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: no known allergies / adverse drug reactions attending: chief complaint: seizures major surgical or invasive procedure: 1. transcranial magnetic brain stimulation 2. pentobarbital induced coma ( - ) history of present illness: 46 yo m with longstanding history of intractable epilepsy, followed by dr. transferred from hospital for increasing seizure frequency. as per patient's mother the patient has been having increasing seizure freuqency over the past 2-3 months. at baseline, he gets seizures a day as baseline. however over last few months, he has been getting progressively more episodes of seizues. he is getting seizures every day afor last 1 month and nearly 40-50 day in last 3-4 days. events are typically brief (less than 30 secs) and include drop attacks, brief shaking, stiffening, and occasional generalized seizures. there is no h/o fevers, neck pains , falls or travels. he was tried on benzal as opt in by dr. which wasnt very helpful in sz control and was stopped in few weeks. due to these concerns he was taken to osh. he was given 3 mg of ativan there in addition to 2 mg at the ed. cbc and chem 7 were normal. phenobarb level was 28. he was sent to for eval. next, neurology was called. prior medications include tegretol, depakote, gabitril, keppra, zonisamide, topiramate, felbamate, gabapentin, and vimpat. past medical history: -intractable epilepsy as described above social history: -lives with mother and sister family history: non-contributory physical exam: admission physical exam: physical examination; vs; 98.6 88 130/80 20 97% gen; lying in bed, nad heent; nc/at, mucous membranes moist, oropharynx clear cv; rrr, no murmurs pulm; cta anteriorly abd; soft, nt, nd extr; no edema neuro; ms; drowsy and needs to be waken up, answers his name, dob, that he is in hopsital, oriented to person, place. inattentive. speech is slow and dysarthric. able to name thumb. follows basic commands. cn; perrl 3mm-->2mm, eomi, b/l endgaze nystagmus. face sensation intact v1-v3. mild l nlf flattening. palate symmetric, tongue midline. motor; normal bulk and tone, left pronator drift. strength is somewhat limited by effort but appears at r delt, bicep, tricep, wre, fe, ff. 5-/5 at l tricep and finger extensors, otherwise at delt, bicep, wre, ff. at r and l ip, ham, quad, and gastrocs. sensory; intact to light touch throughout. coordination; mild dysmetria in lue and slower with rams on left. gait; deferred discharge physical exam: vs: t 96.6 (ax), bp 115/71, hr 90, rr 14, 100% on 35% fio2 mask gen: middle aged male lying in bed trached and peg'd. cv: rrr pulm: crackles at r lung base, prior chest tube site on r c/d/i abd: soft, nt, nd ext: no peripheral edema . neurological exam: mental status: able to follow simple commands like "stick out your tongue" and "point to the window". he is non-verbal, but is able to nod his head or shake his head no to certain questions. is more interactive today. . cranial nerves: i: olfaction not tested ii: perrl 3->2mm and brisk iii, iv, vi: eomi v: facial sensation intact vii: face symmetrical viii: hearing intact bilat. ix, x: unable to test : shrug bilat. xii: tongue protrudes in midline . motor: normal bulk, able to move rue and lue spontaneously delt tri grip r 5 5 4+ 5 l. 4- 4- 4 4 sensory: patient sensation to light touch intact throughout . coordination and gait: patient bedbound, unable to test pertinent results: admission labs: 03:15pm blood wbc-6.2 rbc-5.24 hgb-16.9 hct-48.1 mcv-92 mch-32.3* mchc-35.2* rdw-14.0 plt ct-249 03:15pm blood neuts-64.2 lymphs-27.5 monos-5.5 eos-1.8 baso-1.0 03:15pm blood glucose-91 urean-9 creat-0.9 na-137 k-4.1 cl-102 hco3-28 angap-11 03:15pm blood alt-20 ast-17 ld(ldh)-153 alkphos-116 totbili-0.4 03:15pm blood lipase-53 03:15pm blood calcium-9.2 phos-3.2 mg-2.2 03:15pm blood phenoba-31.1 phenyto-13.5 05:50pm blood type-art po2-164* pco2-42 ph-7.40 caltco2-27 base xs-1 intubat-not intuba 04:49am blood type-art rates-16/ tidal v-500 peep-5 fio2-50 po2-230* pco2-39 ph-7.42 caltco2-26 base xs-1 intubat-intubated 05:22pm blood lactate-0.7 discharge labs: 05:03am blood wbc-5.8 rbc-3.06* hgb-10.1* hct-29.1* mcv-95 mch-32.9* mchc-34.7 rdw-13.9 plt ct-405 05:03am blood glucose-113* urean-13 creat-0.5 na-138 k-4.2 cl-101 hco3-31 angap-10 05:03am blood calcium-8.7 phos-3.5 mg-2.2 05:03am blood phenoba-44.7* phenyto-12.1 imaging: ct spine impression: 1. prominent multilevel anterior osteophytes without critical spinal canal or neural foraminal narrowing. 2. remote healed right c1 anterior arch and lamina fractures. 3. thyroid nodules, to be further evaluated by ultrasound in non-emergent setting if not already performed. ct head : impression: 1. no intracranial hemorrhage. 2. asymmetric sulcation of right parieto-occipital region as compared to the left, raising question of cerebral edema in this region versus increased atrophy in the rest of the brain. comparison with prior exams when available would be helpful to assess for chronicity of this appearance. if persistent concern for acute process, mri could be considered. 