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: no known allergies / adverse drug reactions attending: chief complaint: epistaxis major surgical or invasive procedure: embolization of right internal maxillary artery stenting of right common carotid artery open gastric feeding tube placement pharyngeal biopsy picc placement. history of present illness: patient is a 60yo man with history of laryngeal scc s/p xrt and total laryngectomy and left modified neck resection, dvt (x2, on lifelong coumadin) who presents with 2 day history of severe epistaxis. . the patient was in his usual state of health until last night he began spitting up large amounts of red blood that was in his mouth/throat. he notes spitting out cupfulls of blood at home. he initially thought this would pass, but it continued to occur a total of four times prompting his presentation to the ed. patient denied any dizziness/lh or abdominal pain. of note, he had pain in his right neck/jaw and aphasia for the past several months. he was recently admitted to the hospital where work-up demonstrated esophageal stricture (s/p egd dilation) and pharygneal diverticulum. there was no sign of recurrence of his laryngeal ca. of note, he had a pet-ct in which was concerning for recurrence in the post-laryngectomy bed and neopharynx and esophagus. . in the ed, initial vs were: t- 98.4, hr- 77, bp- 111/66, rr- 20, sao2- 99% on ra. the patient triggered twice in ed for large epistaxis as he was spitting out large amounts of blood. he also spiked a fever in the ed. while there, ent scoped the patient but could not identify a bleeding vessel. scope demonstarted post-radiation changes. ent placed a balloon for tamponade, however, the patient bled again requiring repacking. there was also a report of a desaturation to 80% and hypotensive episode to sbp 80s. he received a dose of vitamin 5 mg, 3 units of ffp, 5l ns, 1 u prbc, one dose of vancomycin and morphine for pain management. he underwent a cta neck which demonstrated a "large area in anterior right neck with gas and fluid (possibly neohypopharynx from laryngectomy?), common carotid appears involved and has pseudoaneursym 10x9mm from neck of 5mm." he was taken to the ir suite, where carotid was stented. he was admitted to the vascular service and then transferred to the micu given no plan for surgical intervention. . on arrival to the micu, vital signs were t- 99.2, hr- 72, bp- 122/63, rr- 20, sao2- 97% on 35% o2. patient denied any new bleeding, shortness of breath, chest pain, fevers or chills. past medical history: long history of vocal cord dysplasia first identified in . between and he had multiple episodes of carcinoma in situ of the larynx that required striping. in he was diagnosed with microinvasive squamous cell carcinoma of the right true cord, stage i. he was treated with definitive radiation therapy between and by dr. at . he did well until when he developed stridor. an exam under anesthesia on revealed diffuse edema of the supraglottic larynx with fullness of the vocal cord. biopsies revealed squamous cell carcinoma. he was considered to have stage iii, t3, n0 disease, likely of second primary origin. in he underwent total laryngectomy and left modified neck dissection. a sternocleidomastoid rotation flap was used to cover the mediastinal vessels by dr. . pathology revealed no evidence for regional nodal disease. however, the laryngectomy specimen contained a 3.5cm moderately differentiated squamous cell carcinoma involving the bilaterl true cords and extending into the subglottis. the tumor invaded through the thyroid and tracheal cartilages and into the surrounding soft tissues and skeletal muscles. soft tissue resections were negative for tumor, however the tumor was present 1mm from the anterior and left posterior soft tissue margins. the epiglottic and aryepiglottic proximal margins were negative for tumor. the distal tracheal margin was negative. there was no evidence for angiolymphatic invasion, but peroreal invasion was observed. pathology report considered the patient to have t4b, stage iv squamous cell cancer of the supraglottic larynx. surveillance ct of the neck on revealed a new left neck mass and a fine needle aspiration revealed squamous cell carcinoma which was resected. . past medical history: - htn - atrial fibrillation - mitral valve prolapse - gerd - hypothyroidism - bph - sle - h/o dvt in bilateral legs with recurrence, on lifelong anticoagulation social history: former smoker, none currently. denies recreational drugs. lives with wife at home. family history: noncontributory physical exam: admission physical exam: vs - 99.8 149/71 64 17 97% on 35%tm general - 60 y/o m in nad heent - nasal packing in place, lateral neck swelling, trach site with minimal amount of purrulent drainage, oral thrush noted neck - supple lungs - rhonchorous breath sounds throughout anteriorly heart - rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (dps) skin - no rashes or lesions neuro - awake, non-focal . discharge physical exam: vs - t 97.8 bp 112/64 p 55 r 18 s 99%ra general - elderly african american man w/ covered trach and trach mask in no discomfort. heent - perrl, eomi neck - supple, l graft normal. r neck normal very mildly tender to palpation, tract lateral of trach draining clear/whitish fluid (unchaged). sputum from tracheostomy only when patient coughs (unchanged). lungs - clear to auscultation bilaterally heart - rrr, nl s1, s2, no m/r/g abdomen - luq tube with clean bandage. appropriately tender to palpation and improving. no obvious bleeding or erythema. abd in general soft, non-tender aside from g tube site, nabs. extremities - no edema bilaterally. 