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: tylenol / penicillins attending: chief complaint: shortness of breath major surgical or invasive procedure: rigid bronchoscopy upper endoscopy endoscopic ultrasound history of present illness: 53 y/o m s/p self-inflicted gunshot injury to face in with resulting tracheostomy, who presented to in c/o increased secretions from tracheostomy. they were yellowish, and this had been going on x 3 weeks. he reportedly didn't feel his breathing was worse than usual. he denied fevers or chills. he had been seen in the ed one day prior to this with the same complaint and was sent home with levaquin. he continued to require more frequent suctioning and so returned to the osh ed the next day. he also was having coffee-grounds aspirate from g tube, and brbpr. at that time, he was afebrile, bp 140/80, rr 20, and o2 sat 95% on 40% trach mask. he was felt to have bronchospasm, and begun on frequent nebulizers, steroid taper, and iv levofloxacin. gi felt that his gi bleeding was gastritis and hemorrhoids. on hd1 at the osh, he was noted to be in resp distress and tube feeds were suctioned from his lungs. his abg was 7.22/78/64 and he was transferred to the icu. he was tachypneic in the 30s and c/o respiratory fatigue so was placed on the vent in the early morning . in the icu, his uncuffed trach was changed to a cuffed trach with a fair amount of difficulty. he was placed on pcv due to high peak pressures. he was emergently bronchoscoped which revealed severe hemorrhagic bronchitis but was difficult because the bronchoscope that was used was unable to suction. he was changed to zosyn upon arrival in the icu, and was also placed on flagyl when he developed a distended abdomen with a lot of gas on the ruq (cdiff pending). he also was begun on vancomycin when staph grew from his sputum. he had a neck ct done to evaluate the degree of his tracheal stenosis, which was severe. at this point he was transferred to for further management of his tracheal stenosis, for ip procedure. in the micu patient initially put on ventilator and was switched to trach mask the following day. past medical history: -bronchiectasis s/p r pneumonectomy -seizure with anoxic encephalopathy -gunshot wound to face requiring multiple facial reconstructions, trach/g tube -gastritis -gastric ulcer -esophagitis social history: lives with wife, from originally. remote tobacco history. denies etoh. family history: noncontributory physical exam: upon transfer to the floor: pe: t 96.3 hr 85 bp 135-164/80-87 rr 23 o2sat 100% gen: nad, with trach mask heent: disfigured mouth, perrl, op clear lungs: upper airway sound b/l, diffuse rhonchi cardiac: rrr s1/s2 no murmurs abd: soft, distended, nabs, tender to palpation diffuse, no guarding or rebound ext: no edema neuro: aaox3 pertinent results: micro: blood culture inpatient pending stool inpatient toxin a negative blood culture inpatient pending urine inpatient <10,000 organisms/ml blood culture inpatient pending catheter tip-iv inpatient no growth blood culture inpatient no growth serology/blood inpatient rpr nonreactive blood culture inpatient no growth blood culture inpatient no growth blood culture inpatient no growth blood culture ( myco/f lytic bottle) inpatient pending serology/blood inpatient h. pylori ab negative blood culture inpatient no growth blood culture inpatient no growth blood culture inpatient no growth blood culture inpatient no growth stool inpatient toxin a negative bronchoalveolar lavage inpatient gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). respiratory culture (final ): 10,000-100,000 organisms/ml. oropharyngeal flora. staph aureus coag +. 10,000-100,000 organisms/ml.. of three colonial morphologies. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s stool inpatient toxin a negative stool inpatient toxin a negative pertinent reports: radiology cta abd pelvis impression: 1) no new pseudoaneurysms identified. 2) no significant change in soft tissue mass surrounding the hepatic artery branches, though the proper hepatic artery is now somewhat attenuated when compared with the prior study, though still patent. 3) slightly decreased size of retrogastric soft tissue density. cardiology stress interpretation: 53 year old male with iddm and vascular aneurysms presents to the laboratory for evaluation of coronary artery disease. the patient received 0.142 mg/kg/min of dipyridamole over three minutes. no anginal symptoms were reported by the patient. the dipyridamole was reversed with 125 mg of amiophylline iv. no significant st segment changes during the procedure. rhythm was sinus with rare apbs. hemodynamic response was appropriate. impression: no ischemic ecg changes or anginal symptoms. nuclear report sent separately. radiology persantine mibi impression: 1.normal myocardial perfusion study. 