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: morphine / norvasc attending: chief complaint: altered mental status major surgical or invasive procedure: inutbation picc placement lumbar puncture history of present illness: 53 yo w w/ dm1 (brittle on insulin pump), s/p lurt (baseline cr 1.4-1.7), cad (s/p multiple pcis), (ef 45%), htn/hl who initially presented to with a left proximal humerus fracture now transfered to for respiratory distress, septic shock, and renal failure. patient initially went to on after trippering over a chair, falling, and sustaining a left proximal humerus fracture without dislocation. orthopedics saw and advised conservative management and she was given dilaudid for pain as well as a muscle relaxant (unknown type). at 5am on , patient noted to be lethargic with sats to 70s as well as febrile to 103.1. she was given 1 dose of narcan with little change. put on 100% nrb and trasfered to ccu where she was given ceftazidime and vancomycin. abg at time showed po2 of 60%. some question if ekg changes inferiorly (reported as elevations). cardiology saw and thought not a cardiac cause. echo showed ef 40%. cards thought she was developing ards. id consulted and recommended switching ceftazidime to zosyn for asp pna. cr was 2.1 on admission and rose to 2.9 on . continued to be hypotensive despite fluids (unsure how much) and was started on phenylephrine gtt. insulin pump (home med) was discontinued and iss started. and bactrim were held. pts renal transplant attending () was contact and patient was transfered to for further care. immediately prior to transfer patient was intubated due to concerns re transfer saftey with pt still on nrb and concerns by that she was developing ards. pressures dropped significantly after intubation with rocuronium and propofol and had to go up on phenylephrine. patient was stable on ride over and emts were able to go down on her pressor requirement. she did well on the vent with relatively minimal sedation and remained responsive to voice on ride over. on arrival to the micu, patient intubated and sedated, just got propofol bolus. however, able to respond to voice and follow simple commands. reporting no pain. seems to understand what i am saying. review of systems: unable to obtain as intubaed past medical history: - dm1 (), brittle, c/b nephropathy and retinopathy on insulin pump (last a1c at in of 9.6%) - s/p lurt in , c/b humoral rejection followed by multiple plasmapheresis, recent cr baseline (1.4-1.7) - cad, s/p "silent" inferior mi ', s/p lad and lcx des '. - , 40-50%. - hypertension - hl - obesity - s/p vitreous hemorrhage od - l leg swelling lymphocele in the pelvis - charcot-foot deformity on left - hx of rp bleed - ibs - hypothyroidism social history: lives in w/ husband who is her kidney donor. has two adult children who are healthy. retired from medical records. tobacco - denies etoh - denies drug use - denies. family history: dm died at age 50's no h/o of kidney disease physical exam: admission exam: general: intubated and sedated, responsive to voice, comfortable on vent, seems to become drowsy after a few minutes and closes eyes heent: sclera anicteric, perrl, et tube in place neck: supple, no lad, r ij in place without surrounding erythema or induration cv: regular rate and rhythm, normal s1 + s2, no m/r/g lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, non-tender, distended to habitus, faint bs gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, charcot deformity on left with 2+ edema below ankle on left, trace edema on right neuro: nods yes/no to simple questions, moves hands/feet on command, pupils equal and reactive, comfortable, drowsy and drifts off after a few seconds discharge exam: general: aox3, anxious but appropriate heent: anicteric, dry mm cv: rrr, no m/r/g lungs: ctab, no w/r/r abd: soft, not tender, +bs ext: warm, 2+ pulses, charcot deformity on left with 1+ edema below ankle on left, trace edema on right; left arm with limited mobility due to pain neuro: grossly intact pertinent results: admission labs: 07:19pm blood wbc-17.2*# rbc-3.45* hgb-8.6* hct-28.4* mcv-82 mch-24.9* mchc-30.3* rdw-17.6* plt ct-276 07:19pm blood neuts-66 bands-25* lymphs-5* monos-1* eos-1 baso-0 atyps-0 metas-2* myelos-0 