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: pravastatin / ceftriaxone / lisinopril attending: chief complaint: hemoptysis major surgical or invasive procedure: -intubation -rigid bronchoscopy -pulmonary angiography -particle embolization of the dominant right bronchial artery supplying the right lower lung lobe history of present illness: history of present illness: the patient is a 58m with history of nhl s/p chemo and chest xrt in , 70 pack year smoking history (quit 20 years ago), cad, recurrent right sided pneumonia (in , , and with vats/bronch in revealing organizing fibrosis), who presented on with worsening hemoptysis. the patient has had two hospitalizations in the past week for hemoptysis, during which he was treated for right lower lobar pna. . he was admitted on /11 with ct chest showing new right lower lobe opacification abutting the paraesophageal mediastinum. there was increased right paraesophageal, hilar and left retrocural lymphadenopathy. he underwent bronchoscopy which showed purulence in the right lower lobe, no evidence of obstruction or bleeding, culture growing gram positive cocci, and cytology negative for malignant cells. his hemoptysis improved and he was discharged to complete a 14 day course of levofloxacin and clindamycin. he returned home but produced frank hemoptysis w/ clots shortly therafter, up to two cups in one day, and was re-admitted from . chest ct on showed right lower lobar consolidation with central area of hypoattenuation which could reflect necrosis. his antibiotics were initially broadened, but was discharged on levoquin and clindamycin given clinical improvement. during this time, he reports having low-grade fevers, with occasional cough. no shaking chills or drenching sweats. . on , he again presented with hemoptysis, including an episode of 2 cups volume in the ed. in the ed initial vitals were: 97 62 142/78 18 98% 4l. cxr (pa/lat) showed persistent but slight improved aeration of opacity with no new opacities. he was given clindamycin and levoquin iv and transferred to the floor. on , the patient reportedly had ~500cc of hemoptysis while ambulating with a concomitant desaturation to the 70%s. his hemoptysis resolved without intervention. he was transferred to the micu for further care and received 1 unit x prbc. the patient was intubated for airway protection and had underwent an ir embolization procedure on . he was extubated without complication on and transferrred down to the floor on . . pt currently denies any shortness of breath. reports having a sore throat from being intubated. denies any lung or chest pain, but reports chronic neck pain. states that he has had chronic neck pain since a motor vehicle accident in , after which he has become dependent on high dose opiates (oxycontin 20mg plus hydrocodone-acetaminophen 10/325 tid). also reports intermittent "heaviness in his sternum" after his embolization procedure, but none currently. . vitals on arrival: 98.9f, 140/80, 69, 18, 96% 2l. . ros: low grade fevers per hpi. weightloss, 215lb several months ago, 205lb 3 wks prior to admission. . past medical history: past medical history: - cad h/o prior inf wall mi, fixed defect tte - nhl, s/p chemo and chest xrt - recurrent pna (right sided , ', ') persistent r pleural effusion and rll basilar infiltrate -> vats / bronch and pl bx in 8/' revealed only resolving organizing fibrotic changes - mild obstructive dz on pfts - hyperlipidemia - gerd - gout - hypothyroidism - chronic glomerulonephritis - colonic polyps - dm ii on metformin - chronic pain - depression - hypertension - s/p gastric bypass - s/p l and r knee repairs - s/p chest skin fat reduction social history: social history: lives in , but moving to with his wife. retired, pt used to work as salesman. no kids. several siblings live in . 1 sister, , is a nurse and is his preferred contact for medical matters. - tobacco: 70 pack year history, stopped 20 years ago. - alcohol: 1-2 drinks daily - illicits: cocaine use many years ago. pot 4 years ago, none currently family history: family history: -significant for coronary artery disease, type i diabetes mellitus and obesity. denies any fh of rheum disease or autoimmune disease. -cancer: mother died of lung cancer in her late 60s (long time smoker). sister had lung and pancreatic cancer in her 60s (non-smoker, non-drinker). physical exam: physical exam on admission: vitals: bp: 98.9, 140/80, 69, 18, 96% 2l general: alert, oriented, no acute distress heent: sclera anicteric, mmm, normal oropharynx, no lad neck: supple, jvp not elevated cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: decreased breath sounds r base, mild insp crackles bilaterally, no wheezes abdomen: soft, non-tender, non-distended, normal bowel sounds, no masses ext: no pedal edema, 2+ radial and dp pulses bilaterally neuro: cn2-12 intact, 4/5 strength on l upper extremity, strength otherwise, normal sensation throughout skin: erythematous rash on buttocks and bilateral groin physical exam on discharge: . physical exam: vitals: tm 98.2, tc 