2. normal left ventricular size and function. cardiology ecg sinus rhythm poor r wave progression - is nonspecific and may be within normal limits but clinical correlation is suggested since previous tracing of , no significant change cardiology echo conclusions: no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. a small, mobile echodensity (about 5 mm) is attached to a catheter seen in the right atrium (probable thrombus). no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve leaflets are structurally normal. no mass or vegetation is seen on the mitral valve. no mitral regurgitation is seen. there is no pericardial effusion. impression: 1. no cardiac source for systemic embolization seen. 2. a small, mobile echodensity is seen on the tip of a catheter in the right atrium. this likely represents a small catheter-associated thrombus. radiology chest (portable ap) impression: 1) right subclavian central venous catheter is seen with the tip extending into the right ij, beyond the image margin. the results were discussed with dr. at 10:15 a.m. on . 2) stable post pneumonectomy changes are again noted. egd/eus impression: abnormal splenic artery at the level of the celiac axis a 17x17mm soft tissue mass identified normal pancreas, cbd and pd. using the radial and linear echoendoscopes the pancreas, mesenteric vessels and surrounding structures were examined in real time. the celiac axis was identified and the proximal take off appeared normal. splenic artery however had markedly thickened walls with pronounced peri-arterial soft tissue and possible small thrombus. the pancreatic head, body and tail appeared normal and the cbd and pd were also normal without dilatation or filling defects. at the level of the celiac axis take-off a soft tissue mass 17 x 17 mm was identified. this may relate to a lymph node. it was irregular in outline with a tiny cystic component but otherwise solid throughout. it was 4 mm from the celiac axis on eus. cardiology echo conclusions: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall systolic function is mild-moderately depressed (lvef ~35%). the right ventricular cavity size is normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is no pericardial effusion. if clinically indicated, a radionuclide study may be better able to define biventricular systolic function. radiology cta abd pelvis impression: 1) interval presumed thrombosis of the previously noted aneurysms nvolving the splenic artery and hepatic arteries, with stable gastroduodenal artery aneurysm and 2 new tiny intrahepatic aneurysms within the right lobe. no evidence of arterial occlusion. stable peri-arterial soft tissue densities as described. 2) new infarcts within the left kidney as described. given the normal renal arteries, this raises the possibility of embolic etiology, for example, from a cardiac source. clinical correlation is advised. 3) stable retrogastric soft tissue density. cardiology ecg sinus rhythm. since the previous tracing of the rate has slowed and atrial ectopy is no longer seen. the tracing is now normal. cardiology ecg sinus tachycardia with premature supraventricular beats. compared to the previous tracing of premature beats are now present. radiology cta abd pelvis cta abdomen : the patient is status post right pneumonectomy with an unchanged appearance. the left lung base is clear. the liver and gallbladder appear normal. the pancreas appears normal. however, adjacent to the pancreas, in the lesser sac, but not definitely associated with either the stomach or the pancreas, is an area of soft tissue density with minimal if any enhancement of unclear etiology. the spleen has a similar appearance with an area of peripheral hypodensity likely representing an infarct. the kidneys and adrenal glands are within normal limits. the appearance of the gastrostomy tube in the stomach and the small and large bowel are within normal limits. there is no retroperitoneal or mesenteric lymphadenopathy or free fluid. again noted on the arterial phase images is extensive wall thickening of the entire celiac axis with multiple regions of contrast collection which may represent ulcerations into the surrounding soft tissue density. the appearance is not significantly changed since the prior study. the splenic artery may be somewhat stenotic as before but is opacified. more inferior images are available on this ct and these demonstrate a separate small focus over about 1 cm of mural thickening of a major branch of the superior mesenteric artery, although contrast again appears to pass distally. the major mesenteric veins appear open. impression: vascular process involving the celiac axis and its branches (splenic, hepatic to intrahepatic branches and gda) and at least one right branch (ileocolic) of the sma, associated with splenic infarct and soft tissue retrogastric density. these findings are new, developed after . mural hematoma vs dissection is considered. focal gastric perforation with secondary vascular changes is less likely. finally pancreatitis is unlikely due to otherwise normal pancreas. cardiology ecg sinus tachycardia normal for tracing except for rate since previous tracing of , no atrial premature complex egd impression: erosion in the stomach body (opposite the peg tube) peg tube noted in body otherwise normal egd to second part of the duodenum recommendations: ppi therapy serological h pylori testing. treat if positive radiology cta chest impression: 1) status post right pneumonectomy. 