2+ pulses bilateral radial and dp. neuro - a&o x 3, appropriately alert and interactive, moving all limbs independently pertinent results: admission labs 11:55am blood wbc-9.2 rbc-4.04* hgb-11.9* hct-36.6* mcv-91 mch-29.4 mchc-32.5 rdw-13.8 plt ct-317 11:55am blood neuts-85.5* lymphs-9.3* monos-4.3 eos-0.6 baso-0.3 11:55am blood pt-32.2* ptt-31.2 inr(pt)-3.2* 11:55am blood glucose-116* urean-23* creat-1.2 na-140 k-3.7 cl-103 hco3-27 angap-14 03:26am blood calcium-8.0* phos-3.6 mg-1.5* . pertinent studies cta neck - impression: 1. a new pseudoaneurysm arising from the right common carotid artery anteriorly just before its bifurcation. 2. soft tissue surrounding the pseudoaneurysm with multiple foci of gas within. this has increased since the prior study. the foci of gas extend just below the level of the skin. this is likely infective in etiology. 3. soft tissue surrounding the distal right common carotid artery causing its narrowing. this likely represents postoperative fibrosis. 4. thrombosis of bilateral internal jugular veins. 4. postoperative changes in the form of total laryngectomy, left modified neck dissection,reconstruction flap and tracheostomy. ct neck w/ contrast - prelim read - 1. interval stenting of right common carotid aneurysm with interval decrease in pseudoaneurysm. a small focus of hyperdensity (2:101) with attenuation of the blood pool at the level of the prior pseudoaneurysm may indicate small residual aneurysm without connection seen to cca. 2. fistulization from oropharynx to the anterior neck skin surface (2:97-2:125). no adjacent drainable fluid collection. resolution of soft tissue gas. 3. new surgical clip deep to the right zygomatic arch may represent maxillary artery embolization for epistaxis if there is history of this (unable to find record of this in omr). if no history of this, the etiology of this clip is unclear. 4. sinus disease in the maxillary sinuses worse than on . 5. post surgical changes in the neck from total laryngectomy, left modified neck dissection,reconstruction flap and tracheostomy. micro: blood culture, routine-final {propionibacterium acnes}; anaerobic bottle gram stain-final sputum - staph aureus (mssa) fistula swab culture - mixed bacterial types intra-operative fistula swab - mixed bacterial types pathology: phayngeal biopsies - squamous mucosa with chronic inflammation, stromal sclerosis, and focal basilar atypia, most likely reactive. note: stromal sclerosis consistent with previous radiation. multiple levels are examined. brief hospital course: 60 year old man with a h/o laryngeal scc s/p xrt, total laryngectomy, and left modified neck resection, as well as dvts x2 on coumadin presenting with severe epistaxis, concerning for recurrence of scc. . # epistaxis/orapharyngeal bleeding: likely secondary to known laryngeal scc versus radiation fibrosis. patient remained hemodynamically stable in the setting of his blood loss. ent was consulted, who helped initially pack the nares. his warfarin was held and he was given ffp and vitamin k upon admission. he underwent coiling of his internal maxillary artery by vascular surgery. following the resolution of his bleeding, he was restarted on a heparin drip for reversible anticoagulation in case he were to experience additional bleeding. once enteral access was obtained and the patient no longer was actively bleeding, his warfarin was restarted. # pharyngeal/carotid/cutaneous fistula: patient was found to have a fistula between the pharynx and skin eroding near the carotid artery, that itself had a pseudoaneurysm. dr. from ent evaluated the patient and felt that this is not repairable at this time. he also had a family meeting during which it was explained how surgery was unlikely to help at this time given past neck xrt and poor wound healing. a stent was placed in the right carotid pseudoaneurysm. given the fistula and its proximity to the carotid, oral feeds were felt to be too dangerous and the patient underwent open g tube placement on without complication. his tube feeds were started, however a few days later he began to note increased secretions from his trach site, which appeared to be similar to the tube feed formula in color and consistency. the formulation of his tf was changed and he was tolerating his full strength tf upon discharge. # trach site / fistula infection / history of scc: pt initially had significant swelling around trach site and purulent drainage, which was concerning for soft tissue/fistula infection. he was evaluated by plastic surgery who felt that prior to any surgical intervention, the patient required confirmation that his scc did not recur. a biospy was obtained from the neohypopharynx, the results of