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: penicillins attending: chief complaint: delirium. major surgical or invasive procedure: picc line placement , removed on history of present illness: please see the medicine nightfloat admission note for full details. in brief, this is an 81yo man w/ systolic/diastolic chf (ef 45%, dry weight 215lbs in ), htn, afib on coumadin and vascular dementia, admitted for altered mental status, this morning being transferred to the micu for hypoxia. . he was last well about 10 days ago when he initially had urinary retention c/b uti and altered mental status. he improved quickly with antibiotics and went to rehab on po antibiotics. he had low bps and altered mental status. cxr showed pna, and he was started on ceftriaxone/azithro with improvement. yesterday morning he was again altered, could not get out of bed, and was transferred to the . . in the ed he triggered for hypoxia that improved with 6l o2 by nc. given vanc/levo/flagyl. trop 0.08 and bnp >9000. given asa, but not lasix because of concern for infection/sepsis. on the floor overnight he was appearing improved and was given lasix 20mg iv x1. he had an unwitnessed fall early this morning and was found on the ground. at 7am he was again hypoxic with an arterial p02 59 on a non-rebreather. he is profoundly confused, oriented x0 and having trouble speaking. . speaking with his wife, he usually lives in with her, is oriented x3, walks with a walker, and had been hospitalized very little before the last 3 weeks. he had never been hospitalized before 3 weeks ago. he is dnr/dni, but she would like him to get all of the care necessary to improve his current status short of intubation. past medical history: 1.) chronic permanent af, on warfarin/bb. 2.) combined systolic/diastolic heart failure 3.) presumed cad, s/p inferior mi by imaging. 4.) vascular dementia. 5.) htn 6.) recent urosepsis precipitated by urinary retention s/p hospitalization at with foley catheter in place social history: retired. married to , retired rn. children live in and . lives in in , but most recently in rehab. walks with a walker at baseline. - tobacco: previous smoker - alcohol: none currently - illicits: none family history: father: deceased age 79 with cardiac problem mother: deceased age 82 with stroke brother: deceased age 78 colon cancer physical exam: admission physical exam: vs: t 97.1 bp 120/53 hr 79 rr 18 o2 93-96 on 2-3lnc general: alert but very confused, nearly non-verbal. mild respiratory distress. heent: nc/at, sclera anicteric, dry mucous membranes, oropharynx clear with dentures in place. neck: supple, jvp elevated to 10cm when upright, no lad though he does have a ? lipoma at the neck base on the left. lungs: initially diffusely rhoncorus, now improving with diuresis. crackles at bilateral bases. cv: tachycardic, irregular, no audible murmurs or gallops. abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing. ecchymoses on hands and forearms. discharge physical exam: vs: t 97.7 tmax 98.4 bp 121/76 (100-121) hr 78 (65-82) rr 18 o2 91-96 on ra i&o: 650/700 (+0) general: alert, oriented to person and place. responsive, hard of hearing. heent: nc/at, edentulous, oropharynx clear neck: with jvp of approximately 5 cm cv: irregular, no murmurs pulm: ctab. otherwise lungs clear to auscultation, no wheezes or rhonchi abd: soft, non-tender, non-distended. ext: warm and well-perfused, no le edema, 2+dp pulses pertinent results: admission labs: 04:35pm blood wbc-6.8 rbc-3.16* hgb-9.9* hct-29.7* mcv-94 mch-31.4 mchc-33.4 rdw-18.1* plt ct-207 04:35pm blood pt-35.0* ptt-35.6* inr(pt)-3.5* 04:35pm blood glucose-98 urean-20 creat-0.9 na-144 k-3.4 cl-108 hco3-27 angap-12 06:15am blood ck(cpk)-72 04:35pm blood ctropnt-0.08* 04:35pm blood calcium-7.8* phos-2.8 mg-2.0 06:51am blood type- po2-44* pco2-50* ph-7.37 caltco2-30 base xs-1 discharge labs: : wbc rbc hgb hct mcv mch mchc rdw plt ct 7.3 3.20* 9.7* 30.7* 96 30.4 31.6 18.0* 167 inr: 1.6 glucose urean creat na k cl hco3 angap 93 32* 1.6* 148* 3.5 113* 26 13 pertinent results: 04:35pm blood ctropnt-0.08* 06:15am blood ck-mb-4 ctropnt-0.10* 04:05pm blood ck-mb-5 ctropnt-0.08* 02:25am blood ck-mb-4 ctropnt-0.09* 06:15am blood vitb12-587 folate-7.8 micro: : blood cultures no growth x 2 sets : blood cultures no growth x 2 sets : urine culture no growth : c. diff toxin a & b negative 5:20 pm sputum source: expectorated. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast. quality of specimen cannot be assessed. smear reviewed; results confirmed. respiratory culture (final ): sparse growth commensal respiratory flora. yeast. sparse growth. yeast. moderate growth. second morphology. cxr portable : findings: lung volumes are profoundly diminished. the patient was imaged in a somewhat lordotic position. there is diffuse interstitial opacity with cephalad flow most consistent with volume overload likely due to congestive heart failure. aortic tortuosity is present with calcified plaque seen at the arch. the cardiac silhouette size is difficult to assess but is enlarged. there is right pleural effusion with fluid tracking within the minor and major fissures. a left pleural effusion cannot be entirely