07:19pm blood pt-11.6 ptt-27.5 inr(pt)-1.1 07:19pm blood glucose-292* urean-57* creat-3.1*# na-129* k-5.1 cl-93* hco3-21* angap-20 07:19pm blood alt-60* ast-129* ld(ldh)-343* ck(cpk)-1812* alkphos-117* totbili-0.9 07:19pm blood albumin-3.7 calcium-7.9* phos-5.7*# mg-2.0 other pertinent labs: 07:19pm blood ck-mb-32* mb indx-1.8 ctropnt-1.34* 03:27am blood ck-mb-24* mb indx-1.4 ctropnt-1.15* 04:00am blood ctropnt-0.91* 03:20am blood hapto-553* 03:27am blood %hba1c-7.1* eag-157* 04:00am blood tsh-0.75 03:27am blood cortsol-23.8* 07:14am blood igg-524* igm-13* discharge labs: 05:30am blood wbc-10.3 rbc-3.06* hgb-7.9* hct-25.7* mcv-84 mch-25.8* mchc-30.7* rdw-17.8* plt ct-701* 05:30am blood glucose-148* urean-22* creat-1.1 na-137 k-4.6 cl-107 hco3-20* angap-15 05:30am blood calcium-8.6 phos-3.6 mg-1.7 05:20am blood caltibc-189* ferritn-750* trf-145* 05:30am blood rapmycn-4.9* imaging cxr: mild-to-moderate cardiomegaly is stable. et tube tip is low, 1.5 cm above the carina, can be withdraw couple of centimeters for more standard position. ng tube tip is in the stomach, but the side hole is at the eg junction and should be advanced for more standard position. right ij catheter tip is at the cavoatrial junction. left perihilar and lower lobe opacities are worrisome for aspiration given the clinical concern. there is mild vascular congestion. there is no pneumothorax. if any, there is a small left pleural effusion. head ct: findings: there are no comparison studies on record. there is no significant abnormality of the extracalvarial soft tissues, and no underlying skull fracture is seen. there is no intra- or extra-axial hemorrhage, the midline structures are in the midline and the ventricles and cisterns are normal in size and configuration, with slight asymmetric prominence of all components of the right lateral ventricle, likely congenital/developmental. there is mucosal thickening involving scattered anterior ethmoidal air cells, bilaterally, which appears more marked since the sinus ct of . the remaining visualized paranasal sinuses, as well as the mastoid air cells and middle ear cavities are clear. impression: no evidence of acute intracranial injury, and no skull fracture. humerus xray: impression: proximal left humerus comminuted fracture involving surgical neck with mild subluxation posteriorly of distal fracture fragment approximately two cortical widths with fracture line extension also extending towards greater tuberosity. glenohumeral articulation is maintained. abdominal x-ray: impression: air within small and large bowel is nonspecific. no evidence of obstruction. eeg: impression: this is an abnormal continuous icu monitoring study because of significantly abnormal background rhythms. at the beginning of the record, extremely frequent high voltage triphasic-appearing waves admixed with a few more paroxysmal epileptiform discharges were noted. between the bursts, there was evidence of a severe encephalopathy with suppression of electrical activity. later in the record, at that time noted above, there appeared to be a marked improvement in terms of the paroxysmal behavior in the record and an overall improvement in the background rhythms. no significant asymmetry or sustained seizure activity was identified. eeg: impression: this is an abnormal continuous icu monitoring study because of the diffuse encephalopathic features noted above which include background slowing in the slow theta bandwidth and superimposed paroxysmal high voltage sharp slow waves. these latter discharges were predominantly bilateral and synchronous but also showed right hemisphere predominance and periods of multifocality. there were, however, no sustained seizures recorded. eeg: impression: this was a poor electrographic recording session. throughout the session, the recording from the right hemisphere electrodes were non-functional. late in the recording, the left hemisphere electrodes also became disconnected. prior to the left hemisphere electrodes becoming non-functional, the eeg showed improvement in the diffuse encephalopathic features from the previous day and fewer paroxysmal bursts. no sustained seizure discharges in the left hemisphere were identified. mri head: impression: no significant abnormalities on mri of