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: compazine / pepcid / nitroglycerin / dicloxacillin / methylprednisolone / neurontin / bactrim attending: chief complaint: 60f with multiple medical problems including dm2, chronic lbp on morphine pca, lower extrem myelopathy, seizure d/o, chronic uti, metastatic thyroid ca, s/p recent cholecystectomy h/o line infections initially admitted with decreased mental status, lethargy, and confusion. husband states that she had been doing very well at home until the day of admission, when she awoke from a nap with confusion (baseline mental status is fully responsive and communicative). on the night pta, the pt's sbp was noted to be 90 (her normal sbp is ~150). she was awake all night with severe leg pain. on , pt gave herself two boluses of iv morphine 10 mg. she took a nap and when she awoke this afternoon she acted very confused to her husband. advice fr her pcp, husband turned off her morphine pump at 3 pm. she did not improve so he brought her in. no alcohol intake x yrs. only med change over the past several months is addition of 3 days ago. husband did not notice any empty med bottles or misuse of meds. of note, pt had been seen in clinic 3 days prior to this and started on iv vancomycin (administered @ home) for a presumed portacath line infection (?erythematous overlying skin?). ros+ for severe diffuse ha x 24 hrs, which did not respond to acetamin. husband also reports +photophobia, with the pt asking her husband to turn off the lights. she also had 2 episodes of non-bloody, bilious emesis. otherwise, on ros, denies dysuria, diarrhea (has chronic constipation), chest pain, cough, or uri sxs. poor po intake over the past 1 day or so. in ed, fingerstick 123. head ct without bleed, wbc, lfts all wnl with ekg unchanged and neg cxr. in ed, given anzemet, hydralazine, narcan 0.2 mg iv, mrophine 2mg iv, and 1gm vancomycin. sbp remained elevated in ed ranging 157-214 with diastolics 80s-90s. given 500 cc ns iv x 1. pt did not have lp since she has been a difficult lp in the past secondary to spinal stenosis and pt's husband requested to be done by neurology or fluoroscopy. given concern for meningitis or meningoencephalitis, pt was initially admitted to floor by nf overnight with empiric treatment with ceftriaxone (only 1 gm by poe) and vancomycin. when team saw this am, pt was diaphoretic and responsive to voice but otherwise not following commands. ceftriaxone was changed to meningitis dose 2 gm q12, and acyclovir to cover hsv encephalitis, and neuro consulted for lp. micu consulted initially for concern of mental status and concern for sepsis, but at that time was afebrile. through the course of the day, pt spiked temp to 104, hr 130s, sbp persistently elevated above 200s not responding to iv hydralazine and lopressor. required iv labetalol at bedside with md monitoring at bedside. transferred to (no west micu beds) for bblocker drip for htn and for further w/u & monitoring. major surgical or invasive procedure: none social history: pt lives with her husband. etoh or tobacco use. not working. walks with crutches/walker. family history: father - cad, mother - cva physical exam: vs: t 96.8 tm 98.8 hr 70-91 bp 125-198/65-84 r 16 sat 99%ra i/o 1829/4155 pmn 1600/2250 heparin gtt at 1650 units/h morphine 2mg/h gen: nad a+ox3 heent: mmm, neck supple cv: rrr, no m/r/g pulm: ctab abd: s/nt/nd with r subcostal incision c/d/i s/p cck +bs extr: no edema neuro: cn2-12 intact, diffuse hypertonia in all 4 ext, decreased sensation bilat feet pertinent results: 11:00pm blood wbc-7.9# rbc-5.45* hgb-16.3* hct-47.2 mcv-87 mch-29.9 mchc-34.6 rdw-15.0 plt ct-291 06:00am blood wbc-7.8 rbc-5.24 hgb-15.4 hct-43.1 mcv-82 mch-29.4 mchc-35.7* rdw-14.5 plt ct-294 10:06pm blood wbc-11.7* rbc-5.37 hgb-16.0 hct-46.2 mcv-86 mch-29.7 mchc-34.6 rdw-15.8* plt ct-262 06:10am blood wbc-5.1 rbc-4.33 hgb-12.7 hct-36.9 mcv-85 mch-29.4 mchc-34.5 rdw-15.3 plt ct-223 11:00pm blood neuts-85.3* lymphs-10.9* monos-3.2 eos-0.6 baso-0 10:06pm blood neuts-88.0* lymphs-8.6* monos-3.2 eos-0 baso-0.2 07:07am blood neuts-77* bands-1 lymphs-12* monos-6 eos-3 baso-1 atyps-0 metas-0 myelos-0 11:00pm blood pt-21.6* ptt-33.8 inr(pt)-3.1 11:00pm blood plt ct-291 06:00am blood