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: phenothiazines / piperacillin sodium/tazobactam attending: chief complaint: vomiting. major surgical or invasive procedure: ngt placement a-line placement picc-line placement endotracheal intubation () history of present illness: a 71 year-old woman with past medical history of copd and mr, who presented to the ed on the morning of admission with one day of intractable vomiting. the patient reports that for the last 12-24 hours she has been nauseated and vomiting yellowish, non-bloody material. she denies associated symptoms such as abdominal pain, cp, f/c. she believes she last moved her bowels this morning. on arrival, initial vitals were hr 118, 155/109, ra o2 sat 88%. she was placed on nippv briefly and her oxygenation improved. labs were remarkable for polycythemia (hct 63) and lactate of 2.3, later noted to rise to 4.1 (question of spurious sample) before falling to 3.0 in the setting of 10l ns fluid repletion. a ct scan of her abdomen was performed and demonstrated a high grade sbo with a transition point in the region of distal jejunum/proximal ileum, as well as a question of a pulmonary infarct. the patient was emperically treated with vancomycin, flagyl, levofloxacin, solumedrol, asa and antiemetics. the surgery service was consulted concerning this and advised ngt placement, supportive therapy and close clinical observation, as they feel she is a poor operative candidate. the hematology service was also consulted concerning the pt's polycytemia and advised asa, fluids and therepeutic phlebotomy which was performed with 340cc of blood removed. on arrival to the , the patient is generally comfortable. she reports some ongoing nausea but again denies abdominal pain. she states she feels her breathing is at her baseline. the patient denies fever, chills, weight change or difficulty swallowing. no chest, jaw or arm pain. no palpitations. no cough, wheeze or sob. no urinary symptoms. no dizziness or weakness. past medical history: 1. copd - pfts in with fev1 0.77 (40% predicted), fvc 0.91 (33%) and fev1/fvc 118%. spirometry limited by poor patient cooperation. 2. mental retardation 3. bipolar disorder 4. gastroesophageal reflux disease social history: patient reports smoking approximately ppd and has for many years. she denies alcohol or illicits. she lives independently at an apartment in jp with visiting assistance and is followed by the department of mental retardation. family history: mother lived to her mid-90s then suffered an mi. father lived to his mid-70s before dying of natural causes. no other significant fh. physical exam: gen: uncomfortable appearing adult woman, ill but not in extremis. ngt in place. heent: perrl, eomi. mmm. conjunctiva well pigmented. neck: supple, without adenopathy or jvd. no tenderness with palpation. chest: diffuse wheezes and rhonchi. cor: normal s1, s2. rrr. no murmurs appreciated. abdomen: hyperative bowel sounds. soft, non-tender and non-distended. no hsm. extremity: warm, with trace edema. 2+ dp pulses bilat. neuro: alert and oriented. cn 2-12 intact. motor strength intact in all extremities. sensation intact grossly. ==================== at the time of discharge: bp= 112/49-148/95, hr= 103 (93-120), tmax= 98.7 pt is sat'ing 90-93% on 4l nasal cannula. he lung fields are diffusely ronchorous with somewhat decreased bs at the left base. she is tachycardic generally in the 100-110 range with frequent ectopy but otherwise regular rhythm. she has a fungal-appearing rash over her buttocks bilaterally. otherwise physical exam is unchanged from admission physical listed above. pertinent results: labs at admission: 12:45pm blood wbc-9.9 rbc-7.28*# hgb-19.5*# hct-63.0*# mcv-83 mch-25.7* mchc-30.9* rdw-16.8* plt ct-355 12:45pm blood neuts-86.2* lymphs-9.3* monos-3.6 eos-0.4 baso-0.5 12:54am blood pt-13.9* ptt-35.8* inr(pt)-1.2* 12:45pm blood glucose-218* urean-14 creat-0.9 na-141 k-5.1 cl-96 hco3-27 angap-23* 12:45pm blood alt-32 ast-40 ck(cpk)-70 alkphos-148* totbili-0.5 12:45pm blood lipase-32 12:45pm blood albumin-4.7 12:54am blood albumin-3.0* calcium-6.7* phos-3.9 mg-1.3* 05:10am blood triglyc-108 01:00pm blood lactate-2.3* imaging studies: ct abdomen and pelvis (): 1. high-grade small-bowel obstruction with a transition point noted at the approximate junction of the jejunum and ileum with collapsed loops of distal ileum identified (in the right lower quadrant, reference series 300a image 16). no evidence of bowel ischemia or perforation. 2. multiple nodular opacities within the visualized lung in addition to a wedge-shaped area of opacification in the right lower lobe. these findings may be attributed to an infectious process. however, given the wedge-shaped appearance of the right lower lobe opacity, pulmonary infarct cannot be excluded. follow-up with cross-sectional imaging is recomended to ensure clearance. 3. fibroid uterus. ct chest angiogram () 1. negative examination for pulmonary embolism. main pulmonary artery is slightly enlarged, which suggests possible pulmonary hypertension. 