96.2, 107-140 / 71-86. hr 78-140s, rr 18, 93-94% ra. general: alert, oriented, no acute distress heent: sclera anicteric, mmm, normal oropharynx, no lad neck: supple, jvp not elevated cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: decreased breath sounds r base, mild insp crackles bilaterally, no wheezes abdomen: soft, non-tender, non-distended, normal bowel sounds, no masses ext: no pedal edema, 2+ radial and dp pulses bilaterally. mild l antecubital fossa bruise. stable r groin ~1.5cm femoral hematoma. mildly painful, no bruit, good distal pulses. neuro: cn2-12 intact, 4/5 strength on l upper extremity, strength otherwise, normal sensation throughout pertinent results: 06:40am blood wbc-12.2* rbc-3.63* hgb-10.6* hct-30.6* mcv-84 mch-29.1 mchc-34.6 rdw-13.1 plt ct-365 08:40pm blood neuts-80.2* lymphs-11.1* monos-4.0 eos-3.9 baso-0.9 06:40am blood pt-14.7* inr(pt)-1.3* 06:40am blood calcium-7.8* phos-3.9 mg-1.7 08:31pm blood type-art rates-/12 tidal v-600 peep-5 po2-331* pco2-47* ph-7.39 caltco2-30 base xs-3 intubat-intubated vent-controlled 08:31pm blood freeca-1.09* 05:40am blood hiv ab-negative 04:50pm blood c3-177 c4-42* 04:50pm blood igg-1029 iga-523* igm-74 04:50pm blood crp-73.3* 04:50pm blood -negative 03:43am blood tsh-0.62 03:43am blood %hba1c-6.3* eag-134* 04:50pm blood esr-112* 04:50pm blood anti-gbm-test - negative 04:50pm blood wbc-17.6*# rbc-4.41* hgb-12.3* hct-37.6* mcv-85 mch-27.9 mchc-32.6 rdw-13.3 plt ct-497* 05:39am blood wbc-13.4* rbc-3.38* hgb-9.9* hct-29.4* mcv-87 mch-29.2 mchc-33.6 rdw-13.6 plt ct-409 03:43am blood wbc-12.7* rbc-3.52* hgb-10.1* hct-29.6* mcv-84 mch-28.6 mchc-33.9 rdw-13.5 plt ct-328 07:05am blood wbc-9.4 rbc-3.58* hgb-10.2* hct-31.1* mcv-87 mch-28.5 mchc-32.8 rdw-13.4 plt ct-345 sputum gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. reported to and read back by @ 2pm. quality of specimen cannot be assessed. respiratory culture (final ): sparse growth commensal respiratory flora. legionella culture (final ): no legionella isolated. fungal culture (preliminary): yeast. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): blood culture negative x 2 rapid plasma reagin negative radiology chest (pa & lat) findings: there is slight improved aeration of the superior segment right lower lobe opacity previously noted. no new focal consolidations evident. the mediastinum is otherwise unremarkable. the cardiac silhouette is within normal limits for size. no effusion or pneumothorax is noted. degenerative changes are seen throughout the lower thoracic spine. impression: persistent focal opacity involving the superior segment of the right lower lobe with slight improved aeration suggesting interval improvement. correlate clinically. given the persistent symptoms, consider ct for more detailed evaluation. cardiology ecg normal sinus rhythm. normal tracing. no significant change compared to the previous tracing of . rate pr qrs qt/qtc p qrs t 95 158 82 362/423 69 27 59 transcatheter embolization: procedure: 1. right non-tunneled internal jugular vein double-lumen central line placed. 2. right pulmonary artery angiography in multiple projections. 3. selective right lower lobe, third and fourth pulmonary artery branch angiography in multiple projections. 4. right common femoral artery access. 5. selective bronchial artery angiography and particle embolization. contrast: 225 ml optiray was used. anesthesia: general. procedure details: prior to initiation of the procedure, written informed consent was obtained and a preprocedure timeout was performed. the right neck and groin were prepped and draped in a sterile manner. initially under ultrasound guidance, access was obtained using a micropuncture needle into the right internal jugular vein, and pre- and post-access hard copy ultrasound images were obtained. wire was placed, which was exchanged for 7 french dilator followed by a 7 french double-lumen central line, the tip was positioned within the distal svc. the line aspirated and flushed well, was secured to the skin with suture and used by the anesthesiologist for access. next, under ultrasound guidance, a micropuncture access set was used to access the right common femoral vein and after dilatation, a 7 french 55 cm -tip sheath was used and placed in the ivc. an angled catheter and wire were used to access the main pulmonary artery, and over this, a modified 90 cm 6 french guiding catheter was advanced into the right main pulmonary artery. a 4fr pigtail catheter was placed through this and angiography was performed in multiple projections. next, right lower lobe branches in the medial aspect of the right lower lobe, corresponding to recent ct findings were accessed and selective third and fourth order pulmonary angiography was performed in multiple projections using a 5 french catheter and ultimately a transcend wire and stc catheter. following this, these were removed. next, under ultrasound guidance, a micropuncture access set was used to access the right common femoral artery and a 5 french sheath was placed. catheter was advanced