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: upper gastrointestinal bleed. major surgical or invasive procedure: none history of present illness: hpi: mr. is an 89-year-old man with a past medical history significant for cad (s/p cabgx3 ), dchf (ef 55%), dmii, ckd, dvt right leg x2, prior gib presenting with hypotension and hematemesis from nursing home. per report, the patient developed worsening abdominal pain at the nursing home yesterday afternoon. the report from the nh documents that he vomited undigested food, and then this morning he vomited a large amount of coffee ground materal. his vital signs at this time, as documented, were bp 88/48, hr 93, rr 22, t 98.4, satting 97% ra. he was then transferred to for further management. in the ed, he was noted to have elevated lactate 6.0. he was hypotensive to the 60s but with normal hematocrit of 42.7. other labs were notable for white count of 13.3 and platelets of 63. creatinine was 3.1, up from baseline 1.5. ua showed few bacteria, trace leuk esterace, neg nitrites, and few bacteria. cxr showed increased opacities at the right hemithorax, greater at the lung base, could represent aspiration, developing pneumonia, or possibly asymmetric pulmonary edema. he then underwent abdominal/pelvic ct scan that showed urinary bladder wall thickening consistent with cystitis versus neoplasm. notably, there was no evidence of bowel ischemia. urology and gastroenterology consult services were called. blood and urine cultures were sent. patient was given 4l ivf for volume rescucitation and 2u prbcs for concern of gib. he was started on protonix drip, and he was treated empirically with vancomycin and zosyn for sepsis of unclear etiology ?urinary source vs pneumonia. ultimately, as the patient remained hypotensive, a groin line was placed and norepinephrine started. vitals at time of admission were hr 90, bp 129/60, rr 25, satting 100% on ra. of note, the patient had started keflex on for urinary tract infection, per his son. review of systems: currently patient is without nausea or abdominal pain. he denies recent diarrhea. he does endorses recent dysuria and abdominal pain yesterday, as outlined above in hpi. ros otherwise is non-focal: patient denies cardiac or pulmonary symptoms. past medical history: # hypertension # coronary artery disease: status-post three vessel cabg in # dchf (ef 55%), mild-to-omderate mr , mild pulm htn # diabetes mellitus # chronic kidney disease stage iv (baseline creatinine 1.3-1.5) # bph with history of urethral strictures # history of gi bleed # s/p cholecystectomy # hyperlipidemia # history of dvt () on anti-coagulation # squamous cell carcinoma on lip # gout # right eye blindness secondary to trauma at age 12 # history of biliary sepsis c/b septic shock # depression # obstructive/restrictive lung disease with pleural disease, question of pneumothorax in # bilateral hydronephrosis # thrombocytopenia since 's # chronic lower extremity edema # right lower lobe klebseilla pneumonia with sepsis social history: per notes from nursing home, he "can participate in his care, but need constant supervision. b & b continent most of the time, uses diaper for occasional incontinence. he is at significant fall risk....needs walker to ambulate family history: non-contributory physical exam: physical exam: general: elderly man in no acute distress vital signs: 97.1, 107/53, 74 heent: dry mucus membranes neck: jvd to level of angle of mandible lungs: diffuse expiratory wheezes heart: rrr, normal s1/s2 abdomen: soft, without tenderness, guarding, or rebound, negative sign extremities: non-edematous and warm, skin erythema along shins and medial malleoli consistent with chronic venous stasis dermatitis pertinent results: admission results: . 09:30am blood wbc-13.3*# rbc-4.78 hgb-14.5 hct-42.7 mcv-89 mch-30.4 mchc-34.0 rdw-16.1* plt ct-63* 09:30am blood neuts-71* bands-23* lymphs-2* monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-0 04:54pm blood neuts-59 bands-34* lymphs-1* monos-5 eos-0 baso-0 atyps-0 metas-1* myelos-0 09:30am blood pt-17.7* ptt-32.5 inr(pt)-1.6* 09:30am blood glucose-185* urean-42* creat-3.1*# na-140 k-5.6* cl-96 hco3-28 angap-22* 09:30am blood alt-88* ast-78* alkphos-168* totbili-1.2 04:54pm blood alt-76* ast-68* ld(ldh)-251* alkphos-140* totbili-1.3 09:30am blood calcium-9.9 phos-3.8 mg-2.1 04:54pm blood hapto-21* 09:30am blood ctropnt-0.14* 04:54pm blood ctropnt-0.10* 03:50am blood ck-mb-4 ctropnt-0.10* . ekg (): normal sinus rhythm with right bundle-branch block and secondary st-t wave abnormalities. left atrial abnormality. compared to the previous tracing of no diagnostic interim change. . pcxr (): increased opacities at the right hemithorax, greater at the lung base, could represent aspiration, developing pneumonia, or possibly asymmetric pulmonary edema. . ct abdomen and pelvis (): 1. extensive bladder wall irregularity, as above, representing either cystitis or possibly neoplasm. further workup with cystoscopy is recommended. small foci of air either within or adjacent to the urinary bladder wall are likely related to prior foley catheter placement, less likely due to emphysematous cystitis. 