the brain with and without gadolinium with somewhat limited post-gadolinium images by motion. fluid in both bilateral mastoid air cells. microbiology: - 10:20 pm stool consistency: not applicable source: stool. **final report ** c. difficile dna amplification assay (final ): clostridium difficile. -blood cultures (): no growth -csf studies: cyptococcal antigen - not detected cmv dna, ql pcr - not detected varicella zoster virus (vzv) - not detected adenovirus dna, qn pcr - no dna detected herpes simplex virus pcr - negative borrelia burgdorferi antibody index for cns infection: negative csf ebv-pcr: negative csf toxoplasma gondii by pcr: negative -dfa negative brief hospital course: 53 yo w w/ dm1, s/p lurt (on sirolimus/pred), cad (s/p multiple pcis), (ef 45%) who presented to with a fall and l humerus fracture now transfered to for management of , respiratory distress, and shock. patient had complicated micu course where she was treated for altered mental status, pneumonia, and c. diff. she stabilized and was sent to rehab from the floor. # altered mental status: on arrival from outside hospital, patient had altered mental status. she was intermittently confused, agitated, and somnolent with definite waxing and components. in the setting of fevers and confusion, there was concern for encephalitis or meningitis. patient had an lp which was significant for elevated opening pressure of 37 and elevated rbcs - wbc was 5 (lymph predominant). she was empirically treated for bacterial and viral meningitis until cultures negative and patient improved. hsv pcr from csf negative. numerous other viral tests from csf were sent and were negative at time of discharge. also, some concern for possible seizures so neuro consulted and eeg done. eeg initially was concerning for seizure-like activity so keppra started. however, repeat eeg's without seizures and ultimately thought that seizures were highly unlikely so keppra was down-titrated and discontinued. a significant portion if not all of ams may have been due to delirium and toxic-metabolic encephalopathy in patient with two significant infections and admitted to the icu for a prolonged period. mental status improved slowly over 10 days of icu stay suggesting toxic-metabolic delerium as the reason for the alteration. at discharge, patient is alert and oriented x 3 and back to her baseline mental status. # respiratory failure/pneumonia: was transfered to intubated after respiratory distress at an osh which may have been triggered by aspiration event. chest imaging showed prominent bilateral pneumonia. she was covered with broad spectrum coverage for hcap. was extubated shortly after arrival at icu, but had significant oxygen requirement for the next few days. had another questionable aspiration even a day or two after arrival so was given very limited po intake for first few days. pneumonia ultimately improved and antibotics stopped after roughly 10 total days of hcap coverage. she was discharged on lasix 60mg daily and she was on room air. # severe cdiff colitis: a couple days into hospitalization, developed diarrhea and worsening wbc. stool sent for cdiff toxin which was positive. rectal tube placed and patient started on po vancomycin 500mg q6hrs. couple days later also started on iv metronidazole for both this and pneumonia. never developed acute abdomen or significant ileus although did require an ngt for a few days due to vomiting. plan to complete 14 days of po vanco/po metronidazole after last day of other antibiotics. last day of cdiff treatment antibiotics should be . she was also started on cholestyramine to help reduce the amount of diarrhea she was having and this can be discontinued at the patient's discretion in a few days. # acute on ckd: s/p lurt in , c/b humoral rejection followed by multiple plasmapheresis, recent cr baseline (1.4-1.7) on sirolimus and prednisone. cr up at presentation and presumed that was due to septic shock. cr improved initially with fluids and patient continued on home prednisone 4mg daily with reduction of sirolimus to 0.5mg daily. renal consult service followed and helped manage sirolimus dosing, and she should continue this dose of 0.5mg daily until she follows-up in clinic. valsartan held initially due to infection