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 / sulfonamides attending: chief complaint: seizure major surgical or invasive procedure: none history of present illness: the patient is a 63 yo r-handed woman with a sah in , s/p clipping of acomm aneurysm, vp-shunt placed 2 weeks later, history of siadh, hypothyroidism, hemifacial spasm for many years, htn and hypercholesterolemia who presents to the ed after seizure at home. she was in her usoh and sleeping, when her husband noted around 2.30am that she was smacking with her mouth. he asked her whether she was ok, and she was able to respond. then shortly thereafter she became acutely unresponsive with stiffening up of her body; there was no shaking observed. she did become incontinent and she may have bitten her tongue. the episode lasted minutes. in the ambulance she was able to open her eyes, and in the ed she was able to say a few words. she remained rather somnolent. she did not receive ativan. her husband tells us that he has noticed that she has r-facial twitching and l-hand twitching since a few months. according to a family friend, this activity has actually been present for at least 7-8 years. she was evaluated years ago by dr. , who found this activity to be consistent with hemifacial spasm. she has been drooling from the right side of the mouth. she has also noted to have a decreased in energy level and stamina over the past six months. she does not seem to engage in activities that she once enjoyed (exercise/physical activity). in , the patient had a subarachnoid bleed related to an acomm aneurysm rupture; several weeks later, a shunt was placed for management of hydrocephalus. she had several strokes apparent on imaging at the time that were likely related to vasospasm. since the strokes, she has had significant cognitive and memory problems. left side (both arm and leg) are not as strong as the right side, but she is able to walk unassisted. she can cook and can ambulate by herself according to her husband, but cannot manage certain other activities that require more extensive processing (ie, paying bills, shopping). she has also been noted to be progressively abulic since then. she has been seen in clinic by dr. and . their last visit was more than a year ago. she has never had seizures in the past. she was recently seen at mnt , for "change in mental status" that her husband says was possibly similar to this episode. she had imaging that was unchanged from prior imaging, and an lp significant for rbcs (thought traumatic), but an otherwise benign workup, though right facial twitching was noted. she has had both high and low sodiums in the past few years, mostly low sodium levels recently, including a sodium in the low 120's several days before this admission, on bloodwork ordered by her pcp. ros: per husband: denies any fever, chills, weight loss, visual changes, hearing changes, headache, neckpain, nausea, vomiting, dysphagia, weakness, tingling, numbness, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. has been flushy a few days back. past medical history: sah, aneurysm s/p clips, strokes and shunt per hpi hyponatremia, thought to be related to siadh history of hypernatremia hemifacial spasm per hpi hypothermia (chronic) high cholesterol hypothyroidism htn osa information obtained later in the hospitalization from pcp details recent elevated esr to 80s. she has had an elevated esr in the past few years (60 in , and 80 in ). memory loss, cognitive decline social history: she is married and has 3 children. she lives with her husband. she formerly provided child care; she does not work at present. she does not smoke or drink alcohol. family history: her brother died of kidney disease. physical exam: exam vitals: t33.7 hr83 bp135/102 rr14 so2 98% gen: in bed, lethargic, but able to respond heent: mmm, no iceterus neck: no lad; no carotid bruits; neck supple lungs: clear to auscultation bilaterally heart: regular rate and rhythm, normal s1 and s2, no murmurs, gallops and rubs. abdomen: normal bowel sounds, soft, nontender, nondistended extremities: no clubbing, cyanosis, ecchymosis, or edema mental status: opens eyes to voice, inattentive. initially only oriented to name; later oriented to place, month, not year. recognizes husband. attention: not able to do dowbw or fw. memory: registration: 0/3 items; recall 0/3 at 5 min. language: able to repeat "cats dogs". naming intact for body parts. comprehension intact (can point to ceiling); slight dysarthria, some paraphasic errors. writing and not able to test. apraxia: able to wave goodbye, not able to do more difficult tasks. cranial nerves: ii: blinks to threat; pupils equally round 1.5-->1mm. not able to visualize discs iii, iv, vi: horizontal eye movements intact, couldn't get her to look up and down (poor cooperation). v: facial sensation intact to tickle vii: facial movement symmetrical; no facial droop, but drooling from r-mouth viii: responds to voice xii: tongue protrudes in midline motor system: normal bulk. tone in her legs