and formed over the aortic arch and used to select the bronchial arteries. initially, a common bronchial artery trunk supplying both the right and left lungs was identified and was felt to be relatively small in caliber. attempts to advance a headliner and double-angled glidewire into the small artery were unsuccessful, and embolization could not be performed. next, a 5-french angled glide catheter was advanced into the left subclavian artery, and was used to identify feeding of a dominant right bronchial artery. this was accessed using a headliner wire and an stc catheter, which was positioned well into the branch. angiography was performed. next, particle embolization with 300-500 micron embospheres was performed to stasis. the catheters were removed. both the venous sheath and the arterial sheath were removed and manual compression was applied to hemostasis of the groin. the patient was returned to the micu in stable condition, intubated. findings: 1. placement of a 7 french double-lumen central line with the tip in the svc, non-tunneled. 2. pulmonary artery angiography demonstrated slightly abnormal tortuous branches within the right lower lobe in the area of consolidation and inflammation. however, no correlative finding consistent with the pseudoaneurysm seen on recent cta was identified. specifically, in one or two projections, a focal round filling defect was noted. however, this likely represented a pulmonary vein en face when viewed in other projections. no extravasation was identified. 3. bronchial artery angiography demonstrated a dominant right bronchial artery arising in an aberrant/variant anatomical location arising from the main left subclavian artery (also seen on prior cta). this was accessed, and demonstrated a dilated hypertrophied appearance consistent with this being the dominant branch supplying the area of infection/inflammation. no definite pseudoaneurysm was identified in this branch, or evidence of extravasation. however, given the hypertrophied appearance, this is likely the source of bleeding and this was embolized with 300-500 micron particles. 4. bronchial artery angiography also identified a second, diminutive common bronchial trunk giving rise to right and left branches supplying the lower lungs. no definite correlative finding representing that pseudoaneurysm was noted. the right branch could not be accessed due to its diminutive size and inability to advance the microcatheters adequately into the artery, and so no embolization was performed. 5. of note, no contributors to the anterior spinal artery were identified on any of the angiograms performed. impression: 1. successful access and particle embolization of the dominant right bronchial artery supplying the right lower lobe. 2. pulmonary angiography did not demonstrate any contribution to a pseudoaneurysm. radiology chest port. line placem as compared to the prior study obtained on at 01:32 a.m. the et tube has been advanced, currently in appropriate position approximately 7 cm above the carina, at the level of the clavicular heads. there is improvement of the right upper lobe atelectasis. right hilar mass and right lower lobe opacities and left basal opacities appear to be unchanged as compared to the most recent chest radiograph. video swallow evaluation aspiration/penetration: pt had penetration with nectar thick liquids x 1 on a cup sip of nectar thick liquids, cleared at the height of the swallow. he had multiple episodes of trace to mild penetration with thin liquids by cup which appeared to be related to a mild swallow delay. on consecutive sips of thin liquid, he had reduced coordination / increase in swallow delay and had resultant mild- moderate aspiration before the swallow. pt was without an immediate cough but with delayed cough (question if spontaneous or cued) that was not effective at clearing the aspirate material. treatment techniques: pt benefited from smaller, single sips of thin liquids that prevented aspiration on today's exam. he also benefits from repeat swallows to clear oral and pharyngeal residue. summary: mr. presented with a mild oral and pharyngeal dysphagia with penetration of thin and nectar thick liquids and one episode of aspiration on consecutive sips of thin liquid with ineffective spontaneous vs cued cough. it appears aspiration can be prevented with compensatory techniques below which the pt demonstrated excellent understanding of. if is unclear if this is the only contributing factor to his recurrent pnas, as he also reports occasional episodes of emesis overnight and frequent reflux for which he is medicated. agree with planned work up for esophageal motility / reflux to rule this out as a contributing factor. if his motility study is normal and he develops a repeat pna, suggest returning to our department to trial further dietary modifications. fois rating of 7. recommendations: 1. po diet of thin liquids and regular consistency solids with the following precautions: a) single sips of liquids only- no consecutive sips b) swallow 2 x's for each bite