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: lipitor / pletal / biaxin / / hydrochlorothiazide attending: chief complaint: ams major surgical or invasive procedure: picc line placement central line placement and removal history of present illness: 83 yo f with htn, hyperlipidemia, and one week of bronchitis who was at her baseline, until 2 hours pta when she became acutely confused and not ambulatory, and vomited. ems was called. in the ed, initial vs were:t 98 p 114 bp 146/113 r 29 90 o2 sat. on physical exam, she was intermittently following commands. a code stroke was called but patient was found to be more inattentive and confused on exam and was not consistent with a focal deficit. a ct head was negative for acute bleed. cxr showed infiltrate, with question of aspiration. given concern for aspiration during likely seizure event at home she was given ceftriaxone 1gm, levofloxacin 750mg, and flagyl 500mg iv. renal was consulted and hypertonic saline was initiated. cardiology was contact regarding defuse ekg changes and in setting of underlying metabolic derrangements, feel not primary cardiac etiology. she did receive an aspirin and 2gm of iv magnesium. urine and blood cultures were sent off. at the time of transfer, vs hr 122 bp 140/83 rr 36. on the floor, patient was unable to provide further details of the events leading to presentation due to mental status change. she denied pain. review of systems: unable to assess mental status. per daughter, no recent fevers or chills. dry cough x 1 week that was not responding to azithromycin with poor po intake over the past few days. no diarrhea or vomiting. past medical history: htn pvd hyperlipidemia h/o rheumatic heart disease social history: lived in , visiting daughter in last 4 weeks. lives alone. no prior tobacco or ivdu. social etoh. never worked outside of the home. family history: nc physical exam: general: alert, oriented to self, unable to answer simple questions, no acute distress, waxing and in responsiveness to questioning, thin w/ multiple ecchymoses overlying arms heent: sclera anicteric, mmd, oropharynx clear neck: supple, jvp not elevated, no lad lungs: coarse rhonchi bilaterally, no wheezes, rales cv: tachy rate and regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema pertinent results: pertinent labs on discharge: sodium 138 (low 96 on admission) wbc 13.3 (peak 37 on ) plt 72 cre 1.8 (peak 3.8 ) ast612* alt76* ldh 406* ap 107 tbili 1.2 (all improving from peak) . . cxr: pa and lateral views of the chest are obtained. airspace consolidation is noted in the lower lobes bilaterally and in the right upper lobe adjacent to the minor fissure. findings are compatible with multifocal pneumonia or possibly aspiration. no large pleural effusions are detected. cardiomediastinal silhouette is normal. no pneumothorax is seen. bones are diffusely demineralized. impression: multifocal pneumonia as described above. . ct head: no evidence of acute infarction. . ekg: sinus tach at 104, st elevation v2-v4 vs. repolarization changes, no change in avr or inferiorly, no old for comparison. . ct chest: impression: multifocal consolidation and alveolitis consistent with widespread pneumonia. this is not the usual pattern for bacterial infection unless patient suffered widespread aspiration. it suggests an atypical organism including legionella and mycoplasma. mild cardiomegaly predominantly left ventricular, with mild left atrial enlargement. atherosclerotic coronary calcification predominantly left main, anterior descending and circumflex branches. . echocardiogram the left atrium and right atrium are normal in cavity size. a small left-to-right shunt across the interatrial septum is seen at rest c/w a very small secundum atrial septal defect. the right atrial pressure is indeterminate. left ventricular wall thicknesses and cavity size are normal. there is severe left ventricular systolic dysfunction of the distal 2/3rds of the left ventricle and an apical aneurysm. basal segments contract well. no masses or thrombi are seen in the left ventricle. the estimated cardiac index is borderline low (2.0-2.5l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size is normal with focal hypokinesis of the apical free wall. there are simple atheroma in the abdominal aorta. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: extensive left ventricular systolic dysfunction c/w takotsubo's cardiomyopathy or multivessel cad. right ventricular focal dysfunction. mild pulmonary artery systolic hypertension. increased pcwp. small secundum type atrial septal defect with left-to-right flow. . abd u/s with doppler impression: 1. normal hepatic echotexture, without a focal lesion. 2. trace free fluid in the abdomen. 3. large bilateral pleural effusions, partially imaged. 