2) no evidence of pulmonary embolism. 3) patchy parenchymal densities in the left lung, suggesting atypical pneumonia or inflammatory changes. 4) new peripancreatic fluid, raising a question of pancreatitis. 5) extensive soft tissue density or edema tracking along the entire celiac axis, and ivolving the hepatic artery, including the intrahepatic branches and the splenic artery. although this appearance could represent sequelae of pancreatitis, a primary vasculitis is felt more likely. 6) new splenic infarct. cardiology ecg sinus tachycardia. atrial premature beats. probable right atrial abnormality. since the previous tracing of atrial ectopy is present and the sinus tachycardia rate has increased. radiology chest (portable ap) portable chest: comparison is made to prior film dated . previously noted picc catheter and tracheostomy tube remain in place, without significant change. changes of prior right pneumonectomy are again identified. there is associated rightward shift of midline structures. there is stable pleural based density in the left apex. no acute changes are seen within the parenchyma of the left lung. impression: no acute change. radiology abdomen (supine only) impression: no evidence of bowel obstruction or significant ileus. radiology chest (portable ap) impression: picc tip in the lower svc. radiology ct abdomen pelvis ct abdomen/pelvis :impression: 1) no ct evidence of colitis or other intraabdominal source for the patient's abdominal pain. 2) pulmonary parenchymal opacity within the left lower lobe, raising the question of aspiration or other infectious/inflammatory processes in this patient status post right-sided pneumonectomy. rigid findings : the right side was absent surgically. the stoma seems to be very clean. the left main stem was patent. the left lower lobe showed evidence of some very thick, greenish mucous secretions. bronchoalveolar lavage was done at that side. at that moment, a rigid bronchoscope was retrieved to the subglottic area. under direct visualization, tumor excision with the use microdebrider was done to the granulation tissue. at that moment, a 6 portex, cuffless, nonfenestrated tracheostomy was placed under direct visualization. there were no complications. the patient tolerated the procedure well, and he was transferred to recovery. radiology chest (portable ap) impression: status post right pneumonectomy. suggestion of bronchiectasis at the left lung base. no pneumonia radiology abdomen (supine only) impression: no evidence of obstruction and no free air. prominent loop of large bowel in the right mid/upper abdomen, which appears to represent a prominent cecum. if clinical symptoms continue, repeat kub or ct may be helpful. pertinent labs: 06:16am blood wbc-11.0 rbc-4.05* hgb-12.3* hct-36.9* mcv-91 mch-30.2 mchc-33.2 rdw-13.1 plt ct-400 12:56am blood wbc-9.8# rbc-4.72# hgb-14.4# hct-43.6# mcv-92 mch-30.6 mchc-33.1 rdw-12.3 plt ct-181 12:56am blood neuts-90.0* lymphs-6.2* monos-3.7 eos-0.1 baso-0 01:03pm blood neuts-90.8* lymphs-5.4* monos-3.7 eos-0 baso-0.1 06:01am blood pt-13.4* ptt-89.6* inr(pt)-1.2 05:45am blood esr-65* 08:42am blood esr-60* 12:56am blood glucose-89 urean-24* creat-0.6 na-141 k-4.3 cl-101 hco3-35* angap-9 06:16am blood glucose-112* urean-21* creat-0.5 na-137 k-3.9 cl-98 hco3-34* angap-9 12:56am blood alt-32 ast-32 alkphos-48 amylase-72 totbili-0.6 05:45am blood alt-22 ast-16 ld(ldh)-255* alkphos-76 amylase-56 totbili-0.6 12:56am blood calcium-8.3* phos-3.9# mg-2.1 06:16am blood calcium-9.2 phos-3.1 mg-1.9 04:47am blood albumin-3.5 06:06am blood cryoglb-no cryoglo 05:48am blood hbsag-negative hbsab-negative 05:45am blood anca-negative b 06:19am blood psa-4.8* 08:42am blood crp-3.46* 05:48am blood -negative 05:48am blood rheufac-5 05:48am blood c3-164 c4-49* 11:57am blood hiv ab-pnd 10:14pm blood vanco-10.7* 10:00pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg 10:00pm urine rbc-0 wbc-0 bacteri-none yeast-none epi-0 06:15pm urine color-straw appear-hazy sp -1.050* 06:15pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg brief hospital course: ## tracheal stenosis: based on ct results patient has severe tracheal stenosis. patient underwent rigid bronch with excision of granulation tissue and change of cuff. no residual problems throughout rest of hospital course. . ## hemoptysis: pt initially transferred to micu. had rigid bronch to assess tracheomalacia. hd stable and weaned off vent. he was transferred to the floor . on the night of , he began to have episodes of hemoptysis, necessitating emergent and transfer back to the micu. bronch revealed that pt was bleeding from granulation tissue on upper stoma. anticoagulation was stopped and his bleeding resolved. pt was hd stable and was transferred back to the floor for further management. while