and sip c) follow solids with a sip of liquid if you feel residue in your throat d) limit mixed consistencies w/ liquids and solids (cereal with milk, chicken noodle soup)- if eating them, drain the liquid from the spoon and eat solids first, followed by liquids 2. medications whole with apple sauce or pudding brief hospital course: mr. was admitted on with persistent hemoptysis (his third episode), this time he c/o ~2 cups of bright red blood witnessed in the ed. on the medicine floor on the afternoon of , mr. again had 500cc of hemoptysis, with concomitant, transient desaturation to the 70%. his sp02 rapidly improved and the hemoptysis spontaneously resolved. of note his hct dropped from 37-31. he was transferred to the micu for further evaluation and treatment. . in the micu, the patient was intubated. he was taken to ir where no definite source of bleeding was found. a hypertrophic bronchial artery was found and embolized. bloot clots were suction out. after ir, bronchoscopy was performed and no obvious site of bleeding was observed. on the morning of the , the patient was extubated without difficulty. three subsequent hct's were stable at 29. then he was transferred to the floor, where he remained stable with hcts ~30. . active issues: . #. massive hemoptysis: unclear etiology. presumably due to pneumonia but malignancy cannot be ruled out. ct chest showed a question of necrosis in r lower lobe given repeated infections / pneumonias and perhaps inflammation induced erosion through a bronchial vessel. ddx also includes vascular malformations or vasculitis, especially in light of chronic poorly explained history of long-term glomerulonephritis. vasculitis work-up however was negative. the patient remained hemodynamically stable with a stable hematocrit. his sertraline was tapered from 150 mg to 100 mg daily for concerns that this might be contributing to bleeding risk. further tapering is deferred to his outpatient providers. . per pulmonary, pt will need to continue levofloxacin 750 mg po daily and clindamycin 450mg po 6hrs for 4 more weeks and have pulmonary appointment in weeks, who will arrange follow-up workup and repeat imaging. pt also had a workup for chronic rll pneumonias, including negative hiv, a speech and swallow eval that showed only minimal aspiration w/ taking large gulps. our speech and swallow specialists recommended some behavioral modification but no dietary restrictions (see previous sheet for details). they also agreed with utility of gastric motility study, which pt will need to have scheduled as an outpatient, to be arranged by his pcp, his prior intermittent episodes of vomiting during sleep. . chronic issues: . #. cad: intermittent chest pain. pt describes as sternal "heaviness" after his pulmonary embolization procedure. no evidence of active cardiac ischemia, ecg unchanged. holding aspirin in setting of acute bleed. outpatient propranolol 20mg po bid was restarted w/out incident. . #. dmii: sugars well controlled on floor. held metformin in-house, provided insulin sliding scale. metformin restarted on discharge. . #. depression: stable. psychiatry has been following in house. began tapering sertraline by 50mg q4-7 days per psych recs for bleeding risk, currently on 100mg daily since . rsr normal, tsh normal. pt will need to address sertraline taper with outpatient psychiatrist. . #. anxiety disorder: continued clonazepam 2mg po qhs. pt also asked for clonazepam 1mg po tid prn anxiety. . #. gout: stable. continued home allopurinol. . #. hypothyroidism: stable. tsh normal at 0.62. continued home levothyroxine . # hyperlipidemia: stable. continued home lovastatin. . # chronic pain: continued on home oxycontin and vicodin. no pain on discharge. . transitional issues: - further work-up as dictated by pulmonary specialists to continue to evaluate for possible underlying malignancy. - consideration for gastric motility study. - consideration for further tapering of sertraline dose. medications on admission: -clindamycin 450mg qid -levofloxacin 750mg daily -allopurinol 200mg daily -levothyroxine 200mcg daily -lovastatin 40mg daily -oxycodone er 20mg tid -hydrocodone-acetaminophen 10/325mg tid prn (but pt always takes tid) -trazadone 100mg qhs -clonazepam 2mg po qhs -pantoprazole 40mg -sertraline 150mg daily -propranolol 20mg discharge medications: 1. levothyroxine 100 mcg tablet sig: two (2) tablet po qam (once a day (in the morning)). 2. levofloxacin 750 mg tablet sig: one (1) tablet po once a day for 4 weeks. :*28 tablet(s)* refills:*0* 3. clindamycin hcl 150 mg capsule sig: three (3) capsule po q6h (every 6 hours) for 4 weeks. :*336 capsule(s)* refills:*0* 4. allopurinol 100 mg tablet sig: two (2) tablet po daily (daily). 5. lovastatin 40 mg tablet sig: one (1) tablet po once a day. 6. oxycodone 20 mg tablet extended release 12 hr sig: one (1) tablet extended release 12 hr po tid (3 times a day): do not operate machinery or drive with this medication. 7. hydrocodone-acetaminophen 10-325 mg tablet sig: one (1) tablet po three times a day as needed for pain: do not operate machinery or drive with this medication. 