2. diffuse diverticulosis without diverticulitis. 3. no evidence of small-bowel obstruction or small bowel ischemia, however, evaluation is limited secondary to lack of iv or oral contrast. 4. stable liver and renal cysts. 5. stable focal abdominal aorta aneurysm at the origin. 6. r>l lower lobe opacities likely represent atelectasis, but pneumonia cannot be completely excluded. 7. stable right pleural calcified plaque, which may be postinfectious, posthemorrhagic, or from prior asbestos exposure. . interval results: . cxr (): in comparison with the study of , there is little overall change. opacification at the right base again could reflect aspiration or developing pneumonia. pleural calcification at the right base is consistent with a calcified fibrothorax. there is enlargement of the cardiac silhouette without definite pleural effusion or pulmonary vascular congestion. intact midline sternal wires are in place. . . . (last updated on ) 05:23am blood wbc-3.9* rbc-4.47* hgb-13.2* hct-39.7* mcv-89 mch-29.6 mchc-33.3 rdw-15.7* plt ct-39* 08:15am blood wbc-4.1 rbc-4.70 hgb-14.1 hct-42.7 mcv-91 mch-30.0 mchc-33.0 rdw-15.7* plt ct-48* 08:05am blood wbc-4.6 rbc-4.48* hgb-13.6* hct-39.3* mcv-88 mch-30.4 mchc-34.7 rdw-15.9* plt ct-47* 04:50pm blood wbc-5.0 rbc-4.59* hgb-13.5* hct-40.0 mcv-87 mch-29.5 mchc-33.9 rdw-15.7* plt ct-61* 06:00am blood wbc-4.5 rbc-4.34* hgb-13.1* hct-38.9* mcv-90 mch-30.1 mchc-33.6 rdw-15.9* plt ct-67* 08:05am blood pt-15.3* inr(pt)-1.3* 04:23pm blood glucose-153* urean-47* creat-2.1* na-143 k-4.2 cl-111* hco3-24 angap-12 08:15am blood glucose-132* urean-39* creat-1.7* na-145 k-4.2 cl-112* hco3-26 angap-11 06:00am blood urean-30* creat-1.2 04:54pm blood alt-76* ast-68* ld(ldh)-251* alkphos-140* totbili-1.3 03:50am blood alt-72* ast-54* ld(ldh)-195 ck(cpk)-97 alkphos-120 totbili-1.0 05:23am blood alt-52* ast-32 ld(ldh)-163 alkphos-130 totbili-0.9 08:15am blood alt-42* ast-23 ld(ldh)-181 alkphos-209* totbili-0.9 04:54pm blood ctropnt-0.10* 03:50am blood ck-mb-4 ctropnt-0.10* 08:15am blood calcium-8.4 phos-2.6* mg-2.5 04:19pm blood glucose-139* lactate-1.5 echo conclusions the left atrium is mildly dilated. the right atrium is moderately dilated. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is mildly depressed (lvef= 40-45 %). the right ventricular cavity is dilated with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. the pulmonic valve leaflets are thickened. there is no pericardial effusion. impression: suboptimal image quality. mildly depressed left ventricular function. technically suboptimal to exclude focal wall motion abnormality. moderate pulmonary hypertension. moderate mitral and tricuspid regurgitation. dilated right ventricle. compared with the prior study (images reviewed) of , left ventricular function has declined. the severity of pulmonary hypertension has slightly increased. the right ventricle appears more dilated. cxr history: picc placement. findings: in comparison with the study of , there has been placement of a picc line that extends to the mid portion of the svc. little overall change in the appearance of the heart and lungs. again there is enlargement of the cardiac silhouette with pleural calcification at the right base consistent with calcified fibrothorax. suggestion of patchy opacification at the right base again could reflect aspiration or developing pneumonia. prominence of pulmonary vessels suggests some elevated pulmonary venous pressure. brief hospital course: 89-year-old man with complex cardiovascular history who presents with abdominal pain, coffee-ground emesis once and hypotension, who was found to have acute renal failure, an elevated white count with bandemia, and lactic acidosis consistent with severe sepsis. . #. severe sepsis (uti/hap): patient was sent in from his nursing home to the ed for an episode of coffee-ground emesis and hypotension and on arrival was found to have septic physiology consistent with severe sepsis. on exam the patient had a systolic blood pressure in the 80s and a heart rate of 93. lactate was 6.0, white count was 13.1 with a bandemia of 23% (increased to 34% subsequently), and serum creatinine was 3.1, up from a known baseline of 1.5. a urinalysis was performed and was equivocal (though the patient had recently received cephalexin for a uti) and urine