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: none history of present illness: 76 yo male w/ severe copd (fev1 28%) p/w acute worsening of dyspnea this pm, called 911, brought by ems to ed. pt reports that he did not have any precipitating symptoms to note such as fevers/chills/cough/allergies but that this "has happened before. he denies cp/orthopne/n/v/abd pain/hemoptysis/diarrhea. in ed the patient was tachtpneic to the 30's, he was placed on a non-rebreather w/ nebs every hour. he was also given solumedrol and a dose of levofloxacin w/ good improvement. past medical history: 1. copd ?????? pt with severe copd. his last pfts on were consistent with marked obstructive defect. measurements included a fvc of 59% predicted, fev1 28% predicted, and fev1/fvc of 48% predicted. there was no significant change since a prior study from . pt is on 3 l home o2. 2. asthma ?????? diagnosed in . 3. crohn??????s disease ?????? diagnosed in 4. steroid-induced niddm ?????? present for two to three years. 5. peripheral neuropathy 6. hypertension 7. osteoarthritis 8. osteoporosis 9. cervical spinal stenosis 10. bph s/p turp 11. gerd social history: former banker. retied since . wife is deceased; patient lives alone at home. has four children ?????? 2m, 2f.etoh: denies use tob: 25 pack-year prior historydrugs: denies use family history: brother ?????? niddm sister ?????? ??????chest cancer?????? physical exam: on admission: temp bp 106-193/59-101 rr 25 o2 sat 95% nrb gen: able to speak in complete sentences heent: + pursed lips when breathing, anicteric, dry mm, eomi, neck: jvp 8 cm cv: tachycardic no m/r/g resp: scattered diffuse expiratory wheezes ext: no c/c/e neuro: grossly intact . on transfer out of micu vs: t96.5, p93, 115/59, rr24, 100%4lnc gen- alert and oriented. able to speak in full sentences. appears mildly uncomfortable but reports that he is at his respiratory baseline. cardiac- rrr. pulm- poor air movement bilaterally. diffuse wheezing. pt using ascesory muscles which he reports is baseline for him. abdomen- soft. nt nd. positive bs. extremities- no c/c/e. neuro- alert and oriented. 5/5 strength in upper and lower extremities bilaterally. pertinent results: 01:45am wbc-13.3* rbc-4.19* hgb-12.1* hct-36.5* mcv-87 mch-28.9 mchc-33.1 rdw-13.6 01:45am plt count-360# 01:45am neuts-63.6 lymphs-29.2 monos-5.8 eos-1.2 basos-0.2 . 01:45am glucose-228* urea n-17 creat-1.1 sodium-141 potassium-3.9 chloride-107 total co2-22 anion gap-16 09:25am calcium-9.0 phosphate-3.0 magnesium-2.0 . 01:45am ck(cpk)-154 01:45am ck-mb-15* mb indx-9.7* ctropnt-0.08* 01:26am blood ck(cpk)-162 01:26am blood ck-mb-16* mb indx-9.9* ctropnt-0.13* 06:25am blood ck(cpk)-71 06:25am blood ck-mb-notdone ctropnt-0.09* 04:29pm blood ld(ldh)-774* totbili-0.3 04:29pm blood ck-mb-15* ctropnt-0.15* 10:46pm blood ck(cpk)-140 10:46pm blood ck-mb-13* mb indx-9.3* ctropnt-0.21* 05:03am blood ck(cpk)-127 05:03am blood ck-mb-12* mb indx-9.4* ctropnt-0.18* . cxr portable chest x-ray, portable ap: comparison is made to prior study of . the heart is at the upper limits of normal in size. the aorta is calcified. there is increased density in the right middle lobe and left suprahilar region which has been demonstrated on multiple prior studies and is likely chronic. no new infiltrates are seen. there is stable blunting of the left costophrenic angle. there is no pneumothorax. . impression: stable appearance of the chest from . no acute pulmonary process. no pneumothorax. . cxr: chest x-ray, portable ap: comparison is made to prior study of . the heart is at the upper limits of normal in size. the aorta is calcified. there is increased density in the right middle lobe and left suprahilar region which has been demonstrated on multiple prior studies and is likely chronic. no new infiltrates are seen. there is stable blunting of the left costophrenic angle. there is no pneumothorax. impression: stable appearance of the chest from . no acute pulmonary process. no pneumothorax. . echo ()- mild symmetric lvh with lvef of 40 to 45%. normal rv chamber size and wall motion. severely thickened/deformed aortic valave leaflets with severe as. aortic valve area is 0.7 cm2 with a peak gradient of 82 and a mean of 52. 