8. trazodone 100 mg tablet sig: one (1) tablet po at bedtime. 9. clonazepam 1 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. sertraline 100 mg tablet sig: one (1) tablet po once a day. 12. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for skin problem. :*qs 1 bottle* refills:*0* 13. propranolol 20 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home discharge diagnosis: primary: -hemoptysis -right lower lobe pulmonary consolidation -mild aspiration discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr , you came to the hospital because you were coughing up significant amounts of blood. you had several diagnostic tests, which showed that you continued to have a disease process in the lower lobe of your right lung. you received a blood transfusion and you were transferred to the medical intensive care unit, where a breathing tube was placed to help protect your airway. you had a rigid bronchoscopy and pulmonary artery angiography and embolization procedure to find and stop the bleeding in your lung. you tolerated the procedure well and had the breathing tube removed after one day. you were then transferred to the medical floor, where you were closely observed and your antibiotics were continued. by the day of discharge, you did not require any oxygen and were only coughing up occasional blood clots. your red blood cell counts remained stable for several days and you did not show any signs of acute bleeding. the exact cause of your symptoms remains unclear. include severe recurrent right lower lobe pneumonia, the inflammation from which may have caused erosion through a lung blood vessel. other possibilities include a lung cancer or blood vessel disease. your recurrent pneumonias may also be related to aspiration when you eat or to regurgitation of food from you stomach due to poor motility. you had a video swallow study here which showed that you do aspirate materials when you take big gulps and mix solids and liquids. our speech and swallow specialists did not feel that you had to limit any particular foods or drinks from your diet, but they made several suggestions to you to adjust how you eat and drink in order to minimize the chance that you will aspirate materials into your lungs. they recommended a normal diet with the following precautions: a) single sips of liquids only- no consecutive sips b) swallow 2 x's for each bite and sip c) follow solids with a sip of liquid if you feel residue in your throat d) limit mixed consistencies w/ liquids and solids (cereal with milk, chicken noodle soup)- if eating them, drain the liquid from the spoon and eat solids first, followed by liquids, and medications whole with apple sauce or pudding. . you will need to have a gastric motility study arranged by your primary care physician since you state that you have been intermittently vomiting up food at night onto your pillow. . we made the following changes to your medications: -reduce your sertraline to 100mg tablets, 1 tab by mouth daily. -start using miconazole powder 2% on your groin rashes three times daily as needed. . you should continue taking your other medications as previously prescribed. it is especially important that you continue both your levofloxacin 750mg tabs, 1 tab by mouth daily, and your clindamycin 150mg tabs, 3 tabs by mouth every 6 hours, for 4 more weeks. . we have made appoints for you to see your lung specialists (see below). you should schedule an appointment to see your primary care physician and your psychiatrist. followup instructions: department: pulmonary function lab when: wednesday at 10:40 am with: pulmonary function lab building: campus: east best parking: garage department: medical specialties when: wednesday at 11:00 am with: dr. & dr. building: sc clinical ctr campus: east best parking: garage department: medical specialties when: wednesday at 11:00 am with: dr. & dr. building: sc clinical ctr campus: east best parking: garage -please make an appointment to see your primary care physician 1 week -please make an appointment to see your psychiatrist to discuss the best way to adjust your anti-depressants. procedure: insertion of endotracheal tube other endovascular procedures on other vessels arteriography of pulmonary arteries central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified other chronic pain coronary atherosclerosis of native coronary artery esophageal reflux pure hypercholesterolemia unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism other specified disorders of arteries and arterioles gout, unspecified personal history of tobacco use depressive disorder, not elsewhere classified other malignant lymphomas, unspecified site, extranodal and solid organ sites anxiety state, unspecified old myocardial infarction postinflammatory pulmonary fibrosis precipitous drop in hematocrit chronic glomerulonephritis with unspecified pathological lesion in kidney bariatric surgery status other hemoptysis 

Answer: The patient is high likely exposed to