium normalized and he was discharged with serum na of 140. . #. acute renal failure: the patient's creatinine increased at the osh from his baseline of 0.5 to 2.6, in the setting of extensive diuresis. cr quickly normalized to baseline after admission to . upon transfer out of the micu back to the floor, patient's creatinine was back to baseline at 0.4 where it continued to be until discharge. . #. hematuria: the patient was found to have hematuria at osh while on anticoagulation, and there was concern for bladder cancer, given his history of smoking. urology was consulted and recommended an outpatient cystoscopy. his hematuria improved after anticoagulation was held, but resumed with restarting coumadin. the patient will need follow up with urology as an outpatient and his home flomax should be restarted prior to discontinuation of his foley which was in place at the time of discharge. . #. anemia: patient with an anemia on admission. guaiac was negative at osh. b12 and folate were normal. fe studies showed 19% saturation, fe 43, and ferritin 1190, consistent with ongoing inflammation and possible mild fe deficiency. ferrous sulfate 325mg po daily was continued. his hematocrit did intermittently decrease to lows of 23, felt likely due to the procedures he underwent. he did not require any prbc transfusions while in the micu or on the medicine floor and was discharged with a hct of 24.8. . # hypertension: patient's home regimen is lopressor 25mg twice daily and nifedipine 30mg daily. while in the hospital, patient was kept on amlodipine 10mg daily and his lopressor was titrated to 50mg tid. his blood pressures were well-controlled on this regimen. . # dysphagia: patient developed dysphagia, likely secondary to stroke. peg placed on without any complications, but he continued to fail speech and swallow evaluations until the day of discharge and was recommended to remain npo. . # code: full medications on admission: home medications: lasix 40 mg po daily lopressor 25 mg po bid flomax 0.4 mg po daily glucophage 500 mg po bid nifedipine 30 mg po daily coumadin 5 mg po daily ativan 1 mg tid prn . medications on transfer: fluconazole 100 mg po daily imipenem 500 mg po iv q12h levofloxacin 500 mg iv qod protonix 40 mg iv daily combivent nebulizer qid digoxin 0.25 mg via ng daily cardizem 90 mg via ng q6h lactobacillus 1 pack via ng tid with meals metoprolol 25 mg ng tid modafinil 200 mg ng daily lovenox 100 mg sq daily ssi zyprexa 7.5 mg im q4h prn reglan 5-10 mg iv q6h prn combivent nebulizers q2h prn tylenol prn colace prn milk of magnesia prn zantac 150 mg ng daily prn senna prn artificial tears 1 gtt each eye prn discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses: - pericardical effusion/tamponade - respiratory failure requiring intubation - stroke - atrial flutter/atrial fibrillation . secondary diagnoses: - diabetes - hypertension discharge condition: mental status:confused - sometimes level of consciousness:alert and interactive, with expressive aphasia activity status:bedbound discharge instructions: it was a pleasure to be involved in your care, mr. . you were admitted to for fluid around your heart. a drain was placed, which provided sufficient drainage of the fluid. the drain was pulled out 3 days later after an echocardiogram confirmed no more accumulation of fluid. furthermore, you were treated with antibiotics for your pneumonia. your heart rhythm showed atrial flutter / atrial fibrillation, which are arrythmias coming from the top of your heart. you had some trouble with your speech and you had some mental status changes, so you were evaluated by our neurology service. the neurology consult concluded that you had a stroke. you will need to be on blood thinners for further stroke prevention. you were also seen by the speech and swallow service, who noted that you have a high risk of aspirations, so a gastric tube was placed by the gastroenterology service. you will get tube feeds through this gastric tube. your medications have been changed and are as follows: acetaminophen 325-650 mg po/ng q6h:prn pain/ fever lansoprazole oral disintegrating tab 30 mg po/ng daily metolazone 5 mg po daily amlodipine 10 mg po/ng daily metoprolol tartrate 50 mg po/ng tid artificial tears 1-2 drop both eyes prn dry eyes docusate sodium (liquid) 100 mg ng ferrous sulfate 300 mg po/ng daily senna 1 tab ng :prn constipation warfarin 4 mg po/ng qhs followup instructions: please follow-up with a neurologist, dr. , md on at 2:00pm. to reschedule, please call:. please follow-up with your primary care physician, . , on at 3:00pm. his offices are located at . , ,. to reschedule, please call: . please schedule a pulmonology appointment at your convenience by calling: (. please scheduled a follow-up appointment with your regular cardiologist, but if you would like to see a cardiologist, please call to schedule an appointment. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances pericardiocentesis thoracentesis other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] right heart cardiac catheterization diagnoses: pneumonia, organism unspecified acidosis anemia, unspecified unspecified pleural effusion congestive heart failure, unspecified toxic encephalopathy unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified protein-calorie malnutrition atrial fibrillation atrial flutter hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) systolic heart failure, unspecified unspecified disease of pericardium acute respiratory failure hyperosmolality and/or hypernatremia cerebral artery occlusion, unspecified with cerebral infarction hematuria, unspecified dependence on respirator, status cardiac tamponade 

Answer: The patient is high likely exposed to