culture and blood cultures were performed. cxr was performed on arrival that was concerning for right-sided aspiration pneumonia vs. pneumonitis. a ct of the abdomen and pelivs was also performed that revealed bladder wall thickening concerning for cystitis vs. possible neoplasm. the patient was started empirically on vancomycin and zosyn, received 4 l of normal saline and was started on norepinephrine in the ed. a femoral line was placed for delivery of fluids and products. vancomycin was continued on the floor but zosyn was switched to cefepime (for hcap and uti coverage) and zosyn was initiated given concern for aspiration. he also received an additional 2 l of normal saline while in the icu. the patient improved significantly overnight and it was felt that the flagyl could be discontinued. the patient's blood pressure improved and was taken off pressors, his white count and bandemia resolved, lactate decreased to 1.4, serum creatinine decreased to 1.9. urine culture also came back negative. the femoral line was pulled prior to transfer from the icu. the patient was subsequently transferred out to the medicine floor for further management as he no longer required an icu level of care. vanco + cefepime was continued for concern of hap and would recommend he complete a 2 week course (through ). vanco trough = 16.6. a picc was placed . recommend following vancomycin trough every 4 doses. . # picc line: placed -- will need to be removed after completion of antibiotic course. . #. coffee-ground emesis: patient had one episode of coffee-ground emesis by report but had no further episodes after arrival to the ed. hematocrit on arrival was 42.7 which was considered up from the patient's baseline given his degree of hypotension as described above. the patient received two units of packed red blood cells and was started on a pantoprazole drip in addition to receiving the fluids as above. gi was consulted while the patient was in the ed but declined intervention given the limited nature of the patient's presentation. in the icu, the patient's hematocrits were monitored every four hours initially but were spaced out to once daily when it became apparent that his hematocrit had stabilized. additionally, given the concern for gi bleed, in the setting of severe sepsis, dic labs were followed closely but the patient's fibrinogen never fell below 400 nor did fdp rise above 40. hematocrit upon transfer to the floor was 39.7 which was believed to be close to his baseline. the patient was transitioned from a pantoprazole drip to iv and, finally, to an oral formulation prior to transfer to the medicine floor. asa wsa discontinue, and should he prove to maintain his hct in another week, would recommend restarting 81mg daily. if hct were to decline, arrange for egd. . #. acute on chronic renal failure: the patient was admitted with a serum creatinine of 3.1, up from a known baseline of 1.5, which was considered likely secondary to the patient's hypotension in the setting of hypovolemia and severe sepsis. patient received intravenous fluids, blood products and norepinephrine as above and the serum creatinine had decreased to 1.9 the morning of transfer to the medicine service. was 1.2 prior to discharge. . #. thrombocytopenia: patient had a history of thrombocytopenia with levels on admission similar to levels in when he underwent his cabg. on admission, the patient's recurrent thrombocytopenia was attributed to sepsis and dic labs were trended as per above. although the dic labs remained negative throughout his time in the icu, the platelet count, which was initially stable, did decrease from the admission count, from 60 to 39. it was possible that part of this could be explained by dilution. of note, the patient never received heparin during her icu stay, and dvt prophylaxis was by pneumoboots. . #. elevated troponin: on admission, the patient had a tn of 0.14. it was believed that this reflected demand ischemia in the setting of acute on chronic renal failure. an ekg revealed a normal sinus rhythm with right bundle-branch block and secondary st-t wave abnormalities that showed no new changes when compared to an ekg on . troponins were followed for a total of three sets with the second and third sets settling at 0.10. the patient remained chest pain free throughout his stay. echo was done which showed new mild systolic dysfunction ef 40-45%. because of lowish blood pressures, ace-inhibitor therapy was not initiated. this should be attempted as tolerated as an outpatient. . # combined chronic dystolic and mild acute new systolic chf: see above. he was not fluid overloaded on the medical floor after icu stay. because of naturally lower blood pressures, his outpatient lasix dose is reduced from 