2. rapidly progressing lower lobe consolidations as well as additional widespread multifocal opacities are likely due to an evolving pneumonia, possibly secondary to aspiration. 3. enlarged hilar and mediastinal lymph nodes that are increased in size compared to study in , are likely reactive to the infectious process. follow-up ct in three months is suggested to assess for resolution. picc placement () uncomplicated fluoroscopically guided picc line exchange for a new 4 french single-lumen picc line. final internal length is 45 cm, with the tip positioned in the svc. the line is ready to use. pelvic ultrasound (): limited examination shows abnormally thickened endometrium for postmenopausal patient, and probable uterine fibroid. malignancy cannot be excluded in the setting of postmenopausal bleeding. echo : 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. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. compared with the prior study (images reviewed) of , the severity of mitral regurgitation has increased slightly. the estimated pulmonary artery systoocli pressures are higher. a bubble study demonstrates no apparent intracardiac shunt. resting heart rate is higher. cta of chest : 1. severely limited study secondary to cardiac and respiratory motion artifact. evaluation of the lobar, segmental and subsegmental pulmonary arteries is non- diagnostic. no massive central pulmonary embolus identified. 2. improving multifocal pneumonia with persistent collapse of the left lower lobe and partial opacification of the left lower lobe bronchus. an obstructing lesion cannot be excluded, and bronchoscopy is recommended for further evaluation. 3. mediastinal and hilar lymphadenopathy, likely reactive. 4. stable mild pulmonary edema and small bilateral pleural effusions. 5. stable sternal fracture. 6. marked tracheomalacia. cxr on day of discharge : there is no interval change in the left retrocardiac atelectasis but slightly improved aeration of the lateral portion of the left base most likely due to decreased pleural effusion. the lungs otherwise unchanged with no interval development of pulmonary edema with new focal opacities. compared to , there is interval significant improvement of left lower lobe atelectasis with more central position of the mediastinum. discharge labs: cbc wbc hgb hct mcv plt ct 12.2* 14.4 44.1 83 189 chem7 glucose urean creat na k cl hco3 120 18 0.7 137 4.2 93 33 ekg : atrial rhythm at 115 c/w either sinus tachycardia with frequent atrial ectopy vs mat. no st-t changes concerning for ischemia. brief hospital course: 70 year-old woman with known copd presents with nausea & vomiting secondary to sbo which was conservatively managed to resolution, then had bilateral lower lobe pneumonia secondary to aspiration (treatment course completed) requiring transient intubation. subsequently she had repeated episodes of hypoxia attributed to aspiration vs mucus plugging in the setting of severe copd. # pneumonia and respiratory status: cta showed bilateral lower lobe pneumonia with mediastinal and hilar lymphadenopathy, consistent with evolving aspiration pneumonia. she was started on vancomycin and zosyn initially; this was switched to levofloxacin and flagyl after she developed a rash on vanco/zosyn. in addition to the antibiotics, she was diuresed with small boluses of iv lasix due to pleural effusions on imaging. bipap was attempted for mild respiratory acidosis on serial abgs; however, patient could not tolerate this. initially, her respiratory status improved with the above treatments. however, around the fifth hospital day, she was noted to have increasing oxygen requirements, also with low grade temperature and increasing white count. there was concern that the antibiotic coverage (levo/flagyl) was not adequate and she was broadened back to vancomycin with aztreonam added for treatment of gram negatives and pseudomonas; flagyl was continued for treatment of anaerobes. solumedrol was added for possible inflammatory component, as wheezes were heard on exam. ultimately, due to hypoxemia on maximum supportive oxygen, she was intubated on hospital day 7. pt was bronched for suctioning of secretions with improvement in hypercarbia. she was able to be extubated on hospital day 10 and oxygenating well on nasal cannula with no further fevers. she was called out to the floor where she intially did well on 3-4l nc. she had an episode of dyspnea during which she was found to be hypoxemic so was given o2 via nrb and transfered back to the icu. during her second stay in the icu she went on bipap for a brief time. there was concern that she may have re-aspirated. she was noted to frequently have episodes of coughing and desaturation after eating. speech and swallow followed her and recommended that she remain npo despite a relatively normal video swallow evlaution b/c the temporal association btw her eating and desaturations was so strong. she had an ng tube placed and tolerated tube feeds. she was restarted on ceftriaxone and flagyl for possible aspiration pneumonia on . on , one day after she had been transferred back to the floor from her second stay in the icu, she was noted to have decreased oxygen saturations (in the 70's) on