3. status post right craniotomy and right parietotemporal resection. cxr : impression: subtle opacities in the lower lungs could represent early pneumonia, though given low lung volumes, may reflect atelectasis versus bronchovascular crowding. correlate clinically. cxr : findings: in comparison with the earlier study of this date, there has been placement of an endotracheal tube that projects at the supraclavicular level, approximately 7 cm above the carina. nasogastric tube extends to the stomach where it crosses the lower margin of the image. there is minimal asymmetry at the bases with more opacification on the left and possible silhouetting of the outer aspect of the hemidiaphragm, again raising the possibility of consolidation in this region. unfortunately, the external stimulator device somewhat obscures this region. eeg : impression: this is an abnormal continuous eeg due to the presence of 44 electrographic seizures, characterized by rhythmic hz activity starting over the right frontotemporal region, 176262with subsequent spread to the left hemisphere and evolution into diffuse rhythmic sharp theta activity, lasting between 30 seconds to 3 minutes. these seizures occurred between 4-5 times per hour during the initial part of the recording. at approximately 9 pm, the frequency of the electrographic seizures decreased to approximately 1 event per hour. in addition, for most of the recording, a mixed diffuse hz alpha-beta frequency activity and hz theta frequency activity, with frequent bursts of generalized suppression, is observed, consistent with pharmacologic sedation. there are frequent spike interictal discharges seen over the right frontotemporal region, phase reversing at f8-t4, are indicative of a focal region with high epileptogenic potential. finally, the activity over the entire right hemisphere appears more attenuated with more delta slowing compared to the left, suggestive of a large underlying structural defect involving the cortex. eeg : impression: this is an abnormal continuous eeg due to the presence of 33 electrographic seizures, characterized by rhythmic hz activity starting over the right frontotemporal region, with spread to the left hemisphere and evolution in diffuse rhythmic sharp theta, lasting between 30 seconds to 2 minutes. these seizures occurred approximately 4 times per hour during the initial part of the recording, but decreased to 1-2 per hour after 1 pm. in addition, for most of the recording, a mixed diffuse hz alpha-beta frequency activity and hz theta frequency activity, with frequent bursts of generalized suppression, is observed, consistent with pharmacologic sedation. there are frequent interictal spike discharges occuring in brief runs seen over the right frontotemporal region, phase reversing at f8-t4, indicative of a focal region with high epileptogenic potential. finally, the activity over the entire right hemisphere appears more attenuated with more delta slowing compared to the left, suggestive of a large underlying structural defect involving the cortex. head ct : impression: persistent asymmetry of the parietal and occipital sulci, suggesting mild edema on the right. recommend mri for further evaluation. mri : impression: 1. right parietal and occipital cortical thickening with mild restricted diffussion, most likely ictal changes. 2. status post remote right pterional craniotomy with resection of much of the right temporal lobe. 3. calvarial thickening and posterior fossa volume loss likely sequela of chronic anticonvulsant therapy. echo : impression: mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. mildly dilated aortic root. kub : impression: findings concerning for small bowel obstruction. consider ct for further evaluation. ct chest : impression: 1. interval mild increase of bilateral pleural effusions and bibasilar opacities, likely representing atelectasis. 2. enlarged main pulmonary artery, likely representing chronic pulmonary hypertension. 3. interval decrease of ascending colon and small bowel dilatation. 4. moderate anasarca and free fluid in the upper abdomen remains. eeg : impression: this is an abnormal 24-hour video eeg telemetry due to the presence of prolonged periods of generalized periodic epileptiform discharges (gpeds) with a right temporal predominance at 1 hz, indicative of generalized cortical irritability. furthermore, there were prolonged and repetitive focal epileptiform discharges in the right temporal region isoelectric at f8/t4 and, at times, these were better rhythmic at 2-3 hz. however, the right temporal discharges were less organized and less continuous compared to the previous day. both the right temporal discharges and gpeds were accentuated by bedside care, consistent with sirpids. there wereno clear electrographic