on floor patient continued to have minimal bleeding from trach and bronch was performed again and trach cuff was changed. no further bleeding from trach site. . ## respiratory failure: initially on transfer patient felt to possbily have aspiration pna. in the icu he was kept on a ventilator overnight and was quickly extubated the following day put on trach mask. patient continued to have many secretions so given 7 day course of zosyn which was completed in the hospital. the osh reported that sputum aspirate showed mrsa and patient was started on iv vanco. patient underwent bal during fisrt bronch which came back possitive for mrsa which was consistant with results from osh. treated with iv vancomycin total 14 days. once on floor, secretions decreased, had no further episodes of respiratory distress. . ## abdominal pain - while in the icu, patient complained of abdominal pain. a kub was done which came back normal. when transferred to the floor patient still had abdominal pain so underwent a ct abdomen which was negative. patient was started on flagyl for presumed c diff which was stopped after 4 days when patient's diarrhea and abdominal pain resolved and first set on c. diff toxin came back negative. after a few days being pain free, diarrhea and abdominal pain returned along with increased wbc. patient was started on po vancomycin for c. diff colitis. another set of c. diff toxins were sent which again came back negative however felt that 14 day po vancomycin course should be completed. patients abdominal pain and diarrhea resolved. patient put on ppi . gi saw patient in icu for blood in peg, which was felt to be secondary to hemoptysis. while on the floor patient found to have blood mixed with tube feeds (bright red, no clots); hct stable but egd was done to rule out active bleeding. egd showed no active bleeding and mild gastritis opposite peg site. on cta of abdomen to further eval the multiple aneurysms discovered on cta chest, a retrogastric mass as well as a splenic infart was found, which was thought to possibly be the cause of the patient's pain. the pain resolved over 2d after transfer to the floor. . ## abdominal aneurysms - on a chest cta done to r/o pe, multiple abdominal aneurysms were seen along celiac trunk, and a 2x2cm retrogastric mass was noted. patient had cta abdomen which revealed what appears to be a vasculitis picture affecting the hepatic artery, splenic artery, gastroduodenal artery, with multiple aneurysms. rheumatology was consulted and sent hepb and hepc, rh factor, complement, . rh factor and c3, c4 wnl. patient esr slightly elevated and anca neagative. consulted gi who performed eus with intention of getting fna of soft tissue mass, but given proximity (4mm away) of celiac artery this was deferred. vascular was also consulted who felt aneurysms were likely infectious in etiology given the rapid time course of onset, as they were not seen on the abd ct . id felt that there was unlikely to be an infectious cause of the aneurysms. multiple mycotic and bacterial blood cultures were sent with no growth. patient also had a tte and then tee to r/o embolic cause of splenic and renal infarct, especially as there was no aneursym or thrombosis proximal to the l kidney which had an infarct. a 4mm clot vs. bacterial growth was found off the end of the pt's picc line, which was subsequently removed and cultured without growth. double lumen picc placed thereafter. . a second cta of abd/pelv showed thromboses of aneurysms, two new small intrahepatic aneurysms, new renal infarcts. steroids were started in case of pan or similar vasculitis, and repeat cta (#3) showed stabilization/improvement of the aneurysms. vasc rec no anticoag, cont abx x 6 week course, f/u cta and clinic appt in 6 mths. rheum recommended high dose prednisone, f/u cta in 2 wks and appt with dr. in 3 weeks, as well as bactrim, calcium, vit d, fosamax, hiv test which is pending. presumptive diagnosis is vasculitis, likely pan however consensus among multiple consultants was that empiric six weeks of antibiotics given the lack of biospy proven diagnosis and the rare chance of an infectious etiology which could prove fatal if treated with steroids alone. . ## retrogastric mass - was initially 17mm x 17mm per eus. fna was felt to be too risky given proximity to celiac axis. gen was consulted for possible lap bx. pt had repeat cta after abx/steroids that showed mass had shrunk. gen holding off on lap bx at this time, want to re-evaluate mass by ct in 2 weeks . ## sinus tachycardia - after patient returned to floor from icu for the second time he was found to be tachycardic. felt that tachycardia was due to aggressive albuterol nebulizer treatments. a cta of the chest was done to make sure tachycardia was not secondary to pulmonary embolism, which was ruled out. tachycardia went away after nebs decreased. . ## depression - maintained on zoloft, mood fluctuated but was overall appropriate . ## diarrhea - while on abx and steroids near the end of hospitalization for vasculitis, developed