slightly increased, r>l. would twitch around her r-eye and mouth (few secs at the time), mainly when woken up. moves all 4 extremities. good strength in rue, less so in lue (may be baseline). no asymmetry in her le, but rle is exorotated. no formal exam possible. sensory system: responds to tickle and noxious throughout with withdrawal. reflexes: b t br pa pl right 2 2 2 2 1 left 2 2 2 2 1 all rather brisk. grasp reflex present bilaterally toes: downgoing bilaterally. coordination: could not be assessed. gait: could not be assessed. pertinent results: 06:15am cerebrospinal fluid (csf) wbc-0 rbc-5100* polys-90 lymphs-7 monos-3 06:15am cerebrospinal fluid (csf) wbc-0 rbc-3075* polys-100 lymphs-0 monos-0 03:20am tsh-2.8 03:20am free t4-1.8* 03:20am wbc-9.8 rbc-3.71* hgb-11.0* hct-33.9* mcv-91 mch-29.8 mchc-32.6 rdw-16.5* 03:20am neuts-60.1 lymphs-34.0 monos-4.6 eos-1.0 basos-0.2 03:20am anisocyt-1+ macrocyt-1+ 03:20am pt-11.1 ptt-26.4 inr(pt)-0.9 03:20am plt count-417 03:20am urine color-straw appear-clear sp -1.009 03:20am urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 03:20am urine rbc-0 wbc-0-2 bacteria-none yeast-none epi-0-2 03:45am glucose-85 lactate-7.8* na+-128* k+-3.9 cl--92* tco2-23 04:28am lactate-3.1* 03:30pm lactate-1.2 na+-129* 03:30pm type-art po2-135* pco2-33* ph-7.35 total co2-19* base xs--6 03:45am ph-7.29* comments-green top 03:20am glucose-82 urea n-11 creat-0.9 sodium-127* potassium-4.2 chloride-90* total co2-18* anion gap-23* 03:20am ck(cpk)-241* f/u on : 448* with negative index 03:20am ck-mb-9 ctropnt-<0.01 ekg: sinus rhythm normal ecg since previous tracing of , sinus bradycardia absent hdl: 101 chol/hd: 2.2 ldlmeas: 124 hba1c: 5.8 recent vit-b12:1567 folate:>20 (). am cortisol: 22.1; random cortisol: 10 other urine chemistry: na:124 osmolal:573 osms:304 other blood chemistry: fsh: 53 lh: 23 prolact: 35 initial ct: non-contrast head ct. findings: the patient is status post bilateral craniotomies. a catheter is seen with its tip located within the third ventricle exiting the skull and continuing inferiorly along the left skull and out of view. numerous surgical clips are seen within the middle cranial fossa causing moderate streak artifact, which limits assessment of this area. allowing for this factor, there is no acute intracranial hemorrhage, shift of normally midline structures or mass effect. a focal area of low density within the right frontal lobe with dilatation of the adjacent ventricle likely reflects encephalomalacia from prior surgery. a similar area of hypodensity is also seen within the left frontoparietal lobe. given the lack of mass effect and preserved cortices, it most likely reflects an old infarct. the sulci and basal cisterns are grossly unremarkable. bilateral periventricular white matter hypodensity is consistent with chronic microvascular ischemia. bone windows demonstrate bilateral craniotomy defects. the visualized paranasal sinuses and mastoid air cells are well aerated. impression: limited evaluation of the middle cranial fossa secondary to artifact from surgical clips. no definite acute intracranial hemorrhage or mass effect. the patient is status post bilateral craniotomy with a left ventriculoperitoneal shunt in place. no evidence of hydrocephalus. these findings were relayed to the ed dashboard at 4:30 a.m. on the date of dictation. repeated head ct: findings: motion artifact limits assessment. again seen is a left-sided ventricular catheter with its tip terminating in the region of the third ventricle. artifacts from multiple aneurysm clips cause significant streak artifact. again seen are encephalomalacic changes in the left frontoparietal and right frontal regions, unchanged. no gross intracranial hemorrhage is identified, although as mentioned, motion and metallic streak artifact prevent full evaluation. the ventricular size is stable. right craniotomy defects are again seen. the incompletely visualized paranasal sinuses demonstrate extensive mucosal thickening within the ethmoid air cells. impression: limited study does not demonstrate any gross intracranial hemorrhage or mass effect. initial cxr to eval shunt patency: pa and lateral upright chest radiograph was compared to the previous film from . the patient is status post vp shunt placement. the heart size is slightly enlarged, unchanged. mediastinum is wider than it was on the previous ct most probably due to the ap and pa projections. the lungs are clear. no pleural effusion or pneumothorax is seen. impression: 1. no evidence of acute cardiopulmonary process. 