seizures seen. the background was otherwise slow at 4-5 hz with periods of burst-suppression pattern, due to pharmacologic therapy. overall, the record showed a slight improvement compared to the previous day's recording. cxr : impression: ap chest compared to : positioning, now supine, may account in part for increased opacification in both hemithoraces due to posteriorly layering pleural effusions, as well as greater distention of mediastinal vessels, nevertheless it looks like these findings are more pronounced suggesting volume overload. mild edema may be present. tip of the tracheostomy tube abuts the right tracheal wall, nasogastric tube still passes as far as at least the upper stomach and out of view. right jugular line ends in the svc. no pneumothorax. mr head : impression: interval resolution of diffusion signal changes in the right parietal and occipital region with minor cortical thickening. status post right pterional craniotomy with a large resection of the right temporal lobe and volume loss of the cerebellar hemisphere is stable. no abnormal enhancement is demonstrated. kub : impression: 1. large amount of stool diffusely throughout the colon and most predominantly within the ascending colon. 2. resolving right lower lobe pleural effusion. eeg : impression: this is an abnormal 24-hour continuous video eeg telemetry due to the presence of interictal spike discharges seen broadly over the r>l fronto-temporal region as well as slowing seen more focally over this region. these patterns are suggestive of an underlying focus with epileptogenic potential. in addition, the frequent periods of hz frontal delta activity is suggestive of a moderate diffuse encephalopathy commonly seen with medication effect, metabolic disturbance, or infection. there may be a slight increase in the focal frontal temporal slowing today compared to the prior day's telemetry cxr : impression: frontal and lateral chest radiographs compared to and at 2:38 p.m.: moderate to large right pleural effusion is appreciably smaller than it was four hours ago and there is no pneumothorax. i do not see an indwelling right pleural drain. except for the pleural effusion projecting over the right lower chest lungs are clear. heart size is top normal. tracheostomy tube in standard placement. ct chest : impression: 1. small right pleural effusion, decreased since recent thoracentesis. ground glass and consolidative opacities in the right lung (most marked in the rll) may be due to pneumonia, but given the recent large volume right thoracentesis, reexpansion pulmonary edema is an additional diagnostic consideration. 2. small left pleural effusion and adjacent atelectasis. 3. secretions in the central airways. no obstructing lesion. 4. chest tube in place with small pneumothorax. 5. 3mm right apical nodule is unchanged from . if the patient has no risk factors for lung malignancy, no follow up is needed. if the patient has risk factors for lung malignancy, recommend follow upwith dedicated chest ct in . 6. 10mm left thyroid nodule can be evaluated by nonemergent ultrasound if clinically indicated. cxr : reason for exam: assess right chest tube. comparison is made with prior study ct . cardiomediastinal contours are normal. right chest tube is not visualized. there is a small right pneumothorax. bibasilar opacities, right greater than left, are unchanged ; on the left likely atelectasis, on the right could also be due to pneumonia or re-expansion pulmonary edema. et tube is in a standard position. gastric tube is in place. brief hospital course: is a 46m h/o intractable epilepsy since childhood, s/p 2 epilepsy surgeries, admitted for status epilepticus. # neuro: status epilepticus 46 year old man with intractable epilepsy since childhood, recent increase in seizure frequency, admitted with status epilepticus with seizures every 10-20 minutes over the past days. on initial examination, his speech was slow and dysarthric with mild left hand weakness and clumsiness, which appears to be at baseline. he had no improvement in seizure frequency after intravenous lorazepam, but developed some respiratory depression and sedation. he was therefore admitted to the icu, where loading doses of phenytoin and phenobarbital did not stop his seizures. he was then intubated and started on intravenous propofol, but continued to have electrographic seizures every 10-20 minutes. a switch to midazolam resulted in bradycardia without improvement in seizure control, so he was switched back to propofol. however he continued to have very frequent seizures despite maximum doses of propofol, and he was therefore switched to pentobarbital drip. on head ct there were findings of possible edema in the right posterior quadrant. on brain mri with and without contrast, there were some changes in the right posterior quadrant, possibly related to seizures, but also raising the possibility of an underlying cortical dysgenesis. lumbar