and but was restarted at discharge. continued on bactrim prophylaxis. she requires a once weekly rapamycin level, cbc, chem7, calcium, phosphate, ast, alt, ua, urine protein/creatinine ratio checked every tuesday and results faxed to . # anemia: suspect secondary to renal failure and mild gi losses secondary to c.diff (trace guaiac positive) +/- some bone marrow stunning in setting of severe infection. no evidence of hemolysis or iron deficiency. hct responded to 2units hct 20 ->27 and stabilized. patient receives epo as an outpatient and should continue this on discharge. # dm1: has history of brittle diabetes on home insulin pump (although somewhat unclear how much she takes). was placed on an insulin gtt while in the icu and consulted to help with management. day before icu callout was transitioned to lantus with humalog sliding scale. she was discharged on lantus with sliding scale insulin and should not resume her insulin pump until following up with her outpatient dm provider. # left humeral fracture: had gone to osh initially with fall and found to have a proximal left humerus fracture. ortho saw here and recommended conservative management with a sling. due to mental status tried to limit narcotics (and some history that she is very sensative to narcotics), so given tylenol, lidocaine patch. patient will have to call orthopedic clinic to schedule follow-up in four weeks and she was discharged with a cuff and collar sling. # depression/anxiety: high dose citalopram at home as well as busprione and clonazepam at home. citalopram was decreased to 20mg in setting of multiple other meds and buspirone and clonazepam were initially held given ams. the buspirone and clonazepam were restarted at home dose, and citalopram was reduced to 40mg at discharge. # cad/nstemi: had elevated cardiac markers at osh thought to be demand ischemia in setting of septic shock. cards saw here and said no need for heparin gtt. continued on asa, statin, metoprolol. cardiac markers trended down. # (ef 40-50%): baseline mild decreased ef. clincally stable without evidence of exacerbation. once infectious issues stabilized, restarted lasix with prn doses in the icu, and discharged on lasix 60mg po daily. # charcot-foot deformity on left: associated left sided le swelling. # hypertension: initially bp meds held in setting of infection. ultimately restarted all home meds. # hld: continued home atorvastatin # hypothyroidism: continued home levothyroxine # fen: was npo initially, then received tube feeds for a few days, ultimately advanced to diabetic diet # code: full # disposition: she is very deconditioned and needs significant rehab. . transitional issues 1. please check rapamycin level, cbc, chem7, calcium, phosphate, ast, alt, ua, urine protein/creatinine ratio every tuesday and results faxed to 2. she needs to call her diabetes provider and schedule an appointment to discuss restarting her insulin pump once she is on a stable diet 3. rapamycin dose changed during this hospitalization, will have weekly level checked and follow up with renal regarding dose titration. 4. can discontinue cholestyramine in a few days once diarrhea improves 5. consider up-titrating patient's citalopram dose from 40mg back to baseline dose of 60mg for her anxiety/depression medications on admission: medications on osh transfer: acyclovir 750 mg iv q12h () cefepime 2 g iv q12h () vancomycin 1500 mg iv q 24h () vancomycin oral liquid 125 mg po/ng q6h () prednisone 4 mg po/ng daily sirolimus 1 mg po daily senna 1 tab po bid:prn constipation docusate sodium (liquid) 100 mg po bid heparin 5000 unit sc tid aspirin 81 mg po/ng daily start: in am atorvastatin 80 mg po/ng daily start: in am levothyroxine sodium 50 mcg po/ng daily acetaminophen 650 mg po/ng q6h:prn pain/fever insulin 100 units/100 ml ns @ unit/hr iv drip acetaminophen iv 1000 mg iv q6h:prn fever ondansetron 4 mg iv q8h:prn nausea promethazine 12.5 mg iv q6h:prn nausea/vomitting levetiracetam 750 mg iv q12h metoprolol tartrate 37.5 mg po/ng tid furosemide 40 mg po/ng daily sulfameth/trimethoprim ss 1 tab po/ng daily quetiapine fumarate 25 mg po/ng : prn agitation valsartan 80 mg po/ng daily ipratropium bromide neb 1 neb ih q6h albuterol 0.083% neb soln 1 neb ih q6h albuterol 0.083% neb