2. status post vp shunt placement. initial eeg: findings: abnormality #1: throughout the recording the background rhythm was slow and disorganized, typically reaching a hz frequency in any given area. there were frequent bursts of sharp activity in the right frontal area and right hemisphere, appearing to indicate movement or muscle artifact. this correlated with right facial twitching on the video. abnormality #2: there was some additional right frontal intermittent hz slowing. hypervententilation: could not be performed. intermittent photic stimulation: produced no activation of the record. sleep: no normal waking or sleeping morphologies were seen. cardiac monitor: showed a generally regular rhythm. impression: abnormal eeg due to the slow and disorganized background and due to the intermittent right frontal slowing. the first abnormality signifies a widespread encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. the right frontal slowing is concern for a focal subcortical abnormality in the right hemisphere though its nature cannot be specified by the recording. there were no clearly epileptiformfeatures seen in association with the facial jerking or at other times. cta head/neck to eval for vasc anomaly/aneurysm: findings: study is of limited diagnostic utility secondary to technical difficulties and pooling of contrast material within the left venous system including the left subclavian vein and spinal epidural plexus. this finding raises concern for possible occlusion within the distal left subclavian vein/brachiocephalic trunk. there is resultant very faint opacification of the carotid arteries and vertebrobasilar circulation. the circle of is poorly visualized. images of the brain again demonstrate a left-sided ventricular catheter with its tip terminating in the region of the third ventricle. artifacts from multiple aneurysmal clips cause significant streak artifact. the ventricular size is stable. areas of encephalomalacic change within the left frontoparietal and right frontal regions are unchanged. right craniotomy defect is again seen. there is extensive mucosal thickening within the visualized ethmoid air cells. large bilateral pleural effusions are identified at the lung apices. impression: 1. limited evaluation of the vascular system secondary to clip artifacts and pooling of contrast within the left subclavian vein and spinal epidural venous plexus. given these findings, there is concern for possible occlusion/stenosis within the distal left subclavian/brachiocephalic vein. was this the site of prior central line placement? clinical correlation recommended. 2. no definite acute intracranial hemorrhage or mass effect. these findings were discussed with dr. at 3 p.m. on . mri/a brain: technique: multiplanar t1- and t2-weighted imaging of the brain. comparison is made with a recent head ct from and a brain mr . findings: there is a t2 signal hyperintensity in the right frontal and left parietal lobes consistent with postoperative encephalomalacia. there is a left frontal ventriculostomy shunt catheter which terminates in the third ventricle. compared to the previous exam from , there is no new mass effect. there is considerable metallic artifact emanating from the suprasellar cistern and right middle cerebral artery region. allowing for the limitation due to the artifact, the diffusion-weighted imaging is normal. impression: somewhat limited exam due to metallic artifact. no significant interval changes compared to a previous head ct from . no evidence of an acute infarct. mra of the brain technique: 3d time of flight of the circle of is performed. findings: there is limitation of the exam due to extensive metallic artifact emanating from the aneurysm clips. there is flow within the carotid arteries and vertebrobasilar circulation. the circle of is not directly visualized. impression: limited exam. no evidence of major vascular occlusion. telemetry to look for sz, eval hemifacial spasm vs sz: day #1 impression: this 24-hour eeg telemetry without video demonstrates a background pattern most consistent with moderate to severe encephalopathy. there are two brief periods of what appear to be very sharp and slow wave 2 hz activity which seem more focussed over the left temporal region as well as right frontal region more briefly. this could represent motion artifact from the patient's known clinical condition and hemifacial spasm or truly epileptiform in nature. it is difficult to discern this without video correlation at this time. we will continue to monitor to observe for further electrographic changes. both events were self-limited lasting seconds and without generalization to suggest seizure. no ongoing or prolonged rhythmic activity was seen. day #2 impression: this 24-hour eeg telemetry captured no clear electrographic seizures. a moderate encephalopathy is evident based on this recording. there are some sharp and slow wave morphologies seen over the left temporal as well as both frontal regions which could represent muscle artifact or potential epileptiform activity; however, no clear evolution of the event to seizure occurs. no clear waking and sleep cycles were seen during this recording. day #3 impression: this 24-hour eeg/telemetry captured multiple pushbutton events. electrographic and clinically no clear evidence for seizure was seen. the background rhythms remained slow and disorganized for the recording. no clear cycling through normal stages of sleep was seen. brief hospital course: 63 yo right-handed