puncture did not show any evidence of inflammatory disorder or infection. it has therefore remained unclear what precipitated the increase in seizure frequency. he was continued on pentobarbital drip, and was put into burst suppression. a ketogenic diet was attempted, but this was limited by his developing ileus and had to eventually be completely stopped. we continued to add on antiepileptic medications including keppra and vimpat. he then underwent transcranial magnetic stimulation (tms). after this, his eeg started to improve, and his pentobarbital drip was slowly tapered off, then stopped on . his eeg remained stable with only a few very short seizures each day. we therefore attempted to gradually decrease his phenobarbital levels to allow him to wake up. he had repeat brain mri with and without contrast on , which showed interval resolution of diffusion signal changes in the right parietal and occipital region with minor cortical thickening, and no abnormal enhancement. his phb level peaked in the low 90s, and the dose was gradually decreased. as he awakened from the ptb and phb, his pht level remained relatively stable on stable dosing. once his phb fell to the 40s-50s, he began opening and closing his eyes and gripping with both hands on command, which then improved to ability to complete midline, appendicular commands and cross-body commands. he still has lue and lle weakness, which he thinks is worse since he woke up from his phenobarb coma. this is likely related to his prior epilepsy surgery and will hopefully improve over time back to baseline. his primary neurologist, dr. is aware of this problem, and will follow. # id: the patient developed fevers of unknown origin. initially, bal grew mssa and enterobacter and he completed a course of vancomycin and cefepime. however, he continued to spike fevers after treatment. id was consulted and an extensive workup was completed with no evidence of infectious etiology. there was a concern this was drug fever, but none of the aeds that may be responsible could be stopped at this time. his fevers and wbc began to trend down, then spiked again when he was found to have 2 positive blood cultures and his central line catheter culture all grew coag negative staph. he was treated with vancomycin for a 14-day course ending (for suspected pathogenic coagulase-negative staph epi). on pt's cxr showed a r-sided pleural effusion, for which he had a thoracentesis on with 1l of fluid drained. he was started empirically on vanc for suspicion of pna, but chest ct showed only atelectasis. he then had a chest tube placed on , which he pulled out on . he then had no further reaccumulation of his fluid seen after that date. interventional pulmonary felt that he did not need a repeat chest tube, but if the pleural effusion reaccumulates and effects pt's respiratory status he may need a repeat chest tube placed in the future. his vanc was stopped on discharge () per id recs. # gi: patient developed severe ileus, thought to be due to pentobarbital. surgery was consulted and did not recommend acute intervention. he was monitored closely, given aggresive bowel meds, and made strictly npo with ngt to suction. this finally resolved the ileus and he was able to undergo peg placement and tolerate tube feeds, though he continued to have some intermittent high residuals. later, on the floor at the end of , increased bowel regimen was used along with restarting reglan (10 ) to good effect, with reduced gastric residuals and increased stooling with a benign exam. his residuals improved while on the floor and he no longer need the reglan, but if this problem occurs again at rehab, reglan will be helpful for this issue. he began having loose stools on , so his bowel regimen was made entirely prn. # resp: in the icu patient developed bilateral pleural effusions which were not loculated on chest ct. they were likely transudative in the setting of hypoalbuminemia and third spacing, as he did also develop anasarca. this improved with autodiuresis. tracheostomy was placed. he developed a pleural effusion as above between and this was drained via thoracentesis on and a chest tube places on . # renal: acute kidney injury, atn vs. prerenal, resolved. # pending labs: acid fast cx of pleural fluid from (but suspicion is low for tuberculosis) # transitional care issues: pt had a lung nodule found on chest ct (see results section) that will require a repeat ct chest in for further evaluation. pt had 10mm l thyroid nodule that should be evaluated by a nonemergent u/s as an outpatient or at rehab. patient will need his phenytoin levels maintained between and phenobarb between 40-50. his phenobarb can be transitioned to po on , but his levels will need to be monitored more closely at this point to ensure stability. if patient decomenstates from a respiratory standpoint, he may need a repeat chest tube to drain previously noted r sided pleural effusion. medications on admission: -phenobarbital 50/50/50 -phenytoin 100/100/30 -lyrica 150 mg tid -lamotrigine 200 mg tid discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezing. 