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: mediastinal failure major surgical or invasive procedure: endobronchial/endotracheal stenting history of present illness: 22 yom with a h/o germ cell tumor of mediastinum with airway obstruction s/p 2 rounds of chemotherapy complicated by pancytopenia, pseudomonal pneumonia, and pseudomonal abscess at the site of a central line who is transferred to from for airway stent placement. . patient initially presented to osh in respiratory distress and was found to have an anterior mediastinal mass on cxr, confirmed by ct. patient continued to desat from 80s to low 50s and was eventually intubated. patient was transfered to on per request of family according to family, patient was in his usual state of health until he started to have generalized symptoms 6 months prior to presentation to osh including sore throat, cough, and respiratory symptoms. patient had been treated for 2 weeks for bronchitis without resolution. . at , patient was intially intubated with double lumen ett for acute respiratory distress and started on aprv ventilation. patient had multiple episodes of desaturation requiring intervention with bronchoscopy for better et positioning. on bronchoscopy, anterior mass was noticed to cause trachea narrowing and obstruction of mainstem bronchi bilaterally. patient's double lumen ett changed to single lumen 6/15 per anesthesia request for better ventilation. patient also developed bilat. pneumothoraces requiring bilat chest tubes which were d/c'ed on and . patient was extubated on but then required reintubation on due to hypercarbic respiratory failure. . he underwent u/s guided bx of his anterior mediastinal mass on . given elevated afp (4093 on ) and biopsy of undifferentiated carcinoma, patient was treated for germ cell tumor with neoadjuvant cisplatin and etoposide from . patient prophylaxed for tls with alopurinol, dexamethasone, and iv fluids. chemotherapy complicated by pancytopenia and neutropenic fever, requiring prbc transfusions on neupogen. cycle 2 of chemotherapy delayed due to development of pseudomonas sepsis and arf. however, with stabilization, patient underwent cycle 2 of carboplatinum and etoposide . at the time of transfer, patient is reportedly at his chemo-induced neutropenic nadir. however, hct and platelets have been stable. . from an id perspective, following cycle 1 of chemotherapy, patient was diagnosed with a vap on and was started on vanco and cefepime. both were continued with the addition of fluconazole for neutropenic precautions following chemo. cefepime was changed to zosyn when patient's sputum culture was (+) for achromobacter on . patient then developed an abscess in his r groin at the site of a prior line which was i&ded by surgery on and was also the source of the above mentioned mdr pseudomonas sepsis. patient had pseudomonas in blood, urine, and r groin abscess cultures. he completed a 15 day course of gentamicin and cefepime, despite nephrotoxicity as pseudomonas in wound culture was only sensitive to gentamicin. patient was then started on vancomycin secondary to coag negative staph growing on quinton tip culture. this was continued after 14 days secondary to neutropenia. also started on amikacin for pseudomonas in sputum and urine. also on empiric flagyl for diarrhea and elevated wbc. diarrhea started on . c diff was negative x 3 and was thought to be secondary to chemotherapy. tube feeds were held with minimal improvement in diarrhea. a ct scan was obtained on showing ileocecal thickening and ? typhlitis (necrotizing enterocolitis) as well as some ? intusseception fo ascending colon, although there was no evidence of obstruction. patient then had temp spike through above broad antibiotic coverage and empiric caspofungin started on . . from a renal perspective, arf thought to be secondary to pseudomonas sepsis and hypotension on . patient developed poor uop and lasix gtt started with poor response. patient eventually required cvvh for volume overload on with 6l removal, and on with 4l removal. r quinton placed in r ij and patient was started on hd on . quinton eventually clotted on and he recent emergent dialysis through a newly placed left femoral line. he then went to ir for possible l quinton placement for hd, but was discovered to have bilat dvts in ijs which prevented placement. he eventually responded to 140 mg iv lasix with good uop on and the l femoral line was d/c'ed to prevent further infection. arf eventually resolved with normal cr and good uop. past medical history: # germ cell tumor in mediastinum - s/p 2 rounds of chemotherapy # pancytopenia chemotherapy social history: unobtainable. intubated and sedated. not in records from osh. family history: unobtainable as above physical exam: t: 99.3 bp: 160/97 hr: 112 rr: 24 o2 100% fio2 0.4, ac 500x18, peep 5 gen: intubated, sedated heent: no conjunctival pallor. no icterus. et/og in place neck: supple. thick neck but no palpable lad. cv: regular. tachycardic. nl s1, s2. no murmurs, rubs or lungs: ctab with good bs. bronchial bs in ru lung zones abd: nabs. soft, nt, nd. no hsm. r groin wound, packed, cdi. no discharge expressable. ext: wwp, no cce. 2+ dp pulses bl neuro: cn 2-12 grossly intact. opens eyes and moves arms to voice. . pertinent results: 08:18pm glucose-99 urea n-27* creat-0.6 sodium-134 potassium-4.1 chloride-105 total co2-23 anion gap-10 08:18pm calcium-10.4* phosphate-2.6* magnesium-1.7 08:18pm wbc-2.3* rbc-2.75* hgb-8.2* hct-23.9* mcv-87 mch-29.9 mchc-34.3 rdw-15.0 08:18pm neuts-33* bands-2 lymphs-46* monos-12* eos-2 basos-0 atyps-5* metas-0 myelos-0 08:18pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 08:18pm pt-14.2* ptt-34.2 inr(pt)-1.3* ct neck- wet read! - : preliminary report !! wet read !! tumor extends above the clavicles on the left (approximately 2.5 cm above the superior margin of the clavicle at the sternoclavicular junction. tumor is not identified in the neck directly anterior to the trachea. dr. ct chest - prior to stent placement: final report ct chest reason for examination: evaluation of patient with known anterior mediastinal germ-cell tumor. no prior exams were available for comparison. technique: unenhanced mdct of the chest from thoracic inlet to upper abdomen was obtained with subsequent 1.25 and 5 mm collimation axial images reviewed in conjunction with coronal reformat. findings: generally prevascular soft tissue mediastinal mass is heterogeneous, 9.5 by 10.0 x 5.0 cm in diameter. the mass extends towards the left lower neck with right tracheal displacement. the entire trachea is narrowed by the mass starting from the thoracic inlet with the tracheal area equivalent to the area of the et tube. just below the et tube tip the tracheal diameter is 6 x 12 mm with the area of 75 cm2. the carina is markedly narrowed as well as the main bronchi origins with almost complete collapse of the left main bronchus by the markedly posteriorly displaced aorta. the right bronchial tree is patent. the carinal diameter is 4.2 mm. large right lower paratracheal mass most likely a lymph node is at least 3.0 x 3.3 cm in size although precise determination over the boundaries is difficult due to absence of contrast enhancement. svc can be followed to the superior margin of this mass and then and no obvious svc continuation is demonstrated within the limitation of this unenhanced study. the ng tube tip terminates in the duodenum. the lungs demonstrate multiple subpleural and central parenchymal nodules and and subpleural consolidations, the largest one in lul, up to 1.6 cm in left lower lobe, 2.7 cm in left upper lobe, and 2.0 cm in right lower lobe mass representing metastatic spread of the disease. the heart size is mildly enlarged with small pericardial effusion. the imaged portion of the upper abdomen is unremarkable within the limitation of this unenhanced study. there are no bone lesions suspicious for malignancy. impression: 1. large anterior mediastinal mass consistent with known diagnosis of germ- cell tumor, which significantly deviates posteriorly the mediastinal structures with subsequent tracheal encasing and narrowing up to almost complete occlusion of left main bronchus. 2. at least one right lower paratracheal lymph node. 3. multiple lung metastases in both subpleural and central location. 4. small pericardial effusion. ct chest - s/p stenting: final report ct chest reason for exam: s/p placement of airway stent. comparison is made with prior study performed the same day in the morning. technique: multidetector ct through the chest was performed without iv contrast. 5, 1.25 mm collimations images and coronal reformations were provided and reviewed. findings: in the interval, there has been placement of a y-tracheobronchial and left bronchial stents. at the tip of the left bronchial portion is the stent 2 cm from the carinal bifurcatio, the left main stent reopens the previously almost collapsed left main bronchus, now measuring 7 mm ap. this stent extends to the bifurcation of the main bronchus, the upper and lower bronchi are widely patent. tip of an endotracheal tube is 15 mm above the carinal bifurcation of the tracheal stent. bibasilar posterior atelectasis is new. there are no short term interval changes in the large anterior mediastinal mass, lung metastasis, and small pericardial effusion. ng tube remains in place. there is no pneumothorax, pleural effusion, or pneumomediastinum. impression: successful