4. very limited doppler evaluation of the liver and kidneys due to difficulties with positioning and patient's difficulties at breath holding. however, grossly unremarkable doppler evaluation as detailed above. portable tte (congenital, complete) done at 3:52:53 pm final conclusions the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the apical 2/rds of the ventricle. basal segment contract relatively well (lvef 30-35%). no masses or thrombi are seen in the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg).right ventricular chamber size is normal with focal hypokinesis of the apical free wall. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is mild to moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , global left ventricular systolic function is minimally improved. the severity of mitral regurgitation has increased. the remaining findings are similar (an atrial septal defect is not seen on the current study, but the images were not as comprehensive for this assessment and is unlikely to reflect a true change). unilat up ext veins us left study date of 5:15 pm impression: within limitations of study, no evidence of dvt in the left upper extremity. soft tissue edema superior to ac fossa. ct chest/abd/pelvis w/o contrast study date of 9:11 pm ct chest: there is evidence of tracheal collapse, suggesting trachomalacia (2:19,20). there are focal areas of consolidation in the lungs, in the right upper and middle lobe, and left upper lobe, which are less prominent compared to ct chest and could represent foci of pneumonia. there are bilateral pleural effusions, which have increased in size compared to prior study, with bibasilar consolidation, which could be atelectasis; however pneumonia cannot be excluded. evaluation is limited due to lack of iv contrast administration. there are no pathologically enlarged lymph nodes in the mediastinum, hilum, or axilla. there are multiple vascular calcifications. the ascending aorta measures 34 mm in diameter, upper normal limit for patient age. the heart size is enlarged, but stable compared to prior study. there is no pericardial effusion. ct abdomen: the patient did not receive iv contrast due to renal failure, which is limiting the evaluation of solid organs. with this limitation in mind the liver appears homogeneous, there is no intra- or extrahepatic biliary duct dilatation. the gallbladder appears normal, with no gallstones, and no significant fat stranding. the pancreas appears normal. the spleen is normal. the kidneys are symmetrical in size, with no large focal lesions seen, and no evidence of hydronephrosis. the right adrenal gland appears normal; and there is some mild fullness of the left adrenal gland, 2:59. there is a calcification in the right liver lobe, 2:65, which was also seen on the prior scan, of uncertain etiology, could be old calcified cyst or hematoma. there is a small amount of free fluid in the abdominal cavity. the loops of small bowel are normal, with no evidence of bowel obstruction. the loops of large bowel appear normal, with no dilatation and no evidence of obstruction. there is no free air. there is no evidence of significant retroperitoneal or mesenteric lymphadenopathy, according to ct size criteria; however due to lack of iv contrast evaluation is limited. ct pelvis: visualized loops of small bowel within the pelvis, rectum, sigmoid appear within normal limits. the uterus is normal. urinary bladder contains a foley catheter, and there is some air within, likely due to placement of the foley catheter. there is a mild amount of free fluid in the pelvis. there are no pathologically enlarged lymph nodes in the pelvis or inguinal area. osseous structures: no suspicious lytic or sclerotic lesions are seen in the bones. in the soft tissue diffusely there is stranding, associated with diffuse anasarca. impression: 1. large bilateral pleural effusions, with bibasilar consolidation, and multiple small scattered foci of consolidation. 2. cardiomegaly. 3. possible tracheomalacia. 4. diffuse anasarca. small amount of ascites. note: due to lack of iv contrast evaluation of solid organs is limited. brief hospital course: 83 yo f w unknown pmh p/w life threatening hyponatremia after seizure found to have takasubo's cardiomyopathy and multifocal aspiration pneumonia with course c/b transaminitis, acute kidney injury and thrombopenia. pt's admission began in the micu and she was transferred to general medical floor on . the complicated medical course is summarized by issues below: . # hyponatremia - appeared euvolemic to hypovolemic on exam, w/ urine osm >300. differential included siadh, ai, hypothyroidism. picture complicated by home use of hctz and recent poor po. home hctz was held. cvl was placed for hypertonic saline administration and q2h labs. renal was consulted and suggested 3% saline at 25ml/hr. tsh was wnl. cortisol was not low. urine lytes in prerenal range. on the medical floor, hyponatremia improved and there was no further need for hypertonic saline. hyponatermia was ultimately attributed to siadh due to pna and hctz. pt was discharged with a sodium of 138, and hctz should be held indefinately. . # takotsubos cardiomyopathy - presented with diffuse st elevations in v1-v4. cardiology was consulted in ed and felt underlying metabolic abnormalities. received aspirin in ed. denied chest pain. follow