soln 1 neb ih q2h:prn wheezing/sob ipratropium bromide neb 1 neb ih q6h:prn sob/wheezing discharge medications: 1. aspirin 81 mg po daily 2. atorvastatin 80 mg po daily 3. buspirone 5 mg po tid 4. calcium carbonate 500 mg po tid 5. clonazepam 0.5 mg po bid:prn anxiety 6. fluticasone propionate nasal 1 spry nu 7. levothyroxine sodium 50 mcg po daily 8. omeprazole 40 mg po daily 9. prednisone 4 mg po daily 10. sulfameth/trimethoprim ss 1 tab po daily 11. sirolimus 0.5 mg po daily start: in am daily dose to be administered at 6am 12. albuterol 0.083% neb soln 1 neb ih q2h:prn wheezing/sob 13. ipratropium bromide neb 1 neb ih q6h:prn sob/wheezing 14. lidocaine 5% patch 1 ptch td daily apply to left arm in area of fracture 15. metoprolol succinate xl 100 mg po daily 16. glargine 40 units breakfast glargine 18 units bedtime insulin sc sliding scale using hum insulin 17. metronidazole (flagyl) 500 mg po q8h 18. vancomycin oral liquid 125 mg po q6h 19. citalopram 40 mg po daily 20. fish oil (omega 3) 1000 mg po bid 21. multivitamins 1 tab po daily 22. nystatin cream 1 appl tp 23. vitamin d 800 unit po daily 24. valsartan 80 mg po bid 25. cepacol (menthol) 1 loz po prn sore throat 26. cholestyramine 4 gm po tid please space out 3-4 hours from vanco 27. guaifenesin-dextromethorphan 5 ml po q6h:prn cough 28. trazodone 25 mg po hs:prn insomnia 29. furosemide 60 mg po daily hold for sbp <100 30. epoetin alfa 10,000 unit sc qmowefr start: hs 31. outpatient lab work - have rapamycin level, cbc, chem7, calcium, phosphate, ast, alt, ua, urine protein/creatinine ratio checked every tuesday and results faxed to discharge disposition: extended care facility: house nursing home - discharge diagnosis: pneumonia altered mental status discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , you were admitted to after you developed a serious infection in your lungs requiring intubation, blood pressure support, and close monitoring in the intensive care unit. your lung infection resolved with antibiotic treatment. you became very confused while in the icu but this was not thought to be due to an infection in your spinal cord as a spinal tap was performed which was negative. there was some concern that you were having seizures so you were briefly started on seizure medications but the neurologists feel you do not actually require this medication so this was discontinued. you also developed a diarrheal infection in your colon called clostridium difficile for which you will continue to require antibiotics once you leave. followup instructions: 1. dr. renal transplant medicine where: , transplant medicine (nhb) where: , when: thursday, at 8:20am 2. dr. orthopedics where: building, where: , when: tuesday, at 8:30am 3. please call your diabetes doctor to arrange for a follow-up appointment in the next few weeks to discuss when it is safe for you to restart your insulin pump. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours spinal tap incision of lung enteral infusion of concentrated nutritional substances central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified anemia in chronic kidney disease nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery congestive heart failure, unspecified toxic encephalopathy acute kidney failure, unspecified unspecified septicemia severe sepsis unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified depressive disorder, not elsewhere classified percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified other and unspecified hyperlipidemia anxiety state, unspecified acute respiratory failure pneumonitis due to inhalation of food or vomitus long-term (current) use of insulin septic shock intestinal infection due to clostridium difficile chronic systolic heart failure surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation fall from other slipping, tripping, or stumbling closed fracture of unspecified part of humerus complications of transplanted kidney diabetes with renal manifestations, type i [juvenile type], uncontrolled diabetes with ophthalmic manifestations, type i [juvenile type], uncontrolled background diabetic retinopathy arthropathy associated with neurological disorders insulin pump status tabes dorsalis 

Answer: The patient is high likely exposed to