woman with history subarachnoid hemorrhage associated with acomm aneurysm in s/p vp shunt, associated infarcts (right frontal and left parietal), hyponatremia, hypothyroidism, hypertension, high cholesterol and obstructive sleep apnea who presented following an episode of unresponsiveness with stiffening, incontinence and tongue-biting thought likely related to seizure. she also has a history of hemifacial spasm, an episode of which occurred shortly before the seizure, raising the possibility that the facial movement in fact represented focal motor seizure activity. neurology: she was admitted to the neurology service on the floor for further workup. on the first day of hospitalization, she was found to be markedly hyponatremic (na 127); history later obtained from daughter and husband suggested that she had been given two liters of water to drink after the sodium had been drawn, and that perhaps it was even lower. on lp, csf was significant for rbcs 5000-> 3000, suspicious for traumatic tap. initial head ct showed a patent shunt system (confirmed with cxr), and no new signs of bleeding. she was loaded with dilantin in the er prior to transfer to the neurology floor. on the first hospital day, following the dilantin load, she became unresponsive again, with hypotension and hypothermia. as her lactate had been elevated as well, she was transferred to the neurology icu for further workup and suspicion of sepsis. she was monitored overnight, and had improved blood pressure but persistent hypothermia. further history obtained suggested that she has had chronic problems with hypothermia in the past. once she stabilized (overnight), she was transferred back to the floor, though she continued to be markedly somnolent (difficult to arouse) on exam, with small, minimally reactive pupils, not following commands, but mumbling few words in her native language. for the possibility that dilantin had further suppressed her mental status, and possibly even caused the hypotensive episode, the dilantin was discontinued and keppra was started for seizure prophylaxis. she continued to have facial twitching on the floor. eeg did not show any seizure activity, with no epileptiform correlate to her facial twitching, suggesting that the diagnosis of hemifacial spasm had been accurate. to confirm further that this was not associated with seizure, and to rule out subclinical seizures once her dilantin had begun to be weaned, she was monitored on ltm for several days. there was no evidence of seizure activity. she was continued on a low dose of keppra (500 mg ) for seizure prophylaxis, despite negative eegs, as she had presented with clinical diagnosis of first time seizure, and had imaging suggestive of seizure focus. a discussion was held with her family about whether to continue the seizure medication, as it was considered by the team to be safe to discontinue it; for peace of mind, and with the protection it might afford the patient from having a similar episode in the future, and considering the abnormalities on her head imaging, the keppra was continued. this could be continued for several months, at which point, if she has no further seizure episodes, it could be discontinued. this discussion will be held between her family and dr. , her epileptologist, as an outpatient. mri/a was performed to evaluate her past infarcts, and for a possible new structural lesion to explain the seizure. mri showed evolution of her right frontal and left parietal infarcts. it was difficult to visualize the circle of due to artifact from the clip, though poor filling of the right aca and mca was noted. compared to prior studies, she seemed to have progressive occlusion of the ica, mca and aca on the right, perhaps responsible for evolving right sided infarct, which had increased in size since prior exams. the aca territory infarct (mesial frontal on the right) was thought to potentially be responsible for some of the symptoms of apathy, and signs of abulia on exam. this was also considered to a potential focus for seizure activity. to optimize further stroke prevention, fasting lipid panel was checked and demonstrated elevated hdl of 101, ldl 124. hba1c was within goal. no further intervention was made. cta was also performed to better visualize the vasculature, but the study (read one week after it was performed) was technically limited due to pooling of the blood in the epidural venous plexus and therefore no available imaging of the arterial system. ct of the head confirmed no new bleed. her exam improved significantly, and by hospital day five, she had returned to baseline. she was feeling well, with some persistent cognitive difficulties as well as disorientation (particularly to place). she was ambulating and talking without difficulty. neuroendocrine: as she had known hypothyroidism, once sepsis was ruled out, hypothermia was initially thought possibly related to this disorder; however, thyroid studies confirmed that she was on the appropriate dose of medications (tsh was normal and