up ekg was at baseline. she had a tte that showed likely takotsubos cardiomyopathy. cardiology was consulted and recommended a heparin gtt with transition to coumadin and a beta blocker/ace inhibitor when she was more stable. repeat tte on demonstrated slowly improving cardiomyopathy. pt was not anticoagulated on general medical floor as hepatic dysfunction produced anticoagulation. metoprolol was selected for rate control as no lvot obstruction seen on echo. amlodipine was not used for rate control as lft were elevated. cause of takotsubo cm is unknown. perhaps na of 96, pna and ?seizure could induce sufficient stress rxn, but will seach for alternative cause of tcm, urine and serum metanepherines, catecholamines, vma, 5hiaa were sent and results were pending at discharge. please follow up urine and serum metanepherines, catecholamines, vma, 5hiaa . # heart rate: patient developed afib with rvr with rates in the 130s. at this time her bps dropped to map of 40 sbp 70s. she was started on an amio gtt and heparin gtt but both were stopped in the setting of shock liver. metoprolol was intiated when pressures were able to tolerate this and her rate was well controlled. heparin remained off in the setting of thrombocytopenia. on general medical unit, pt was rate controlled (hr 50-70, sbp 110-150) with metoprolol. pt was in sinus rhythm but thought to occasionally be in afib. score is 2 (age, hf) so will continue asa 325mg daily for now. need for anticoagulation should be reassessed after resolution of acute hepatic injury. amlodipine was not used for rate control as lft were elevated. . # shock: patient had hypotension initially thought likely sepsis from pna however was not responsive to fluids and cv o2 sat was low suggesting cardiogenic origin. once takotsubos was diagnosed attempted diuresis without change and then started on neosynephrine. did not start dopamine or levophed given h/o af with rvr and possibility of having lvot obstruction with takotsubos if started on pressors. with the hypotension patient had elevation in transaminases to 10k range and arf with oliguria which also supports cardiogenic shock in the setting of takotsubo's cardiomyopathy. she transitioned off pressors for >24 hrs prior to transfer from micu. . # transaminitis: likely shock liver in setting of hypotension. hepatitis serologies were hbsag neg, hbsab pos, hbcab neg, havab pos. ruq u/s showed normal hepatic echotexture with no gross doppler abnormalities. lfts trended down once she was weaned off neosynephrine and inr also came down. on general medical floor lfts continued to trend toward normal. associated coagulopathy improved. . # arf: creatinine from 0.4->3.1 and patient became oliguric in setting of hypotension requiring pressors. urine lytes consistent with pre-renal physiology. renal u/s showed no evidence of hydronephrosis. upon arrival to the general medical floor, cr was elevated to 3.8 and urine lytes shifted towards an atn physiology. arf from pre-renal injury transitioned to atn due to iv contrast and prolongued pre-renal physiology due to hypoperfusion/hypovolemia. in the setting of resolving hyponatremia, anasarca, and heart failure, the volume status was allowed to normalize without fluid resuscitation. cr improved to 1.8 by day of discharge and renal signed off. medications were remally dosed. as atn improved, pt was monitored for hypernatremia and hypokalemia following recovery autodiuresis. electrolytes were repleted prn. . # metabolic acidosis (anion gap +): bicarb was 16 after transfer to general medical floor. anion gap metabolic acidosis was most likely due to uremia from known renal injury. sodium bicarb 650mg po tid was given to replete bicarb. as renal function improved, bicarb was d/ced. metabolic acidosis resolved as uremia improved. . # hypoxia - aspiration pneumonitis vs. pneuomnia on top of stable rul infiltrate from 6 days ago. subsequently thought to be a multifocal pna developed after seizure. upon admission she was not deemed to have any risk factors for health care associated organisms. repeat cxr showed increased haziness in rul. she was started on levoquin for 7 day course and then switched to vanc/unasyn (day 1 ) as levofloxacin can contribute to hyponatremia. ct chest showed advanced multifocal pna. upon transfer to general medical floor pt was not hypoxic and oxygen saturation on room air remained appropriate for the remainder of the admission. . # pneumonia. improving on ct . vancomycin was d/ced as it remained in the blood stream for quite sometime due to arf. due to leukocytosis to 37 on , unasyn (7 day course, initiated ) was changed to zosyn (piperacillin/tazobactam) on . pt was placed on aspiration precautions. s/s evaluation on noted no aspiration risk. multifocal pna was thought to be likely due to aspiration during seizure. no h/o smoking or neurologic deficit to suggest silent aspiration. continuation of the soft liquid diet was recommended. . # leukocytosis with left shift: wbc was slowly increasing since and increased to 37 on . abx were broadened to zosyn (piperacillin/tazobactam) to cover psudomonas and renally dosed. pt's vs remained normal. c-diff neg x3. nl stool output, not likely to be c-diff per nursing. neg blood cx to date. in setting of known layering effusions and possible occult infection/abscess, pt had chest, abd, pelvis ct w oral contrast. bilateral known plural effusions were noted. uti was discovered. wbc count decreased. source of leukocytosis was thought to be uti. in the setting of improving wbc count it was determined that there was no need to tap effusions as likely due to heart failure and unlikely to be bilateral empyemas. last day zosyn is for total empiric 10 day course. . # uti and yeast in urine: uti thought to be likely source of leukocytosis. zosyn (piperacillin/tazobactam) continued. foley d/ced. yeast was determined to not require treatment as likely present due to abx use. . # schistocytes: hematology was consulted regarding thrombocytopenia. schistocytes were noted on blood smear. pt likely recovering from mild dic due to shock liver resulting in low coagulation factors. althought haptoglobin is low (<20 was 240 on ) not likely hemolyzing as ldh continues to improve, no elevation of i-bili, neg direct coombs and no reticulcytosis. . # thrombocytopenia. unclear, possibly related to a return to baseline (plt 269 in ) after an acute phase reaction and decreased production ability due to low thrombopoietin from hepatic and renal failure and increased utilization from mild dic. heparin was held until hit antibody returned neg and sq heaprin resumed. hematology consult felt that this was likely decreased thrombopoietin due to liver failure or due to her prolonged shock/icu stay. her platelets have continued to drop but all her other counts were looking better. upon discharge, she will have mwf cbc checked and faxed to pcp. continue to fall, would consider outpt heme work-up . # mental status change - likely hyponatremia. head ct neg in ed. question of seizure in setting of hyponatremia prior to presentation and post-ictal state. non-focal neuro exam, delirium on mental status. ams improved with sodium improvement. ms hospital course. upon discharge ms was back at baseline. . # fen: - nutrition was consulted when ms improved to help with baseline diet. - potassium repleted prn (goal >4) - ca repleted prn - magnesium repleted prn (goal <2) . # prophylaxis: - dvt: heparin 5000 units sc, pneumoboots - gi: confirm meds - d/c h2 blocker if not home med . # access: right ej can be d/ced, picc placed . # code: dnr/dni as of , hcp - (c , h ) . # communication: - son is hcp (c , h ) - daughter (h , c ) until patients mental status improves . pcp in : dr. # disposition. pending above medications on admission: avalide - ibasartan/hctz wellchol recent z-pak started 6 days prior to admission. discharge disposition: extended care facility: health care center discharge diagnosis: primary: hyponatremia stress induced cardiomyopathy liver failure acute liver failure thrombocytopenia aspiration pneumonia paroxsysmal atrial fibrillation secondary: hypertension hyperlipidemia discharge condition: stable, mental status at baseline (oriented x 3 and pleasant) discharge instructions: you were admitted with severe low sodium, an aspiration pneumonia and then developed a cardiomyopathy which resulted in decreased blood pressure. as a result of the decreased blood pressure, you had some liver and kidney problems, which are now both recovering. in addition, you have low platelet count which may also be related to your liver injury. we have made the following changes to your medications: 1. stop taking the avalide (ibesartan/hctz). you should never take hctz again. please check with your primary doctor g a medication similar to ibesartan. 2. start toprol xl 50 mg daily for blood pressure 3. you are being treated with an iv antibiotic called zosyn. your last day is . 4. we have temporarily stopped your cholesterol medication due to your liver dysfunction. please check with your primary doctor about restarting please come to the hospital or call your primary doctor if you have any fever, chills, nausea, vomiting, difficulty breathing, confusion, chest pain, palpitations, or any other concerning symptoms. followup instructions: please follow up with dr. in cardiology in one month. you will need a repeat echo (ultrasound of your heart) at that appointment to see if your heart has recovered. , m.d. phone: date/time: 9:00 please make an appointment to follow up with your primary doctor within 1 week of discharge from the hospital md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnoses: acidosis thrombocytopenia, unspecified acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy unspecified essential hypertension acute and subacute necrosis of liver atrial fibrillation other convulsions other and unspecified hyperlipidemia defibrination syndrome pneumonitis due to inhalation of food or vomitus cardiogenic shock acute systolic heart failure other disorders of neurohypophysis takotsubo syndrome saluretics causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to