pt-20.6* ptt-32.2 inr(pt)-2.8 05:33am blood pt-12.3 ptt-33.1 inr(pt)-1 01:40pm blood fibrino-518*# 10:06pm blood fibrino-506* 11:00pm blood glucose-144* urean-45* creat-1.5* na-135 k-5.8* cl-99 hco3-25 angap-17 06:00am blood glucose-186* urean-38* creat-1.2* na-136 k-4.2 cl-100 hco3-23 angap-17 10:06pm blood glucose-236* urean-27* creat-1.0 na-138 k-3.2* cl-102 hco3-21* angap-18 04:57am blood glucose-100 urean-29* creat-1.0 na-139 k-3.6 cl-106 hco3-24 angap-13 04:31pm blood glucose-114* urean-26* creat-0.9 na-137 k-3.7 cl-108 hco3-22 angap-11 07:07am blood glucose-116* urean-16 creat-0.8 na-138 k-4.4 cl-102 hco3-25 angap-15 04:00am blood glucose-126* urean-25* creat-0.9 na-136 k-4.4 cl-100 hco3-28 angap-12 06:10am blood glucose-115* urean-26* creat-0.9 na-135 k-4.6 cl-100 hco3-26 angap-14 11:00pm blood alt-28 alkphos-121* amylase-24 totbili-0.2 06:00am blood ast-18 ck(cpk)-111 amylase-21 04:57am blood alt-23 ast-29 ck(cpk)-508* 04:31pm blood ck(cpk)-405* 04:18am blood alt-29 ck(cpk)-217* 05:34am blood ck(cpk)-23* 07:07am blood ck(cpk)-28 11:00pm blood lipase-19 06:00am blood lipase-17 06:00am blood ck-mb-3 ctropnt-<0.01 02:16pm blood ammonia-11* 06:00am blood tsh-0.16* 06:00am blood free t4-2.5* 04:57am blood vanco-12.0* 10:06pm blood asa-neg ethanol-neg bnzodzp-neg barbitr-neg tricycl-neg 11:00pm blood lactate-1.6 k-5.9* 02:26am blood k-6.0* . -blood cx x2: ngtd -urine cx x2: ngtd -ua: unremarkable -lp : no pmns, no organisms -ekg (in ed): nsr@73, poor baseline, normal intervals/axis, no st/t wave changes, unchanged from prior -cxr (in ed): no acute cardiopulmonary disease -head ct (in ed): no evidence of acute intracranial hemorrhage. -echo : the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a trivial/physiologic pericardial effusion. brief hospital course: *altered mental status / fever / increased muscle tone: patient was admitted with ms changes, hypotension, severe htn, rigidity and fevers. in ed, fingerstick 123. head ct without bleed. wbc, lfts all wnl with ekg unchanged and neg cxr. bedside eeg showed no seizure activity. she was given anzemet, hydralazine, narcan 0.2 mg iv, morphine 2mg iv, and 1gm vancomycin. sbp remained elevated in the ed ranging 157-214 with diastolics 80s-90s. she was given 500 cc ns iv x 1. pt did not have an lp since she has been a difficult lp in the past secondary to spinal stenosis and pt's husband requested to be done by neurology or fluoroscopy. given concern for meningitis or meningoencephalitis, pt was initially admitted to the floor by nf overnight with empiric treatment with ceftriaxone (only 1 gm by poe) and vancomycin. when the team saw the patient in the am, the patient was diaphoretic and responsive to voice but otherwise not following commands. ceftriaxone was changed to meningitis dose 2 gm q12, and acyclovir to cover hsv encephalitis, and neuro consulted for lp. micu consulted initially for concern of mental status changes and concern for sepsis, but at that time the patient was afebrile. through the course of the day, the patient spiked a temp to 104, hr 130s and sbp was persistently elevated above 200s not responding to iv hydralazine and lopressor. required iv to (no west micu beds) for bblocker drip for htn and for further w/u & monitoring. . in the the team was still concerned about an underlying infectious process with primary cns infection vs. portacth line infection on the differential. ua and cxr were negative. neuro suggested that was a recently added medication and could possibly be the source of mental status changes. the most likely diagnosis was thought to be serotonin syndrome given her high dose celexa & trazadone as an outpatient and the recent addition of (non-specific serotonin inhibitor) combined with her sx of fever, rigidity and hypertension. all anti-depressant medications and sedatives were stopped. cyproheptadine was started initally for serotonin sundrome but dc'd per neuro recs. the patient was still continued on her regimen for infectious meningitis since an lp had not been obtained yet. the patient had an lp under fluoro on . the lp showed no pmns or microorganisms, but one wbc was seen. pt remained afebrile with decreased rigidity for several days and the initally elevated ck, likely secondary to