a non-rebreather. no information is available about the quality of the pleth on the pulse oximeter at that time. an abg was performed which showed 7.49/55/44. a chest x-ray was performed which showed no new infiltrates or vascular congestion. she was transferred back to the icu for a third time. there, she continued to have episodes of significant hypoxia not associated with eating as she was receiving tube feeds at that point. we were concerened for pe, shunt, and mucus plugging. a cta was non-diagnostic seconday to motion artifact, but echo showed no sign of rv strain and lower ext dopplers were neagative for dvt. echo was a bubble study and effectively ruled out intracardiac shunt. there was a low suspicion for infectious etiology given lack of leukocytosis or fever. given that her o2 requirement improved over 2-3 days with mucomyst nebs, aggressive chest pt, reinitiation of steroid taper, and that her chest ct was improved, this transient hypoxia was attributed to mucus plugging in the setting of severe copd. as below, she is on a dysphagia diet at the time of discharge and will need repeat evaluation by speeach and swallow. an appointment has been made for her in pulmonary clinic for follow-up. she was discharged on a three week prednisone taper. on the day prior to discharge, she was transitioned back to tiotropium from ipratropium, so we would recommend restarting ipratropium if her oxygen requirement increases. she will need chest pt several times per day and given her cognitive impairment, she will need frequent cardiopulmonary assessment as she will not be able to ask for her prn nebulizer treatments. she should also have a f/u ct scan done within 1-2 months--the need for this was communicated to her pcp. chest x-rays should be done while in pulmonary rehab on a weekly basis to ensure continued improvement in lll atelectasis. # nausea/vomiting/sbo small bowel obstruction was confirmed on ct prior to admission. the etiology of the sbo was unclear. surgery was contact in the and recommended for ngt to suction, npo and conservative management. she was hydrated with ivf and kept npo until the fourth hospital day, when bowel sounds returned and she began to have increased stools. she was then started on tube feeds with no complication. resumption of oral diet on hospital day 11 per speech and swallow, who continued to follow, as above. # polycythemia she has a long-standing history of high-normal hematocrit. evaluated by heme who thought that red cell concentration on admission labs was multifactorial, occurring in the setting of heavy tobacco use, hypoxia chronic lung disease, probable dehydration on presentation and not truly consistent with polycythemia . the hematocrit returned to baseline with iv hydration. # tachycardia: her tachycardia was initially felt to be multifactorial in the setting of pneumonia and respiratory distress. a cta was done to work-up pe and further evaluate lung parenchyma. this was negative for pe but did show bilateral lower lobe consolidations consistent with aspiration pneumonia as above. the tachycardia transiently resolved with treatment of dehydration and pneumonia. for the week prior to discharge, her avg hr increased from 90 to 110. a second cta was non-diagnositic secondary to motion artifact. echo showed moderate pulm htn and preserved lvef 60%. lower ext us were neagtive for dvt--we were confident that this did not represent pe as her hypoxia and o2 requirement were improving during this time. multiple p-wave morpholgies noted on ekg were c/w multifocal atrial tach for which copd is an excellent substrate. metoprolol 25mg tid was started and should be up-titrated with goal of resting hr ~80bpm to prevent tachycardia-induced myopathy. # chronic obstructive pulmonary disease: we continued her home albuterol and substituted ipratropium nebs for tiotropium. as above, solumedrol was added when her respiratory status did not improve, and she was gradually weaned back to prednisone. she is being discharged on 20mg prednisone daily to be tapered as per attached med sheet. she does have a hx of repeat flares soon after completions of tapers. # diahrrea: pt with increased output of semi-liquid stool on day prior to discharge. cdiff toxin sent and pending at the time of discharge. would continue to trend wbc and stool output. would check two more c.diff toxins post-transfer. # rising white count: wbc=12.2 at time of transfer. pt has been afebrile after completion of her abx courses. serial chest x-rays and improving respiratory status imply that she is not developing another respiratory infection at the time of transfer. we were unable to repeat ua/ucx prior to transfer, please consider re-checking. please continue to trend wbc every other day. # possible drug rash: erythematous rash over chest noted when pt was on zosyn, this resolved with discontinuation and partially recurred on ceftriaxone to a much lesser degree. decision made to continue ceftriaxone to completion as already on day 5 of 7 () when rash was noted. no peripheral eos noted. # bipolar disorder home psychiatric medications in the setting of sbo. zoloft 150mg