3. white petrolatum-mineral oil 56.8-42.5 % ointment sig: one (1) appl ophthalmic prn (as needed) as needed for dry eyes. 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for wheeze. 5. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 6. pregabalin 75 mg capsule sig: two (2) capsule po tid (3 times a day). 7. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane (2 times a day) as needed for trach in place. 8. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 10. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day) as needed for constipation. 11. lamotrigine 100 mg tablet sig: two (2) tablet po tid (3 times a day). 12. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 13. polyethylene glycol 3350 17 gram/dose powder sig: one (1) dose po daily (daily) as needed for constipation, recent ileus. 14. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 15. lacosamide 200 mg tablet sig: one (1) tablet po bid (2 times a day). 16. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day) as needed for constipation. 17. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day). 18. levetiracetam 500 mg tablet sig: four (4) tablet po bid (2 times a day). 19. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for fungal rash. 20. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 21. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 22. phenytoin 125 mg/5 ml suspension sig: one y (150) mg po qnoon (): please give q8h as follows: 200mg, 150mg, 100mg. 23. phenytoin 125 mg/5 ml suspension sig: two hundred (200) mg po bid (2 times a day): please do q8h dosing as follows: 200mg, 150mg, 200mg. 24. phenobarbital 50 mg iv q8h start: next dose discharge disposition: extended care facility: - discharge diagnosis: refractory epilepsy discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. neuro exam: notable for being non-verbal, lue weakness worse on distal lue. difficult to assess le's, but able to move both legs bilaterally spontaneously. discharge instructions: you were admitted to for increased seizure frequency, with seizures that were refractory to multiple anti-seizure drugs and you therefore admitted to the icu to be placed in a phenobarbital coma. this helped with your seizures and your phenobarbital level was subsequently decreased. you are able to be discharged to rehab in your current condition. we made the following changes to your medications: 1) we increased your phenytoin dose to every 8 hours as follows: 200mg/150mg/200mg 2) we started you on heparin 5,000mg subcutaneously three times a day for dvt prophylaxis 3) we started you on albuterol nebulizer treatments every 6 hours as needed for wheezing or shortness of breath. 4) we started you on artificial tears in both eyes as needed for dry eyes. 5) we started you on albuterol inhaler 1-2 puffs q4h as needed for wheeze. 6) we started you on simvastatin 40mg once a day. 7) we started you on chlorhexidine gluc 0.12% oral rinse 15ml twice a day while trach is in place. 8) we started you on senna 1 tab twice a day as needed for constipation. 9) we started you on bisacodyl 10mg per day as needed for constipation. 10) we started you on lacosamide 200mg twice a day. 11) we started you on doscusate 100mg twice a day as needed for constipation 12) we started you on famotidine 20mg every 12 hours 13) we started you on miralax 17gm per day as needed for constipation. 14) we started you on lactulose 30ml twice a day as needed for constipation. 15) we started you on tums 500mg four times a day. 16) we started you on keppra 2grams twice a day. 17) we started you on miconazole powder as needed for groin rash/itch. 18) we started you on oxycodone 5mg every 6 hours as neede for pain 19) we started you on tylenol 325-650mg every 6 hours as needed for fever or pain. please continue to take your other medications as previously prescribed. if you experience any of the below listed danger signs, please call your doctor or go to the nearest emergency room. it was a pleasure taking care of you on this hospital admission. followup instructions: department: neurology when: tuesday at 10:00 am with: , m.d. building: campus: east best parking: garage procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung spinal tap incision of lung enteral infusion of concentrated nutritional substances thoracentesis other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus other diagnostic procedures on lung or bronchus diagnoses: acute kidney failure with lesion of tubular necrosis unspecified pleural effusion pulmonary collapse acute respiratory failure grand mal status paralytic ileus hyperosmolality and/or hypernatremia other and unspecified infection due to central venous catheter ventilator associated pneumonia 

Answer: The patient is high likely exposed to