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: hypoxia, hypotension, fevers major surgical or invasive procedure: central line intubation history of present illness: 43 y/o f with pmh sle, polymyositis, hyperlipidemia, htn s/p recent admission /05 for evaluation of chest pain/dyspnea (with extensive w/u which was neg) who presented to hospital with respiratory distress, fevers to 103, hypotension, and acute renal failure. according to her brother in law, she was d/c'd 4 days ago from with baseline dyspnea symptoms (ambulatory sats good on ra) with the only reported complaint by her being decreased blood sugars for the last 2 days pta in 50s, weakness, lethargy, headache on which resolved on its own and ?neck stiffness (unclear if this was musculoskeletal). however, on the morning of admission, she was found by her 19 yr old son on the couch "not feeling herself", reportedly lethargic and in resp distress. per osh notes, she was found by ems to be cyanotic and was given 40 mg iv lasix by ems prior to arrival to ed. at ed, rr in 40s with bilateral rhonchi on exam and cxr c/w +bilateral infiltrates. t 103 rectally, sbp 60s, tachycardic with hr 140s. labs notable for elev bun/creat 57/2.1, trop elev to 0.52 with ck 5449, mb 36.9, mbi 0.7, ldh 776, ast/alt 250/80, wbc nl at 7.2 but with 50% bandemia. u/a neg. pt initially given alb/atrovent nebs but given incr respiratory distress/tachypnea, was intubated: simv 600/rate 12/100% fio2 with abg subsequently 7.38/40/83. pt also had femoral tlc catheter placed, had 2.5l ns given and was also started on dopamine gtt for persistent sbp 80s. she was given 1 dose zosyn 3.375 gm, solumedrol 125 mg iv, versed boluses total 8mg iv, asa 600 mg, tylenol. urine tox screen also neg for etoh, cocaine, +opiates and benzos (after intubation). was then transferred to for further management. past medical history: 1. ?lupus - dxed in , currently in remission; when first dxed, manifested as hand swelling, joint aches, dry eyes, unclear if treated with steroids in past; on last admission, + at low titer 1:40 with neg anti-double stranded dna, neg anti-, neg c3, c4 2. ?polymyositis - dxed 3 months prior to last admission - had muscle bx at due to inability to walk and persistent myalgias; was apparently treated with high dose cyclosporine and prednisone for months prior to presentation at . on last hospitalization, had right thigh bx which was c/w polymyositis. 3. avascular necrosis of r femoral head and both distal femurs and prox tibias 4. htn 5. hypercholesterolemia 6. previous record of narcotic dependence/od/?cocaine use in the past 7. hyperlipidemia 8. dm 9. atypical chest pain - w/u extensive on last admission including neg pain mibi, neg pmibi, neg cardiac mri, neg cta chest and abdomen, neg cxr - echo - mildly depressed lvef - per dr. , 45% but not formally read on echo, mild lvhk social history: she lives in with her two children, a son and daughter aged 19 and 16. she used to work licensing footage for channel 2 and now works on a contract basis. she reports no etoh or illicit drug use. she notes that she has used ms contin for pain. she has smoked cigarettes ppd x 32 yrs. she notes that her husband died of aml 1.5 years ago and she is still very sad about this. she even notes that at times she still looks or calls for him. family history: mother died of mi at age 60 father died of aaa at age 74 has one sister in good health physical exam: t 99.1 oral bp 109/49 p 114, decr to 93 sat 100% ac tv 600/12/5/100% gen: sedated, intubated heent: pupils small, equal and reactive to light; op with dry mm neck: jvd diff to assess chest: coarse rhonchi throughout cv: reg rhythm, tachy, no audible m/r/g abd: soft, obese, nt, +bs ext: cool to touch, could not palpate dp pulses but were dopplerable; r arm warmer than l arm with more palpable pulse on r>l skin: good skin turgor; on right thigh at area of bx, large area of induration and erythema with +palpable hematoma, warm to touch pertinent results: admission labs: 04:26pm blood wbc-10.7 rbc-3.58* hgb-9.4* hct-29.8* mcv-83 mch-26.4* mchc-31.6 rdw-20.5* plt ct-229 04:26pm blood neuts-52 bands-37* lymphs-6* monos-1* eos-0 baso-0 atyps-0 metas-4* myelos-0 04:26pm blood hypochr-3+ anisocy-2+ poiklo-normal macrocy-normal microcy-2+ polychr-normal 04:26pm blood plt smr-normal plt ct-229 04:26pm blood pt-12.8 ptt-30.4 inr(pt)-1.0 04:26pm blood glucose-176* urean-55* creat-1.6*# na-136 k-5.8* cl-101 hco3-25 angap-16 04:26pm blood alt-77* ast-240* ld(ldh)-768* ck(cpk)-4689* alkphos-45 amylase-113* totbili-0.8 04:26pm blood lipase-14 04:26pm blood ck-mb-30* mb indx-0.6 ctropnt-0.15* 04:26pm blood albumin-3.0* calcium-8.5 phos-5.4*# mg-1.6 04:26pm blood osmolal-301 04:26pm blood cortsol-206.2* 05:33pm blood vanco-7.6* 04:26pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg 10:04pm blood type-art temp-37.2 rates-14/8 peep-10 fio2-80 po2-119* pco2-38 ph-7.32* calhco3-20* base xs--5 aado2-429 req o2-72 -assist/con intubat-intubated 08:36pm blood type-art temp-37.3 rates- tidal v-750 peep-5 fio2-100 po2-176* pco2-49* ph-7.31* calhco3-26 base xs--2 aado2-508 req o2-83 intubat-intubated vent-controlled 04:49pm blood type- 04:49pm blood lactate-2.8* 11:26pm blood hgb-8.0* calchct-24 o2 sat-48 05:25am blood