excluded. there is poor visualization of the retrocardiac lung, possibly due to atelectasis and/or edema. no pneumothorax is noted. the bones are diffusely osteopenic with degenerative changes noted in both shoulder joints. impression: findings most compatible with congestive heart failure. correlate clinically. repeat radiography after appropriate diuresis recommended to assess for underlying infection. ct head non-contrast : findings: no hemorrhage, edema, mass effect, or evidence for acute vascular territorial infarction is present. there is no shift of normally midline structures and -white matter differentiation appears well preserved. there is prominence of the ventricles and the sulci compatible with parenchymal atrophy. there are periventricular white matter hypodensities compatible with small vessel microvascular disease. however, no acute infarcts are present. osseous structures appear intact and the visualized sinuses are clear. impression: 1. parenchymal atrophy and small vessel microvascular disease but no acute intracranial findings. swallowing video fluoroscopy : swallowing videofluoroscopy was performed in conjunction with the speech and swallow department. multiple consistencies of barium were administered. there was aspiration and penetration to thin liquids. ecg, : the underlying rhythm is probably atrial fibrillation. left axis deviation. intraventricular conduction defect. one ventricular premature beat is seen. lateral st-t wave changes likely due to left ventricular hypertrophy. cannot exclude ischemia. clinical correlation is suggested. no previous tracing available for comparison. rate pr qrs qt/qtc p qrs t 81 /464 134 -40 118 ecg, : atrial fibrillation with occasional ventricular premature beats. intraventricular conduction delay. left axis deviation. late transition. rate pr qrs qt/qtc p qrs t 76 0 150 446/474 0 -41 134 brief hospital course: 81 year-old man w/ systolic/diastolic chf (ef 45%, dry weight 215 lbs. in ), htn, atrial fibrillation on coumadin and vascular dementia, admitted for altered mental status, transferred to the micu for altered mental status and hypoxia. . # hypoxia: most likely due to combination of acute decompensation of his chf in the setting of diastolic dysfunction secondary to afib with rvr, as well as healthcare acquired pneumonia. hcap: patient completed a 8-day course of cefepime/vancomycin and was afebrile with normal wbc on discharge. acute on chronic chf: he received several doses of 40 iv lasix. subsequently, his exam appeared more dry so lasix was held. on discharge, he weighed 185 lbs and was 93-96% on ra. he will require daily standing weights, ins/outs monitoroing, volume assessment, and every other day (until stabilized) electrolytes monitoring. he can be restarted on his home dose of furosemide 40 mg daily for a goal of maintaining euvolemia. . # toxic metabolic encephalopathy: patient is extremely sensitive to metabolic insult, and has had wide fluctuations in his mental status with his recent infections and chf exacerbation. ct head w/o contrast did not show acute process. scopolamine patch was apparently given at rehab facility, and also likely contributed; this was discontinued. when he was able to take pos, home doses of donepezil and memantine were restarted. . # afib on coumadin: coumadin initially held for supertherapeutic inr (3.5). he was started on iv metoprolol as he was unable to take pos. he was then transitioned to po metoprolol (increased from 12.5 mg to 25 mg ), and his heart rate remained well-controlled. his coumadin was re-started at home dose of 2.5 mg, then increased to 3 mg on ; inr at discharge is 1.6. inr will need to be checked on and thereafter as needed for goal of inr . . # urinary retention: patient underwent foley catheter placement after repeatedly failing voiding trials. etiologies include bph vs recent scopolamine patch. he underwent and failed a repeat voiding trial with pvr 700 , and underwent tid straight catheterization thereafter. he was continued on flomax with up-titrated dose (0.8 mg). as straight catheterization not available at rehab, a foley catheter was placed prior to transfer and will remain in place until follow-up with dr. in urology on . . #) acute renal failure: his creatinine trended up from a baseline of 1.0 to 1.6 in the setting of aggressive diuresis. fena of 0.45% was consistent with pre-renal intravascular depletion. he was hydrated with gentle ivf. ace inhibitor and furosemide were held and medications renally dosed. creatinine was stable (1.6) at time of discharge, up from baseline of 1.0. his ace-i may be restarted as outpatient when his creatinine returns to baseline. his renal function should be monitored at the rehab every other day as needed until improved. . #) nutrition: due to suspicion of aspiration, the patient was evaluated by speech and swallow and underwent a video swallowing study that showed evidence of aspiration with thin liquids. he was started on a pureed (dysphagia) diet with nectar prethickened liquids, which he tolerated. his medications were crushed. \ . # s/p fall: patient found down on the floor. not complaining of focal pain, but he has difficulty cooperating fully with a