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: gluten attending: chief complaint: pneumonia, sepsis major surgical or invasive procedure: intubation right radial arterial line left subclavian central venous line picc line history of present illness: 65yo f with no significant pmh presents with pneumonia and severe sepsis. pt complains of dry cough, nasal congestion, and weakness, gradually worsening over past 1-2 weeks. also with shortness of breath at rest. went to osh (), where initial vitals were bp 110/62, p 102, rr 20, o2 sat 90-98% on fm. cxr showed bilateral pneumonia. abg 7.21/47/57, lactate 1.1. she received duonebs, decadron 10mg iv, and 3l ns. pressure dropped to 70/30--> minimal response w/ 2.5l ns. a femoral artery cv line placed and levophed started. she was transferred to with bp 89/50 on transfer. . at , pt was afebrile (t 97.7) and continued to have sbps 80-90's despite levophed. cefepime 2g iv x 1 was given and potassium repleted. she was transferred to the for further monitoring. . pt denies fevers, chills, chest pain, abdominal pain. does report unintentional weight loss of about 18 pounds over the past 12-15 months. per ems report, pt had a fall last week, w/ back pain since fall. past medical history: fibromyalgia. pt rarely sees a physician. social history: lives with husband in . denies current or prior smoking. no etoh or other drug use. family history: non-contributory. physical exam: t95.4, p 79, bp 108/51, rr 23, o2sat 99% on nrb (levophed @ 0.5) lines: femoral cv line gen: cachectic woman, appears older than age. heent: dry mm, dental caries, brown discoloration of tongue neck: supple, good carotid upstrokes lungs: rhonchi heard diffusely, l>r, with egophony at l base. also w/ bronchial breath sounds in left lung fields. chest: rrr, no m/r/g, no jvd abd: soft, nt, nd, nabs extrem: 2+ pulses, wwp, no edema neuro: oriented to person, place, and time. very tired and not wanting to answer questions. pertinent results: admission labs: 12:15am wbc-15.6* rbc-3.66* hgb-10.7* hct-32.2* mcv-88 mch-29.1 mchc-33.1 rdw-15.9* 12:15am neuts-75* bands-2 lymphs-19 monos-4 eos-0 basos-0 atyps-0 metas-0 myelos-0 12:15am glucose-125* urea n-36* creat-0.9 sodium-143 potassium-2.8* chloride-115* total co2-17* anion gap-14 12:15am calcium-6.9* phosphate-4.3 magnesium-1.6 12:24am lactate-0.7 05:07am plt count-625* 05:07am alt(sgpt)-49* ast(sgot)-34 ck(cpk)-81 alk phos-140* tot bili-0.2 05:07am albumin-1.6* 05:55am pt-21.9* ptt-50.8* inr(pt)-2.1* 06:19am type-art temp-36.1 o2-70 po2-82* pco2-52* ph-7.12* total co2-18* . admission cxr: there is extensive bibasilar consolidation with air bronchograms. right suprahilar opacity is also evident. there is blunting of both costophrenic angles suggestive of small effusions. no pneumothorax is evident. . echo: the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. the estimated right atrial pressure is 11-15mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is normal (lvef 60%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. no vegetation/mass is seen on the pulmonic valve. there is a trivial/physiologic pericardial effusion. . upper extremity doppler u/s (ordered for lue edema on side of subclavian line): no evidence of dvt. . 2:12 pm catheter tip-iv source: arterial line. wound culture (final ): no significant growth. . 4:49 pm blood culture source: line-central. aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. . 4:34 pm blood culture source: line-aline. aerobic bottle (final ): no growth. anaerobic bottle (final ): no growth. . 9:42 am urine source: catheter. urine culture (final ): no growth. . 7:48 am sputum site: endotracheal source: endotracheal. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): . 12:09 pm sputum site: endotracheal source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): moderate growth oropharyngeal flora. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (pending): . 12:09 pm stool consistency: watery source: stool. clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. . 2:19 pm urine source: catheter. legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. . 09:42am urine color-straw appear-clear sp -1.005 09:42am urine blood-lg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg 09:42am urine rbc-3* wbc-0 bacteri-none yeast-none epi-0 . 