80mg to 40mg daily, with instructions for low salt diet, weight monitoring and uptitration of lasix as needed per covering physician. not initiated due to blood pressure, but if tolerated as outpatient, this should be attempted. . #. transaminitis and elevated inr: patient had elevated liver enzymes on arrival to the ed. the most immediate concern was for elevations secondary to shock liver in the setting of severe sepsis. the elevated inr was also considered possibly attributable to dic. the elevated liver enzymes improved with treatment of the patient's sepsis and presumed infections. . # urethral stricture / bladder wall thickening: urology evaluated the patient and performed bedside urethral dilation with foley catheter placement. this should be kept in place for now, until clinic voiding trial which has been scheduled. . # pt's code status is dnr/dni confirmed by hcp his hcp = daughter = has been updated with respect to his hospitalization issues. home: , work: i spoke with dr. (accepting pcp at rehab) and gave him a full report. medications on admission: medications: --cephalexin 250 mg tid --oxycodone 2.5 mg q6h prn --calcium carbonate 650 mg --glipizide 2.5 mg qday --simvastatin 20 mg daily --tamsulosin 0.4 mg qhs --acetaminophen 650 mg q6h prn --bupropion 150 mg --potassium chloride 20 mqe daily --zolpidem 2.5 mg qhs prn --colchicine 0.6 mg daily --senna 8.6 mg qhs --zinc oxide ointment 40% daily --ergocalciferol units q21 days --furosemide 80 mg daily --aspirin 81 mg daily --iron 150 mg every 2 days --tobradex suspension 1 drop qid --atropine sulfate 1% eye drop qid -- /mg /simethicone 30 ml q6h discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day) as needed for constipation. 4. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 5. vancomycin 1000 mg iv q 24h day 1 = 6. cefepime 2 gram recon soln sig: two (2) gm recon soln injection q24h (every 24 hours): through . 7. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. bupropion hcl 150 mg tablet sustained release sig: one (1) tablet sustained release po bid (2 times a day). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheeze, shortness of breath. 11. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheeze. 12. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 13. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 14. tobramycin-dexamethasone 0.3-0.1 % drops, suspension sig: one (1) drop ophthalmic q6h (every 6 hours). 15. atropine 1 % drops sig: one (1) drop ophthalmic qid (4 times a day). 16. glipizide 5 mg tablet sig: one (1) tablet po once a day. 17. oxycodone 5 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain. 18. colchicine 0.6 mg tablet sig: one (1) tablet po once a day. 19. lasix 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: severe sepsis urinary tract hospital acquired pneumonia acute renal failure - resolved myocardial demand ischemia (nstemi) mild acute systolic chf (40-45%) chronic thrombocytopenia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted with severe sepsis due to uti and pneumonia. you are to complete 2 week course of antibiotics intravenously. renal failur from low blood pressure resolved. you suffered mild heart damage. it was suspected that you may have had small bleeding in the gi tract, though your blood count did not drop significantly. you have a bladder obstruction and need to follow up with urology. you have mild heart failure and your weight and medical regimen will need to be monitored. followup instructions: department: surgical specialties when: wednesday at 8:00 am with: urology unit building: sc clinical ctr campus: east best parking: garage procedure: dilation of urethra insertion of indwelling urinary catheter other urethroscopy central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified subendocardial infarction, initial episode of care mitral valve disorders urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver acute kidney failure, unspecified unspecified septicemia severe sepsis chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status depressive disorder, not elsewhere classified chronic kidney disease, unspecified hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (luts) right bundle branch block septic shock other diseases of lung, not elsewhere classified personal history of venous thrombosis and embolism personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits hemorrhage of gastrointestinal tract, unspecified hypovolemia tricuspid valve disorders, specified as nonrheumatic acute on chronic combined systolic and diastolic heart failure other specified causes of urethral stricture profound impairment, one eye, impairment level not further specified 

Answer: The patient is high likely exposed to