placement of tracheobronchial y-stent and left main bronchhus stent. brief hospital course: a/p: 22 yom with a h/o germ cell tumor of mediastinum complicated by airway obstruction, pseudomonal pna and groin abscess transferred to for airway stent placement. . # airway obstruction: secondary to mediastinal tumor. currently ventilating without difficulty. - npo p mn. hold tfs - cbc and coags for pre-op work up - to or for stent placement . # respiratory failure: hypercarbic per prior reports. ventilating well currently. - check baseline cxr - cont ac support pending stent placement - sedation with fentanyl, midazolam - albuterol/atrovent mdis . # germ cell tumor: s/p 2 rounds of chemotherapy as above. - defer management to oncologists . # pseudomonal pneumonia: per cultures. currently afebrile on cefepime and amikacin. - cont cefepime, amikacin - check baseline cxr as above . # febrile neutropenia: not neutropenic currently and afebrile. however, significant complicated id history at osh. will continue prior antimicrobial regimen for now. - vanco for staph on quinton tip - cefepime, amikacin for pseudomonas - caspofungin for empiric fungal coverage - pan-culture if spikes - id consult if patient remains in house after tomorrow . # pseudomonal abscess: wound seems to be improving. - cont wound care per recs - cont cefepime, amikacin . # pancytopenia: hct and platelets reportedly stable from osh recs. - trend cbc . # diarrhea: on empiric flagyl despite negative c diff cultures. presumed secondary to chemotherapy but npo for now and on tpn. not responsive to lomotil at . - cont flagyl - cont npo - consider checking c diff toxin b . # ? necrotizing enterocolitis: reported concern per osh records. at risk given recent neutropenia. c diff negative x 3 at osh. patient afebrile currently. abdomen soft. no tenderness on exam. no need for urgent lapartomy. - cont iv antibiotics - serial abdominal exams . # anxiety: significant anxiety per records throughout admission. - cont diazepam, olanzapine standing - cont haldol, ativan prn . # hypertension/tachycardia: secondary to agitation according to osh recs. - check ekg - cont metoprolol. can increase prn as bp will tolerate - treat pain with methadone, fentanyl gtt . # fen: npo p mn. cont custum tpn from per their nutrition recs. replete lytes prn - nephrocaps . # ppx: ppi. heparin sc. no bowel regimen in setting of diarrhea. . # access: picc . # code: full . # comm: osh records, attending . # disp: return to following stent placement, per family and primary physician . will not have trach by thoracics here at at this time. the interventional pulmonologists (dr. ) and icu team here at recommend trach and peg placement for this patient as it is felt that the patient would be difficult to extubate in the setting of his tumor burden and prolonged course of intubation. however, we will defer to the family and primary team's wishes at this time. . . medications on admission: meds (on transfer): ipratropium bromide mdi 4 puff ih qid acetaminophen 650 mg po q6h:prn lansoprazole oral disintegrating tab 30 mg po daily albuterol 10 puff ih q4h lorazepam 1-3 mg iv q1h:prn anxiety albuterol 10 puff ih q2h:prn metoprolol 12.5 mg po tid amikacin 1100 mg iv q36h methadone hcl 20 mg po q 8h caspofungin 50 mg iv q24h metronidazole (flagyl) 500 mg iv q8h cefepime 2 gm iv q8h miconazole powder 2% 1 appl tp tid diazepam 10 mg po bid nephrocaps 1 cap po daily fentanyl citrate 25-100 mcg/hr iv drip infusion nystatin oral suspension 5 ml po qid haloperidol 5 mg im q4h:prn agitation olanzapine 5 mg po daily promethazine hcl 6.25 mg iv q6h:prn insulin sc sliding scale vancomycin 1000 mg iv q 12h discharge medications: same as above, as per primary team discharge disposition: extended care discharge diagnosis: mediastinal mass discharge condition: stable discharge instructions: you are being discharged back to for care by your primary teams. please follow their recommendations as directed. please return to or the emergency department for any difficulty breathing or any other healthcare concerns. followup instructions: please return to to the care of your primary intensive care, oncology and infectious disease teams. please call your physicians at (dr. in interventional pulmonology) to arrange follow-up regarding your stent placement in weeks. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours parenteral infusion of concentrated nutritional substances other intubation of respiratory tract bronchial dilation diagnoses: diarrhea malignant neoplasm of anterior mediastinum chronic respiratory failure other diseases of trachea and bronchus carrier or suspected carrier of other specified bacterial diseases 

Answer: The patient is high likely exposed to