1+ ar and 2+ mr. regurgitation. trivial/physiologic pericardial effusion. . cxr: ap semi-erect portable chest @ 3:40 p.m.: compared to prior study on , there appears to be increased interstitial markings in the left lung and at the right base sparing the right upper lung zone. this pattern may be seen in interstitial edema in a patient with emphysema. . brief hospital course: floor course 1: pt was initially admitted to the floor service for further care of a copd exacerbation. on the evening of admission (), pt had an episode of left sided cp with concurrent sob that improved with sl ntg. pt's troponin and ck were subsequently positive (0.13 and 162) and ekg had lateral st depressions so he was started on a heparin drip. a cardiology consult was obtained on and further medical management was initially presued. on the evening of hd #1, the pt developed acutely worsening sob with tachypnia to the 40s. abg showed 7.24/57/222 so he was transferred to the micu for management of hypercarbic respiratory failure including noninvasive ventilation. . micu course: in the micu, pt's respiratory status improved with noninvasive ventilation, continuous nebs, iv steroids, and lasix. anxiety related sob was also been an issue for which pt received klonipin. pt continued to be followed by cardiology for his nstemi and had a peak troponin of 0.21 at 10:46 pm on . echo was done on showing a lvef of 40 to 45% with severe as. pt continued to have severe respiratory distress requiring continuous bipap and persistent troponin elevation thought to bue due to secondary demand ischemia. a cardiac cath was not obtained as it would have required intubation which the pt did not desire. tpn was started for nutritional support on . pt was weaned off of noninvasive ventilation on the evening of and has been having an oxygen sat of 100% on 6l nc. he was also started on an insulin drip on secondary to persistently elevated blood glucose levels. insulin drip was weaned off prior to being transferred to the floor for further care; pt was continued on nph and insulin sliding scale. . floor course 2: . 1. respiratory- on the floor, pt continued to have good o2 saturations ranging from 97-100% on 1-2lnc. pt was continued to be aggressively treated for copd with standing and prn albuterol nebs, atrovent nebs, montelukast, azithromycin, and steroid taper. pt was seen by pulmonary consult. from their recommendations, we discontinued atrovent and started spiriva. we also switched from azithromycin to bactrim. azithromycin has anti-inflammatory properties, but there is still little good evidence for its benefit in copd. pulmonary felt that bactrim would be a better antibiotic, in the the setting of long-term steroids since it has pcp . advair was added the the regimen. prednisone taper was continued. the taper is to be as follows: prednisone 50 x 7 days, 40mg x 7 days, 30mg x 7days, then continue with 20mg. klonipin which was given for anxiety was discontinued secondary to lethargy. pt will follow-up with outpatient pulmonologist dr. . . 2. cad/ pt had a nstemi on which was felt to be most probably due to demand but acute coronary syndrome could not be absolutely excluded. he was on heparin for 5 days and was d/c'ed in setting of left subconjunctival hemorrhage. since pt is just recovering from his copd exacerbation, we felt that it would be safer to defer cardiac cath as an outpatient. pt agreed with this plan and stated his wish not to be cath'ed during this admission. cardiology was okay with this plan and they plan to re-evaluate him in 4 weeks. in the meantime, pt was continued on with medical management. he was continued on diltiazem for rate control (beta blocker not used in order to avoid it's bronchospastic effects). however, diltiazem was unable to be titrated up secondary to blood pressure intolerance; pt's hr remained in 90-110 range. pt was continued on captopril, but most doses were held secondary to blood pressure intolerance. for now, we will discontinue acei; please add it back on as tolerated. pt was continued on aspirin and statin. . 3. severe aortic stenosis- pt found to have severe aortic stenosis on echo during this admission. the plan to be have cardiac cath as an outpatient after pulmonary rehab for a formal assessment of the aortic valve. we avoided beta blocker and nitoglycerin. . 4. steroid induced diabetes mellitus- pt was continued on nph and sliding scale. oral glipizide was added. pt is on metformin as an outpatient, but we did not restart that since pt may be at increased risk for lactic acidosis in the setting of hypoxia or cardiac ischemia. please continue to titrate up glipizide and adjust nph as indicated. . 5. pt had a difficult time tolerating diltiazem and acei given his low blood pressures ranging from 90-100 systolic. we will continue diltiazem for rate control and hold acei for now. please titrate up dilt for better rate control. if bp tolerates, can consider restarting acei . 6. subconjunctival hemorrhage- occurred in setting of iv heparin and noninvasive positive pressure. there was slow resolution of the hemorrhage. pt was continued on erythromycin ointment qid. ophtho stated that it may take 2 weeks for the hemorrhage to resolve. after then, pt should be safe for elective cardiac cath. should anti-coagulation be urgently indicated prior to resolution of hemorrhage, ophtho feels the hemorrhage should not be an absolute contraindication. pt will f/u with clinic one week after discharge. . 