multiple loose stools with no pain but increased wbc count that seemed to far out from initiation of steroids to be from demargination; had no fever; c diff toxin a negative, toxin b sent but still pending; did not restart flagyl or po vanc; likely from abx themselves, with wbc elev from steroids. his diarrhea improved spontaneously. medications on admission: prevacid 30 mg per g tube sucralfate 1 mg per g tube 4x/day zoloft 50 mg daily albuterol 25 mg with atrovent m g nebs q4hours decadron 10 iv bid xopenex neb 0.63 mg tid colace zosyn 3.37 g iv q8h (day 1= ) humulin sliding scale reglan 10 mg iv q8h flagyl 500 mg iv q8h (day 1= ) vancomycin 1 gm iv q12h (day 1= ) versed 2-4 mg iv q1h discharge medications: 1. sertraline hcl 50 mg tablet sig: one (1) tablet po daily (daily). 2. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day) as needed. 4. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: puffs inhalation every six (6) hours. 5. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 6. flovent 44 mcg/actuation aerosol sig: two (2) inhalation twice a day. 7. ceftriaxone sodium in d5w 20 mg/ml piggyback sig: one (1) injection intravenous q24h (every 24 hours) for 27 days. 8. vancomycin hcl in dextrose 1 g/200 ml piggyback sig: one (1) injection intravenous q 12h (every 12 hours) for 27 days. 9. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 10. prednisone 20 mg tablet sig: three (3) tablet po daily (daily): continue at current dose until pt sees rheumatologist on . 11. insulin regular human 100 unit/ml solution sig: one (1) injection injection asdir (as directed): per sliding scale, while on steroids. 12. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) mg po daily (daily). 13. calcium carbonate 500 mg capsule sig: one (1) capsule po qday (). 14. vitamin d 400 unit tablet sig: one (1) tablet po daily (daily). 15. alendronate sodium 10 mg tablet sig: one (1) tablet po qsat (every saturday). 16. bactrim 400-80 mg tablet sig: one (1) tablet po once a day: cont while on steroids. discharge disposition: extended care facility: rehab discharge diagnosis: respiratory failure tracheal stenosis mrsa pneumonia abdominal aneurysms: hepatic, splenic, gastroduodenal arteries associated arterial thromboses splenic and renal infarcts retrogastric mass of unclear etiology picc line clot c diff colitis depression discharge condition: patient breathing well on trach mask, hemodynamically stable, no abdominal or chest pain, no shortness of breath discharge instructions: please continue to take all medications as directed and follow up with your doctors. inform your doctors if have bleeding from trach site, abdominal pain, chest pain, shortness of breath, increased secretions or any other concerning symptoms. followup instructions: please follow up with the following appointments: 1. please have the following lab values checked each week for the next 6 weeks while you are at the rehab facility: cbc, chem 10, vanc trough. you should have a physician view the results each week and adjust your medications accordingly. 2. you have a repeat ct scan of your abdomen scheduled as well. provider: scan where: radiology phone: date/time: 9:00 3. you have the following rheumatology appt scheduled: provider: , md where: lm phone: date/time: 11:00 4. vascular surgery follow up: please call dr. office in the next several days to set up a follow up appointment after your ct scan. her office # is . procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more other endoscopy of small intestine reconstruction of eyelid with hair follicle graft other local excision or destruction of lesion or tissue of skin and subcutaneous tissue diagnostic ultrasound of heart fiber-optic bronchoscopy percutaneous abdominal drainage other intubation of respiratory tract closed [endoscopic] biopsy of bronchus bronchoscopy through artificial stoma replacement of tracheostomy tube diagnoses: chronic airway obstruction, not elsewhere classified infection with microorganisms resistant to penicillins depressive disorder, not elsewhere classified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure other specified cardiac dysrhythmias pneumonitis due to inhalation of food or vomitus anoxic brain damage intestinal infection due to clostridium difficile other complications due to other vascular device, implant, and graft methicillin susceptible pneumonia due to staphylococcus aureus chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction embolism and thrombosis of other specified artery staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus accidents occurring in unspecified place vascular disorders of kidney other gastrostomy complications other tracheostomy complications infection of tracheostomy mechanical complication of tracheostomy other abnormal granulation tissue aneurysm of other visceral artery late effect of intracranial injury without mention of skull fracture aneurysm of splenic artery late effects of self-inflicted injury 

Answer: The patient is high likely exposed to