which were negative; revealing chronic inflammation, stromal sclerosis, and focal basilar atypia, most likely reactive and consistent with prior radiation. as per ent, the patient will also require an out patient pet scan to evaluate for any other evidence of malignancy. a culture from the region grew mssa and was notably negative for mrsa or pseudomonas. as per id, he was treated initially with vanc/zosyn, followed by zosyn alone for a total of a 14 day course. he was to be transitioned to augmentin 875 mg po bid with long term follow up with id. # ?pneumonia: pt had a chronic cough w/ unchanged cxr. however, as sputum culture grew mssa the patient was treated with antibiotics as above. # history of 2 x dvt: patient was on warfarin as an outpatient, and as above, the patient was given ffp and vitamin k for reversal of his anticoagulation in the setting of active bleeding. he was then anticoagulated with a heparin gtt until his bleeding had stabilized and enteral access was obtained. after which, he was then bridged to back to warfarin. . # a-fib: the patients home medications (amio and dilt) were held given the lack of enteral access. he hr remained stable in sinus with a rate of 70-80s during the admission. he was given metoprolol iv during his stay for rate control. in the days prior to discharge, the patients heart rate ranged from 55-70, and he often did not receive metoprolol. he was in sinus rhythm and normotensive. prior to and upon discharge, he was continued on amiodarone, however diltizem was not restarted. he should follow up with his pcp in order to appropriately control his atrial fibrillation and hypertension (see below). . # htn: the patient's home antihypertensive medications were adjusted to metorpolol iv as he was unable to take po medications. given his average-low heart rate (generally 60-70s in the days leading to discharge, he often did not receive this medication for multiple days prior to his discharge. upon discussion with pharmacy, his antihypertensive medications were adjusted to amiodarone only for easier administration via the g tube. should he require diltiazem going forward, it would have to be transitioned to the immediate release formulation in order to be crushed and admininstered via the g tube four times daily. . # hyperthyroidism: the patient was continued on his home levothyroxine which was converted to iv while he was unable to take oral medications. he was discharged home on po levothyroixine with instructions that this can not be taken within one hour of his tube feedings. ========================================================== transitional issues: ========================================================== -pt will need close ent follow-up for his fistula involving r carotid as well as the possibility that his cancer has returned. path from the biospy during this hospitalization was negative for recurrence. patient will most likely require an outpatient pet scan, however this could not be scheduled as an inpatient. -poor overall prognosis, pt may benefit from additional palliation and/or goals of care discussions. his code status was changed to dnr/dni during this hospialization. -patient has poor nutritional status due to difficulties with the initiation of tube feeds. -patient will require long term antibiotics to be dictated by the infectious disease team who are following his case. medications on admission: 1. levoxyl 150 mcg tablet : one (1) tablet po once a day. 2. tamsulosin 0.4 mg capsule, ext release 24 hr : one (1) capsule, ext release 24 hr po once a day. 3. omeprazole 20 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po once a day. 4. amiodarone 200 mg tablet : one (1) tablet po daily (daily). 5. diltiazem hcl 180 mg capsule, extended release : one (1) capsule, extended release po once a day. 6. duloxetine 60 mg capsule, delayed release(e.c.) : one (1) capsule, delayed release(e.c.) po once a day. 7. combivent inhalation 8. lovenox 120 mg/0.8 ml syringe : one (1) injection subcutaneous once a day. disp:*7 syringes* refills:*0* discharge medications: 1. tube feeds peptamen 1.5 full strength; 360 cc per feeding: 4 feedings/day: hold feeding for residual >= : 200 ml; please check before each feeding. flush w/200 ml water before & after each feeding 8 cases/month; 2250 calories/day 2. warfarin 5 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. levoxyl 150 mcg tablet : one (1) tablet po once a day: please do not give within 1 hour of tube feeds. disp:*30 tablet(s)* refills:*2* 4. prazosin 1 mg capsule : one (1) capsule po qhs (once a day (at bedtime)): please open capsule and put into water, then administer through feeding tube. disp:*30 capsule(s)* refills:*2* 5. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily): please dissolve in 10 cc of water and administer via feeding tube. disp:*30 tablet,rapid dissolve, dr(s)* refills:*2* 6. amiodarone 200 mg tablet : one (1) tablet po once a day: ok to crush and administer via feeding tube. disp:*30 tablet(s)* refills:*2* 7. semi electric hospital bed semi electric hospital bed 8. compressor compressor use daily as directed x1 year 9. suction machine suction machine use daily as needed x1 year . suction supplies suction supplies daily use as needed x1 year . duloxetine 30 mg capsule, delayed release(e.c.) : two (2) capsule, delayed release(e.c.) po daily (daily): open capsule and dissolve in water. administer via feeding tube. disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 12. amoxicillin-pot clavulanate 875-125 mg tablet : one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 13. metoclopramide 10 mg tablet : one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*120 tablet(s)* refills:*2* 14. combivent 18-103 mcg/actuation aerosol inhalation discharge disposition: home with service facility: homecare discharge diagnosis: primary: neo-pharynx to right carotid to skin fistulous tract right carotid pseudoaneurysm s/p stent mssa pneumonia fistula polymicrobial infection . secondary: atrial fibrillation hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , it was a pleasure taking part in your care. we hope you continue to feel better. you came to the hospital because you had bleeding from your nose. you were seen by our ent (ear, nose, and throat) specialists, general surgeons, neurovascular specialists, and infectious disease specialists. we found that you had a fistula, or internal connection, between your throat through to your neck, near your carotid artery, and the skin. it is unclear what caused this, but given your prior squamous cell cancer, that is a possibility. it may also have been worsened by active infection and your previous radiation treatment. you received blood transfusions and our ent specialists were able to stop the bleeding from your nose. your blood counts remained stable afterwards. our neurovascular specialists put a metallic stent in your right carotid artery because you had pseudoaneurysm, or a buldge, of this very important artery. this has remained stable on repeat imaging of your neck. due of the proximity of your fistula to your carotid artery, our ent specialists felt that you could not be safely allowed to eat or drink anything by mouth. you therefore had a feeding tube placed in your stomach by our general surgeons. our ent specialists also took additional biopsies of your pharynx in order to determine whether or not your squamous cell cancer has returned, the results of which were negative. they felt that there are currently limited options for the reconstruction of the tissues of your neck given the possibility that cancer or an active infection may be present, as well as your history of radiation to the area. you had several bacteria growing from cultures from your fistula and a bacteria called mssa growing from your sputum. you were seen by our infectious disease experts who recommended specific antibiotics. you were placed on iv blood thinners during your stay in the hospital because of your past history of leg and lung blood clots. you tolerated the placement of your feeding tube well and were able to tolerate tube feeds by the time of discharge. we made some changes to your medications to accommodate your feeding tube: start: -prazosin daily (this replaces tamsulosin) -lansoprazole daily (this replaces omeprazole) -warfarin 5 mg daily unless otherwise directed -augmentin daily to control infection -metoclopramide 4x daily to help digest tube feeds stop: -tamsulosin -omeprazole -diltiazem -lovenox you have several follow-up appointments with your primary care physician as well as specialists in ent, general surgery, and infectious diseases. followup instructions: name: ,md specialty:primary care location: - address: , , phone: appointment: monday, at 9:50am **please speak with your pcp about the need to be referred to a general surgeon within 1-2 weeks of your discharge from the hospital.** department: otolaryngology-audiology when: friday at 3:50 pm with: , md building: lm bldg () campus: west best parking: garage department: infectious disease when: tuesday at 9:30 am with: , md building: lm bldg () campus: west best parking: garage md procedure: venous catheterization, not elsewhere classified enteral infusion of concentrated nutritional substances arteriography of cerebral arteries laryngoscopy and other tracheoscopy other gastrostomy control of epistaxis by anterior nasal packing endovascular (total) embolization or occlusion of head and neck vessels pharyngeal biopsy endovascular embolization or occlusion of vessel(s) of head or neck using bare coils diagnoses: systemic lupus erythematosus esophageal reflux mitral valve disorders unspecified essential hypertension unspecified protein-calorie malnutrition unspecified acquired hypothyroidism atrial fibrillation personal history of tobacco use other diseases of pharynx, not elsewhere classified other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation long-term (current) use of anticoagulants methicillin susceptible pneumonia due to staphylococcus aureus personal history of venous thrombosis and embolism do not resuscitate status personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health epistaxis other tracheostomy complications personal history of malignant neoplasm of larynx aneurysm of artery of neck cellulitis of pharynx or nasopharynx 

Answer: The patient is high likely exposed to