neurologic exam. he does open eyes to command and squeeze fingers when asked. ct head without acute ich. . #) hyperlipidemia: patient was continued on home dose of 5mg simvastatin when able to tolerate pos. . #) gout: allopurinol renally dosed. can increase to usual 400 mg daily as renal function improves. . #) outpatient management: once admitted to rehab, the patient needs every other day blood labs to monitor serum electrolytes, creatinine, inr, and daily weights. plan to monitor volum status clinically to reach a balance between his chf and renal failure. outpatient urology follow-up as above. medications on admission: - allopurinol 400mg daily - vitamin c 500mg daily - benefiber - lasix 40mg daily - vitamin d daily - pantoprazole 40mg - namenda 10mg - donepezil 10mg daily - simvastatin 5mg daily - tamsulosin 0.4mg daily - warfarin 2.5mg daily (inr on 2.6) - miralax - azithromycin 500mg daily x 7 days last day was day of admission - lopressor 12.5mg - ctx 1gm iv daily x 10 days - scopalamine patch discharge medications: 1. warfarin 1 mg tablet sig: three (3) tablet po daily (daily). disp:*0 * refills:*0* 2. tamsulosin 0.4 mg capsule, ext release 24 hr sig: two (2) capsule, ext release 24 hr po hs (at bedtime). disp:*0 * refills:*0* 3. simvastatin 10 mg tablet sig: 0.5 tablet po daily (daily). 4. miconazole nitrate 2 % powder sig: one (1) appl topical hs (at bedtime). disp:*0 * refills:*0* 5. donepezil 5 mg tablet sig: two (2) tablet po hs (at bedtime). 6. memantine 5 mg tablet sig: two (2) tablet po bid (2 times a day). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 8. vitamin d 2,000 unit capsule sig: one (1) capsule po once a day. 9. vitamin c 500 mg tablet sig: one (1) tablet po once a day. 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*0 * refills:*0* 11. senna laxative 8.6 mg tablet sig: one (1) tablet po twice a day. disp:*0 * refills:*0* 12. benefiber (guar gum) packet sig: two (2) tsp po once a day. 13. miralax 17 gram powder in packet sig: seventeen (17) gm po once a day as needed for constipation. 14. outpatient lab work please check chem 10 and inr on monday , wednesday , friday , and thereafter as needed rehab md. 15. allopurinol 300 mg tablet sig: 0.5 tablet po once a day. 16. foley placement pt was straight-cathed tid at ; please place foley catheter on arrival to rehab facility 17. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: extended care facility: in discharge diagnosis: primary diagnosis: heart failure exacerbation with acute renal insufficiency healthcare-associated pneumonia secondary diagnosis: chronic systolic/diastolic heart failure atrial fibrillation discharge condition: activity status: ambulatory - requires assistance or aid (walker or cane). mental status: confused - sometimes. level of consciousness: alert and interactive. o2 saturation: 93-95% on ra at rest. discharge instructions: you were admitted to with altered mental status and shortness of breath. you were found to have a pneumonia and too much fluid in your lungs (heart failure exacerbation). you were given antibiotics for 8 days for the pneumonia, as well as medication to help remove the extra fluid. your symptoms improved and you were discharged to a rehab facility. we also monitored you for worsened kidney function; this was stable on discharge. in the setting of your acute illness, there was concern for your ability to swallow liquids/food without aspirating. you were evaluted by the swallowing team and underwent a swallowing study. you aren't able to swallow well when you drink thin liquids (water), so you will need to continue to crush your pills and stay on a puree diet. we made the following changes to your home medications: 1. we increased tamsulosin (flomax) to 0.8 mg instead of 0.4 mg 2. we increased metoprolol to 25 mg twice daily instad of 12.5 mg twice daily 3. we have held your furosemide (lasix) for now; this can be restarted as needed at your rehab. 4. we decreased your allopurinol to 150 mg daily instead of 400 mg daily until your kidney function improves 5. we stopped your scopalamine patch followup instructions: urology follow-up name: , location: urology practice associates address: , , phone: when: tuesday, :30am neurology follow-up: provider: , md phone: date/time: 1:00 md procedure: venous catheterization, not elsewhere classified diagnoses: pneumonia, organism unspecified other iatrogenic hypotension coronary atherosclerosis of native coronary artery congestive heart failure, unspecified toxic encephalopathy unspecified essential hypertension acute kidney failure, unspecified gout, unspecified atrial fibrillation personal history of tobacco use other and unspecified hyperlipidemia old myocardial infarction long-term (current) use of anticoagulants hypoxemia altered mental status do not resuscitate status hypovolemia accidental fall from bed vascular dementia, uncomplicated cerebral atherosclerosis acute on chronic combined systolic and diastolic heart failure dysphagia, oropharyngeal phase hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (luts) parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use incomplete bladder emptying 

Answer: The patient is high likely exposed to