spasticity, trended down. her mental status improved, but she was unable to recall some of the previous days' events. all blood and urine cultures showed ngtd. patient was then transferred to the floor. patient was started on a low dose of celexa, but no other anti-depressants were re-started. acyclovir and ceftriaxone were dc'd b/c suspicion of meningitis was low. she continued tizanidine to help relax her muscles. pt worked with the patient to help her walk prior to d/c. this was difficult for her due to the rigidity in her legs. however, she had baseline rigidity in her legs prior to admission. she was discharged to home on . . * svt/paf: - pt went into svt on prior to an lp. svt did not resolve with adenosine, but she went into rapid afib which resolved with iv lopressor. she had no h/o afib in the past. etiology was thought to be secondary to increased catecholamines prior to lp (pt extremely anxious prior to procedure). ddx also included increased thyroid hormone (level only 2.5), cardiac ischemia (however no cp or st-t changes), or pe (however anticoagulated with ivc filter). an echo was ordered to assess cardiac function and no change was seen from prior echo. ef was >55% and some left ventricular hypertrophy was seen.patient remained in sinus rhythm since that episode so tele was dc'd. she was continued on coumadin and was switched from heparin to lovenox so she could go home, with plan to d/c lovenox once inr >2. . * hypertension: patient had an isolated episode of hypotension pta but was hypertensive at admission with sbps 157-214. she initally required iv labetolol to bring her pressures down, but thus was dc'd and she was continued on low dose bb, hydralazine and clonidine patch. hctz was eventually added back into her regimen and she was discharged on these medications. the etiology was likely secondary to serotonin syndrome vs known longstanding labile bps. . *constipation: pt noted she was straining to have a bm. she was given miralax, colace and her senna was changed to scheduled instead of prn. also added lactulose . * insomnia: patient was unable to sleep. her trazodone was dc'd d/t her possible serotonin syndrome, and she has hallucinations when she takes ambien. she noted benadryl does not work for her and 1 mg ativan did not help her. . * headache: pt c/o frontal headaches, with no nausea or vision changes, but she noted seeing spots. during this admission she had a head ct and lp which were negative, so could r/o meningitis, acute intracranial process or mass. could have been d/t migraine or lack of sleep (which she noted has caused headaches in the past). tried fioricet to help with headaches. . * acute renal failure: patient had arf on admission ad was thought to be pre-renal azotemia since it improved with hydration. she was continued on gentle iv hydration and meds were dosed by cr clearance. . * spinal stenosis: patient had pain secondary to this and was on iv morphine at home. switched to a morphine pca for home use. . * hypothryoid: tsh low, ft4 high; difficult to interpret in acute setting. contined home doses of synthroid. . * dm2: was on metformin as an outpt. continued pt on riss and qid fingersticks. . *elevated inr: was 3.1 at admission and likely secondary to coumadin use. pcp stated that the pt is very hypercoagulable and has a high propensity for pe if subtherapeutic for even a short period of time. fibrinogen was not low so this was likley not secondary to dic. her inr was reversed with vit k and ffp prior to lp. she was discharged on coumadin and lovenox. . *h/o chf: no evidence of failure on exam. ef was >55% by echo at this admission. . *hx of seizures: keppra was continued. bedside eeg showed no seizure activity. . * fen: continued diabetic, heart healthy diet. . *access: 2 pivs and portacath . *prophylaxis: lovenox and coumadin, ppi, bowel regimen . *code: full, confirmed with husband . medications on admission: - vancomycin 1mg iv q12h, started by pcp (started 3 days ago) - celexa 80 qd - toprol xl 25 mg qd - hctz 25 mg qd - glucophage 500 mg - lisinopril 40 mg tablet qd - clonidine 0.1 mg/24 hr patch weekly qsat - hydralazine 25 mg q8h - asa 325 mg po qd - levothyroxine 175 mcg (tid qsunday) - nitrofurantoin 100 mg qhs - levetiracetam 500 mg - trazodone 100 mg hs - quinine 325 mg tid - amitriptyline 50 mg tablet qhs - tizanidine 2 mg tid - tizanidine 4 mg qhs - morphine 1 mg iv q10m prn, 2mg/hr gtt - warfarin 5 mg qd - riss - epogen 5000 u sc qmonday and thursday - o2 2l per min - prevacid - docusate sodium 100 mg tid - polyethylene glycol 3350 17 g (100%) 1 packet po qhs - fleet enema rectal q48hours - magnesium hydroxide 400 tid - nystatin powder - folate 1 mg po qd - fibercon 1250 mg tid - denies any dietary suppl discharge medications: 1. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). 2. quinine sulfate 325 mg capsule sig: one (1) capsule po tid (3 times a day). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. tizanidine 4 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 5. tizanidine 2 mg tablet sig: one (1) tablet po tid (3 times a day). 6. citalopram hydrobromide 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*qs 1 month* refills:*2* 7. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 8. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). 9. polyethylene glycol 3350 17 g (100%) packet sig: one (1) packet po daily () as needed for constipation. 10. morphine 1 mg/ml syringe sig: one (1) as dir injection asdir (as directed): basal: 2mg/h bolus: 1 mg lockout: 6 minutes. as dir 11. levothyroxine sodium 175 mcg tablet sig: one (1) tablet po tid (3 times a day): please take on wednesday and sunday. 12. levothyroxine sodium 175 mcg tablet sig: one (1) tablet po bid (2 times a day): take on mon, tuesday, thursday, friday and saturday. tablet(s) 13. warfarin sodium 5 mg tablet sig: two (2) tablet po hs (at bedtime): please have your inr checked in days to adjust your coumadin dose. disp:*qs 2 weeks* refills:*2* 14. docusate sodium 100 mg capsule sig: one (1) capsule po three times a day. 15. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 16. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 17. glucophage 500 mg tablet sig: one (1) tablet po twice a day. 18. insulin regular human 300 unit/3 ml insulin pen sig: as directed as directed subcutaneous four times a day: please continue your sliding scale insulin as you were prior to admission. 19. nitrofurantoin macrocrystal 100 mg capsule sig: one (1) capsule po at bedtime. 20. fleet enema 19-7 g/118ml enema sig: one (1) ml rectal rectal q48 hours. 21. magnesium oxide 400 mg tablet sig: one (1) tablet po three times a day. 22. nystatin 100,000 unit/g powder sig: one (1) apply to affected areas topical 2-3 times per day. 23. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch transdermal qwednesday. 24. hydralazine 25 mg tablet sig: one (1) tablet po every eight (8) hours. 25. enoxaparin sodium 80 mg/0.8 ml syringe sig: eighty (80) mg subcutaneous every twelve (12) hours: until inr >2, then can discontinue. disp:*qs 2 weeks* refills:*2* 26. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 27. epogen 10,000 unit/ml solution sig: as directed as directed injection every monday and thursday. 28. fibercon 625 mg tablet sig: two (2) tablet po twice a day. discharge disposition: home with service facility: vna discharge diagnosis: seratonin syndrome discharge condition: stable discharge instructions: weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet please call your doctor rigidity or other concerning symptoms. please discontinue your , trazodone, and amitriptyline. continue the celexa at 10 mg dose. please have your inr (coumadin level) checked in days. please continue your insulin sliding scale as directed by your physician prior to you admission. followup instructions: 1. please follow up with dr. in weeks. 2. please have your inr checked in days, to adjust your coumadin dose. md procedure: spinal tap incision of lung enteral infusion of concentrated nutritional substances diagnoses: congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified atrial fibrillation other convulsions infection and inflammatory reaction due to other vascular device, implant, and graft headache other extrapyramidal diseases and abnormal movement disorders antidepressants causing adverse effects in therapeutic use personal history of malignant neoplasm of thyroid neurogenic bladder nos 

Answer: The patient is high likely exposed to