05:39am blood wbc-12.9* rbc-3.03* hgb-9.2* hct-28.4* mcv-94 mch-30.3 mchc-32.3 rdw-15.3 plt ct-529* 05:39am blood plt ct-529* 05:39am blood glucose-119* urean-13 creat-0.4 na-143 k-3.5 cl-108 hco3-30 angap-9 05:39am blood alt-54* ast-26 ld(ldh)-294* alkphos-123* totbili-0.2 05:39am blood calcium-7.7* phos-3.0 mg-1.5* . 03:46am blood lipase-113* 04:27am blood lipase-115* 03:46am blood ck-mb-8 ctropnt-0.04* 07:19pm blood ck-mb-8 ctropnt-0.05* 12:49pm blood ck-mb-10 mb indx-1.2 ctropnt-0.06* 02:18pm blood ck-mb-9 ctropnt-0.03* 05:07am blood ck-mb-15* mb indx-18.5* 04:33am blood hapto-244* 08:58am blood triglyc-155* 04:27am blood tsh-1.3 03:57pm blood pth-400* 02:19pm blood cortsol-10.4 02:19pm blood cortsol-7.6 02:18pm blood cortsol-5.9 03:57pm blood igg-1014 iga-204 igm-48 03:18pm blood freeca-1.04* . 08:20pm blood hct-24.8* 04:33am blood wbc-9.8 rbc-2.78* hgb-8.1* hct-24.9* mcv-90 mch-29.3 mchc-32.7 rdw-15.9* plt ct-492* 04:33am blood neuts-70.4* lymphs-21.1 monos-6.8 eos-1.3 baso-0.4 04:33am blood hypochr-2+ macrocy-1+ 04:33am blood plt ct-492* 04:33am blood plt ct-492* 04:33am blood glucose-97 urean-16 creat-0.4 na-144 k-4.2 cl-112* hco3-27 angap-9 04:33am blood alt-50* ast-27 ld(ldh)-271* alkphos-116 totbili-0.2 04:33am blood calcium-7.9* phos-3.5 mg-1.7 04:33am blood hapto-244* . brief hospital course: admitted to the . . 1) hypotension: pt was hypotensive on admission, with sbps 80's-90's despite high doses of levophed. pt received multiple fluid boluses and vasopressin was added with good effect. pt had an inadequate response to a cortisol stimulation test (baseline 5.9 --> 7.6 @ 0.5hr--> 10.4 @ 1hr), and so a 7 day course of hydrocortisone 100mg iv q8h/fludrocortisone 0.05mg po daily was administered. by hd#4, pt no longer required any pressors and remained hemodynamically stable for the rest of her course. the etiology of the hypotension was likely septic shock from pneumonia. . 2) bilateral pneumonia: pt was admitted with a cxr consistent with multifocal pneumonia. she was intubated on hd#1 secondary to severe acidosis (ph 7.12, pco2 52, po2 82). sputum gram stain showed gram positive cocci in pairs. sputum cultures were negative. pt was initially treated with ceftriaxone/azithro for cap. given lack of clinical improvement (as measured by fever curve, wbc count, vent requirements, and persistent gram pos cocci on sputum gram stain) after a few days of tx, vancomycin was added to the regimen to cover for mssa/mrsa. she subsequently improved and was extubated on hd#7. post extubation, the abx coverage was narrowed to vancomycin and levaquin only to complete an 10 day course (completed on ). given history of weight loss, diarrhea, cough, and positive ppd, pt was also placed in negative isolation room and ruled out x 3 sputum samples for acid fast bacilli. . 3) fever: pt was persistently febrile for the first 5 days of her course despite multiple days of abx therapy. coverage of pna was expanded to vancomycin which coincided with resolution of fevers. a tte was checked early on which showed no valvular vegetations; tee was not pursued given low suspicion for endocarditis. a central line infection was questioned but given the requirement for frequent electrolyte repletions and iv abx, the subclavian line was not pulled until after a picc line was placed on . multiple sets of blood cultures obtained throughout course were negative. . 4) diarrhea: pt had persistent diarrhea from admission. per family, pt had been having intermittent diarrhea and abdominal pain for weeks-months prior to admission, but had never seen a doctor about it. c.diff was negative x 3. given her cachectic appearance a malnutrition syndrome was suspected. ttg-iga was > 120units, highly suggestive of celiac disease. gi was consulted and plan is to undergo colonoscopy and small bowel biopsy as an outpatient. she was put on gluten-free diet and had resolution of diarrhea. . 5) nutrition: og tube feeds were initiated while pt was intubated. high probability of celiac disease prompted change of tube feeds to gluten-free elemental. however, diarrhea did not abate and her persistent electrolyte requirements and low albumin suggested she was not absorbing much through her gi tract. tpn was started on to improve nutritional status. modest po intake was allowed during this time. after several days of tpn, her po intake improved and was excellent. she had good appetite and tpn was discontinued. . 