daily and haldol 5mg qam were discontinued and should be restarted at the discretion of her pcp. (1.5mg qam and 1mf qpm) was replaced with ativan 1mg . olanzapine 7.5mg daily was continued and additional prn doses were used as needed for agitation. # gastroesophageal reflux disease pantoprazole 40mg daily was continued. # fungal rash on buttocks: maintain area dry and continue miconazole. # food, electrolytes, nutrition. initially she was npo. on the third hospital day, tpn was started via picc line. this was weaned down as her diet was progressed slowly as above. pt underwent video swallow evaluation on hospital day 11 s/p extubation and was started on pureed solid, nectar-thick liquid diet per s/s recs. however, given possible aspiration this was discontinued, and she was npo until tubefeeds started . repeat evaluation by speeach and swallow cleared her for the dysphagia diet on which she will be discharged--as per s&s, she should be re-evaluated within one week of transfer. until then, she should be supervised with every meal. # legal guardianship: to admission, pt lived semi-independently in an apartment with ~70 hours of home services per week. due to her serious ongoing medical issues and her inability to make medical decisions given life-long cognitive impairment, legal guardianship was pursued and assignment of a legal guardian is pending at the time of transfer. a health care proxy was assigned: . , . documentation attached. medications on admission: albuterol 1.5mg qam, 1mg qpm advair 250-50 haldol 5mg qam olanzapine 7.5 mg daily pantoprazole 40 mg daily zoloft 150mg daily spiriva trazodone 50 qhs discharge medications: 1. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for pruritis. 2. olanzapine 7.5 mg tablet sig: one (1) tablet po daily (daily). 3. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po bid (2 times a day) as needed for agitation. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for shortness of breath. 5. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 6. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 7. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath. 8. 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. 9. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 11. prednisone 10 mg tablet sig: three (3) tablet po daily (daily): taper to 20mg daily on , then taper to 10mg daily on , then taper to 5mg daily on and complete course on . 12. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po qid (4 times a day): uptitrate as needed to maintain resting heart rate at 100. 13. lorazepam 1 mg tablet sig: one (1) tablet po twice a day. 14. insulin lispro 100 unit/ml solution sig: as per chart subcutaneous asdir (as directed): see attached sliding scale. 15. advair diskus 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation twice a day: on hold during this admission as receiving systemic steroids, restart when course complete. discharge disposition: extended care facility: hospital discharge diagnosis: primary diagnoses small bowel obstruction aspiration pneumonia chronic obstructive pulmonary disease secondary diagnoses cognitive impairment bipolar disorder gastroesophageal reflux disease discharge condition: medically stable for discharge to rehab facility discharge instructions: you were hospitalized for treatment of small bowel obstruction and pneumonia. you were treated conservatively for the obstruction. you were treated with antibiotics for the pneumonia. due to the severity of the pneumonia, you were intubated and assisted by a ventilator. extubation went without complication. because of thick mucous, you had some episodes of shortness of breath and hypoxia. these episodes may also be related to food inappropriately entering your airways. we made the following changes to your medicines: 1. has been stopped and ativan 1mg twice daily has been started 2. haldol and zoloft have been stopped 3. prednisone taper has been started 4. metoprolol 25mg three times per day has been started please call your physician or return to the ed for: -worsening belly pain, nausea or vomiting -fever or difficulty breathing -any other symptoms concerning to you followup instructions: after discharge from rehab, please follow up with your pcp: , an appointment in the pulmonary clinic has been made for you: md: dr. specialty: pulmonary date and time: monday at 2:30 pm location: building medical specialities phone number: procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances insertion of endotracheal tube other bronchoscopy arterial catheterization diagnoses: pneumonia, organism unspecified acidosis esophageal reflux tobacco use disorder other specified intestinal obstruction obstructive chronic bronchitis with (acute) exacerbation acute respiratory failure pneumonitis due to inhalation of food or vomitus dermatitis due to drugs and medicines taken internally diarrhea dehydration bipolar disorder, unspecified other pulmonary embolism and infarction unspecified intellectual disabilities polycythemia, secondary foreign body in main bronchus penicillins causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to