acylcarnitines, quantative, plasma-pnd 10:53am blood anti-jo1 antibody-pnd r leg u/s: subcentimeter anechoic lesion within the right thigh as above deep to the biopsy site. differential is broad and was outlined above. there is no drainable fluid collection. brief hospital course: 1. respiratory distress: pt was extubated on , and was sat'ing well on shovel mask. she had a ?rml infiltrate on cxr as well as diffuse alveolar infiltrates, with a possible component of ards. possible pneumonia sources include cap, atypical organsisms, and pcp/fungal given h/o immunosuppression on cyclosporine and high dose prednisone. a bronch on was neg for pcp. had been initially placed on zosyn/vanc, then switched to ceftriaxone (2gm)/vanc/levofloxacin for initial coverage of ?cns infection, mrsa, atypical as well as broad gp and gn coverage, and is currently on levo/flagyl for treatment for possible aspiration pna. she is continued on ss bactrim for pcp whilst taking steroids. upon transfer to the floor, the patient continued to have coupious secretions, which she was unable to clear due to dysphagia (see below). she was given a yankower for suctioning, as well as an inexeffalator. she was treated with a 14 day course of antibiotics--flagyl and levo, which was changed to azithro/ctx on the last 2 days due to prolonged qtc--for aspiration pna. on discharge, the patient's secretions had noticably decreased. * 2. shock - the etiology was felt to be most likely septic as temp 103 and lactate elevated on admission to . possible sources of infection included pneumonia, urine, blood, csf, right thigh biopsy site. she was given ivfs and gradually weaned off of pressors. she was also on stress dose steroids, which was changed from solu-medrol to prednisone today as treatment for polymyositis. an u/s of her right thigh was negative for fluid collection or abscess, and an echo was negative for cardiogenic etiology of hypotension as well as any pericardial effusion. on the floor, her blood pressure was stable. repeat u/s of ther r thigh showed a small possible hematoma vs seroma, which was not drainable. she was afebrile and with negative blood cultures. * 3. elevated troponin - mild elevation was felt to be likely demand ischemia in setting of infection and tachycardia. ekg with old rbbb but otherwise unchanged. her troponins were trending down, and she was restarted on metoprolol and continued on asa. * 4. anemia - her baseline hct was noted to be 30-33. she was transfused 2 units prbcs, and her hct has since been stable. * 5. acute renal failure - the patient had an elevated creatinine initially, which improved after fluid hydration, indicating that the etiology was likely prerenal. * 6. polymyositis - the diagnosis was confirmed by biopsy at last hospitalization, and thought that this could explain the positive ck. elevated lft's were also felt to be likely from muscle destruction. she was consulted by rheum, and was treated with steroids--stress dose changed to soludmedrol 50mg daily given bronchospasm. there was a question of whether polymyositis could contribute to chest wall dysfunction and weakened diaphragm/resp muscles leading to decreased oyxgenation and anti- antibodies were checked for to see if it could be related to ?ild/pulmonary process--which returned negative. she was changed to prednisone 60mg daily given through ngt. re-evaluation of the tissue biopsy by rheum as well as neuromuscular consult teams led to a question of the diagnosis of polymyositis as the clinical course did not seem consistent with polymyositis. hepatology was also consulted about the possibilty of cryoglobinemia, and empiric treatment with ifn, and determined that there was no evidence on cryoglobinemia (complement levels normal, no evidence on biopsy). she also had a ct torso to check for possible lymphoma (atypical cells on biopsy), which was also normal. carnitine, and other mitochondrial lipid metabolism labs were sent to evaluate for mitochondrial disease, but there was no evidence of lipid abnormality on tissue biopsy, which made these labs of low probability--levels were normal. ultimately, the course of the patients episodes of myopathy was felt to be most consistent with toxin-induced, perhaps from drug abuse although the patient was not forthcoming with this information, in an individual who may have had an underlying predisposition to myopathy. she was started on a slow steroid taper (prednisone decrease 10mg every 3 days until off). her dysphagia, which on the floor was really her only objective evidence of continued myopathy, gradually resolved in a manner that was perhaps consistent with post-intubation dysphagia. her only other notable abnormality was the global hypokinesis on echo, which was of uncertain significance given her history of drug abuse and our inability to establish its acuity given no previous normal echos on file. attempts were made to obtain records from , where the patient had received most of her previous care, but these records were not available at the time of discharge. * 7. elevated transaminases - the admission ast was markedly elevated when compared to alt, although the patient had a negative etoh level at osh. she has h/o hep c but nl transaminases in the past. there was a question of whether these enzymes could have been elevated due to shock liver in setting of hypotension. the lfts were trending down upon transfer. 