7. pt was continued on ppi. . 8. crohn's disease- stable pt was continued on mesalamine dr. . 9. fen- was on tpn in micu which was discontinued. pt was continued on cardiac, diet. . 10. proph- sc heparin; ppi; bowel regimen. . 11. access- picc line () . 12. code- dnr/dni. medications on admission: meds on admission: 1. prednisone 20mg qd 2. prozac 3. azithromycin 250mg qd 4. singulair 10mg qhs 5. alb/atrovent tid 6. glucophage 850mg 7. univasc 7.5mg qd 8. hytrin 9. asacol 400mg qd 10. serevent . meds on transfer from micu: 1. albuterol nebs ih q4h 2. asa 325 mg po daily 3. atorvastatin 40 mg po daily 4. azithromycin 250 mg po daily 5. captopril 6.25 mg po tid 6. clonazepam 1 mg po bid 7. diltiazem 30 mg po qid 8. docusate 100 mg po bid 9. erythromycin 0.5% opth oint 0.5 in ou qid 10. famotidine 20 mg po bid 11. sc heparin 5000 units tid 12. ipratropium bromide neb ih q6h 13. mesalamine dr 400 mg po tid 14. montelukast sodium 10 mg po daily 15. prednisone 50 mg po daily 16. senna prn 17. bisacodyl prn 18. albuterol neb prn 19. tylenol prn 20. insulin- being weaned off drip discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. montelukast sodium 10 mg tablet sig: one (1) tablet po daily (daily). 3. mesalamine 400 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po tid (3 times a day). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 6. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. 7. albuterol sulfate 0.083 % solution sig: one (1) inhalation q2h (every 2 hours) as needed for wheezing. 8. erythromycin 5 mg/g ointment sig: one (1) ophthalmic qid (4 times a day). 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po bid (2 times a day) as needed. 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 12. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 13. prednisone 10 mg tablet sig: five (5) tablet po daily (daily) for 2 days: last day is . 14. prednisone 20 mg tablet sig: two (2) tablet po once a day for 7 days: from to . 15. prednisone 10 mg tablet sig: three (3) tablet po once a day for 7 days: from to . 16. prednisone 20 mg tablet sig: one (1) tablet po once a day: start and continue. 17. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 18. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours). 19. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day) as needed. 20. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day). 21. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 22. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 23. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) capsule, w/inhalation device inhalation qd (). 24. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 25. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for cough. 26. morphine sulfate 2 mg/ml syringe sig: one (1) injection q4h prn as needed for air hunger, pain. 27. clonazepam 1 mg tablet sig: one (1) tablet po qhs prn as needed for aggitation, anxiety: hold for sedation or for rr<12. 28. glipizide 5 mg tablet sig: two (2) tablet po daily (daily). 29. insulin nph human recomb 100 unit/ml syringe sig: one (1) subcutaneous twice a day: 24u qam 12u qpm. 30. insulin regular human 300 unit/3 ml syringe sig: one (1) subcutaneous four times a day: please follow insulin sliding scale qid. discharge disposition: extended care facility: - discharge diagnosis: copd exacerbation s/p nstemi severe as steroid induced dm discharge condition: stable discharge instructions: if you develop difficulty breathing or chest pain, call your doctor or return to the emergency room. followup instructions: follow up with ophthamology on: :15am with dr. located in follow up with your primary care doctor : , md where: phone: date/time:, 10am provider pulmonary breathing test where: pulmonary function lab phone: date/time: 9:45 provider , m.d. where: phone: date/time: 10:30 follow up with cardiology on with dr. at 11am located in . md procedure: venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances non-invasive mechanical ventilation diagnoses: subendocardial infarction, initial episode of care congestive heart failure, unspecified long-term (current) use of steroids other specified disorders of pancreatic internal secretion adrenal cortical steroids causing adverse effects in therapeutic use other pulmonary insufficiency, not elsewhere classified obstructive chronic bronchitis with (acute) exacerbation aortic valve disorders iron deficiency anemia, unspecified conjunctival hemorrhage conjunctival edema 

Answer: The patient is high likely exposed to