6) hypokalemia: pt was hypokalemic on admission and required multiple daily repletions of k throughout her course. initially this was attributed to diarrheal losses, but urine studies revealed massive renal potassium wasting. ddx includes fludrocortisone, mg deficiency, alkalemia. fludrocortisone was d/c'd after 7 days and mg/k repleted aggressively. subsequently stable. . 7) hypernatremia: na was stably elevated throughout course (143-148) despite >2l free h20/day in tube feeds. urine osmolality was inappropriately low (186), c/w diabetes insipidus. on no meds known to cause di, although severe hypokalemia can cause di. sodium stabilized in high normal range. . 8) hypocalcemia: pt was persistently hypocalcemic, with appropriately elevated pth. most likely etiology vitamin d deficiency malabsorption. vitamin d level pending. vit d was supplemented throughout course and cagluconate administered prn. she should complete a 7d course of vit d units daily and then be on vit d 800units and have pth rechecked. . 9) metabolic alkalosis: pt initially had an acidosis diarrheal losses and respiratory acidosis. after intubation, bicarbonate therapy and multiple lr boluses, pt developed a metabolic alkalosis. bicarb trended down toward end of stay. . 10) elevated ck: ck in 800's likely represents rhabdomyolysis, as ck-mb fraction is <2.5%. most likely causes are electrolyte abnormalities and propofol. propofol was d/c'd once extubated and electrolytes repleted prn. ck trended down. . 11) transaminitis: mild hepatocellular pattern likely due to celiac disease and/or propofol. improved though alt remained just above normal range. . 12) anemia: anemia of chronic disease picture via iron studies. pt did not require any blood products. however, hct was variable ranging from mid 20s to low 30s without evidence of blood loss or hemolysis. likely some componenet of marrow suppression from sepsis. on discharge hct stable for 2d at about 25. hct should be monitored as outpt and if remains low, may need further hematologic workup. . 13) coagulopathy: pt admitted with ptt 58.1 and inr 2.0. inr was reversed to normal s/p 3 doses of 5mg vitamin k. elevation of ptt/inr likely secondary to malnutrition. ptt also trended down to normal range. . 14) lbbb on ekg: pt's ekg on presentation showed lbbb. unclear whether new or old as no baseline available. no evidence of wma on echo. cardiac enzymes cycled were negative for ischemia. . 15) acute renal failure: on admission, cr was 0.9. possible atn from sepsis. with recovery from sepsis, cr settled around 0.4. pt had significant post-atn diuresis at times requiring ivf boluses to maintain bp. on d/c sbp in 100-110 range. . communication: husband , . daughter . code: full . medications on admission: multivitamins discharge medications: 1. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po daily (daily) for 3 days. 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 3. multi-vitamin tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: health care center - discharge diagnosis: primary: septic shock community acquired pneumonia, bacterial acute renal failure celiac disease anemia of chronic disease discharge condition: good--afebrile, vital signs stable, tolerating food and liquids. discharge instructions: 1. take medications as prescribed. 2. follow up as below. 3. please seek medical attention for fevers, shortness of breath, chest pain, abdominal pain, diarrhea, lightheadedness, or any other symptoms that concern you. followup instructions: please call your new pcp: . make a follow up appointment after you leave rehab. you will also need referral to a gi specialist for evaluation of celiac disease. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization diagnoses: acidosis anemia, unspecified acute kidney failure, unspecified unspecified septicemia unspecified protein-calorie malnutrition severe sepsis acute respiratory failure septic shock celiac disease hyperosmolality and/or hypernatremia bacterial pneumonia, unspecified 

Answer: The patient is high likely exposed to