8. fen-the patient failed speech and swallow evaluation on several attempts on initial admission to the floor. she had an ngt placed, which was removed by the patient, then replaced, and then self-d/c'd by the patient. while the ngt was in place, the patient was given tube feeds. she was again seen by speech and swallow, who observed no aspiration with bedside eval, but recommended a video swallow study to evaluate for silent aspiration, which was refused by the patient. 9. pain control- the patient continued to require large amounts of narcotics for pain control while on the floor. she attributed the pain to the site of her biopsy, which was stable (above) through several ultrasounds. the nature of her pain complaints was tough to pin down, and upon discharge she said that it was well controlled. we ultimately felt that a large component of the pain was due to dependence, and although we could not pursue this route given her other medical problems, it should be addressed as an outpatient. of note, she was also followed by psychiatry in house, and may benefit continued follow up with social work and/or psychiatry as an outpatient. 10. dispo- the patient repeatedly threatened to sign out ama during the hospitalization, despite the obvious evidence of her inability to clear her own secretions, much less take in anything po, and the risk for aspiration that it posed. she was talked down multiple times, although she was certainly difficult and typically needed the involvement of her brother-in-law to convince her to stay. she was seen several times by psychiatry, who determined that she has an adjustment disorder with depressed mood. this, as well as her likely narcotic dependence, should be followed upon discharge. medications on admission: 1. calcium 2. vitamin d 3. bactrim mwf for pcp (started on last hospital admission) 4. protonix 40 qd 5. senna 6. lasix 20 qd 7. ?plaquenil 400 8. celebrex 200 9. toprol xl 100 qd 10. lisinopril 20 11. prednisone 50 qd 12. ms contin 45 mg 13. neurontin 300 tid 14. colace 15. glyburide 2.5 qd discharge medications: 1. albuterol sulfate 0.083 % solution sig: 1-2 puffs inhalation once a day. disp:*1 inhaler* refills:*2* 2. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 4. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 5. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po qmwf (). disp:*30 tablet(s)* refills:*2* 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. prednisone 10 mg tablet sig: as directed tablet po daily (daily) for 12 days: 3 tab ; 2 tab ; 1 tab ; 0.5 tab . disp:*20 tablet(s)* refills:*0* 8. msir 30 mg tablet sig: one (1) tablet po every 6-8 hours prn as needed for pain. disp:*20 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: septic shock aspiration pneumonia acute renal failure hepatitis c myopathy-unspecified history of avascular necrosis of the r femoral head, distal femurs, proximal tibias diabetes mellitus hypercholesterolemia cardiomyopathy discharge condition: stable, although pt refused video swallow to document absence of silent aspiration discharge instructions: ***take all of your medications as directed. several of your medications have changed during this admission, please see the discharge list. in particular, you should discontinue taking your glyburide and blood pressure medications (lisinopril and metoprolol), until you are seen by your primary care physician on . ***complete your prednisone taper and your antibiotic course. you will take 30mg prednisone (2 tabs) ; 20mg prednisone (2 tabs) ; 10mg prednisone (1 tab) ; 5mg prednisone ( tab) . ***we are concerned that you will aspirate at home. therefore, to minimize the chances of this, take your medications in applesauce, and as we discussed, you should drink thickened liquids. you should be sitting upright when you eat, and do not lie down for 30 minutes after you eat. ***if you are coughing after you eat, this is a sign that you are continuing to aspirate, and should return to the hospital. ***phone your physician or return to the hospital if you experience any fevers, night sweats, cough, chest pain, shortness of breath, rash, or any other symptoms concerning to you. in addition, as you are leaving the hospital against medical advice, we recommend that you return to the er at any time you are willing, so that you can be readmitted to the hospital. followup instructions: , m.d. where: neurology phone: date/time: 10:00 provider: , m.d. where: lm phone: date/time: 3:30 provider: , md where: phone: date/time: 1:30 procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus transfusion of packed cells diagnoses: hyperpotassemia anemia, unspecified pure hypercholesterolemia unspecified essential hypertension chronic hepatitis c without mention of hepatic coma diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified other pulmonary insufficiency, not elsewhere classified unspecified septicemia severe sepsis opioid type dependence, unspecified pneumonitis due to inhalation of food or vomitus septic shock drug withdrawal other myopathies 

Answer: The patient is high likely exposed to