free t4 was slightly elevated, if anything). random cortisol was checked, as was morning cortisol levels - both were normal. endocrinology was consulted regarding possible dysfunction of the pituitary-hypothalamic axis. since her subarachnoid hemorrhage in , the patient has had intermittent episodes of hypothermia that are not related to ambient temperature. she has also had intermittent low blood pressures. her urine culture was negative and blood cultures are pending (although this is unlikely due to infection). this was thought by both neurology and endocrine potentially related to hypothalamic dysfunction secondary to her sah in . unfortunately, her aneurysm clips produce artifact on ct and mr that make imaging of the hypothalamus difficult. upon recommendation, fsh, lh, igf-1, prl were checked. fsh was appropriately elevated for a post-menopausal woman. her lh was normal. her prolactin level was elevated at 35 ng/ml (normal ng/ml). the patient is scheduled for an outpatient appointment with endocrinology on . fluids/electrolytes: initially, the patient's sodium was low; this was followed over the course of several days it normalized. towards the end of her hospital stay, she actually became hypernatremic, with sodium as high as 152. her free water deficit was replaced via iv fluids. urine lytes were sent and revealed excretion of sodium in the urine, but also high osmolality. on the day of discharge, her serum sodium was 146; endocrine recommended stopping iv fluids and pushing for po intake instead. vascular: on hospital day six, the primary care physician the team about labs that were drawn prior to her hospital stay, significant for an elevated esr in the 80s; she suggested initiating workup for temporal arteritis. the patient's esr and crp were repeated and esr was elevated at 97; crp was elevated at 12.1. on exam, her left temporal artery is tender to palpation, slightly enlarged in comparison with the right temporal artery. though she did not endorse any symptoms of temporal arteritis (temporal headaches, visual changes, jaw claudication), her family and the neurology team felt that she might not volunteer these symptoms. she was seen by vascular surgery for evaluation for a temporal artery biopsy. as this could not be done immediately, this procedure will be done on , as an outpatient. pathology results should be made available to dr. as well as her primary care physician. gi: initially, her abdomen was distended. kub revealed stool and gas, and after stool softeners and increased mobility, abdominal exam improved. dispo: she was seen by physical therapy, who recommended discharge to a skilled nursing facility. however, the patient has not done well in rehab centers in the past. she has excellent support at home. thus, he was discharged home with services. exam at discharge was improved greatly over admission, with the patient awake, smiling, and able to converse in english. on entering the room the patient was noted to be walking back to her bed from the bathroom without assistance. left temporal artery remained enlarged and tender compared with the right. otherwise, general exam was unremarkable. the patient did not remember where she was initially, but when asked later, could recall it was . speech was fluent with no errors, and there remained chronic mild weakness of the left arm. medications on admission: -norvasc 5mg daily -levothyroxine 50mcg daily -lipitor 10mg daily discharge medications: 1. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. norvasc 10 mg tablet sig: one (1) tablet po once a day: or as prior. discharge disposition: home with service facility: homecare discharge diagnosis: seizure hypothalamic dysfunction impaired thirst response, with alternating hypo- and hypernatremia based on fluid intake discharge condition: improved - back to baseline. discharge instructions: please md or return to ed if you experience new seizures or change in mental status followup instructions: 'add-on' for temporal artery biopsy on with dr. (vascular surgeon). this is a procedure that is performed under local anesthesia. please be available at home, and the vascular surgery office will call you to schedule and do not eat after midnight on sunday night. if you have any questions about the procedure, call the vascular surgery office at . please f/u with neurology/dr. ( ) - appointment at 3:30. ( please call dr. office for further follow-up instructions. please f/u with pcp: call her office on to schedule appointment. endocrine appointment: provider: . phone: date/time: 4:30 procedure: spinal tap incision of lung diagnoses: pure hypercholesterolemia unspecified essential hypertension hyposmolality and/or hyponatremia unspecified acquired hypothyroidism other convulsions unspecified sleep apnea other late effects of cerebrovascular disease hyperosmolality and/or hypernatremia unspecified disorder of the pituitary gland and its hypothalamic control presence of cerebrospinal fluid drainage device 

Answer: The patient is high likely exposed to