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: no known allergies / adverse drug reactions attending: chief complaint: hypotension major surgical or invasive procedure: subclavian line history of present illness: 68 yo m with history of fibromyalgia with chronic pain, mi s/p rca stent, htn, copd, and afib not on anticoagulation who was transferred from hospital with hypotension. pt was admitted on at hospital for altered mental status. his wife found him and thought that he was weak, confused, acting strange. he was asking for people who were not there. he fell twice when he was at home, did not lose consciousness, but appeared shakey. per records, pt had no preceding symptoms of cp, palpitations, nausea, unilateral weakness, bowel or bladder incontinence, or loss of consciousness. per his wife, the shakiness in his legs and arms has been going on for a couple of months. he was also having stomach pains for "a long time" and has had a barium study before (3-4 years) that was negative and thought that it was possible reflux. at the osh, he had an ecg showing sinus bradycardia, old inferior wall mi, and 2 trops negative. ct scan of head on showed 1cm low density periventricular white matter change and 2 areas on the right, suggestive of chronic ischemic changes. serum tox was negative for salicylates, tylenol, etoh. ua was benign, labs were notable for bun 46, cr 2.8, wbc 11.3 with normal diff, and hct 33.9 with plts 302. given altered mental status, pt had lp which showed csf rbc 274, wbc 8, and he was started on acyclovir for possible hsv encephalitis. prelim gram stain negative, and cultures prelim ngtd (lp done ). neurology was consulted given altered mental status and concern for seizure, and recommended and mri. the mri on showed chronic changes without ic abnormalities; additionally, there was no signal abnls in temporal lobes to support viral encephalities. there was decreased attenuation in periventricular white matter, suggestive of chronic vessel ischemia. he had a c-spine mri as well that showed degenerative changes, but no signal abnormalities. on , he was found to have a rigid body, concerning for serotonin syndrome. his cymbalta had been held 24hrs prior to this. after this episode, he appeared confused and minimally responsive, and therefore, seizure thought to be a possible etiology. neurology recommended loading with fosphenytoin and starting dilantin. he was intubated and transferred to the icu given apnea and inability to protect his airway. he was placed on ac tv 500, rr 15, peep 5, fio2 40%. id consult on , rec possible hsv encephalitis and to continue acyclovir while awaiting hsv pcr. however, per their note, suspected non-infectious etiology. he was discharged with possible diagnoses including nonconvulsive status epilepticus, probable serotonin syndrome, on acyclovir for possible herpes encephalitis (hsv pcr from csf pending), metabolic acidosis with resp compensation, arf, rhabdomyolysis, microcytic anemia, afib. per his wife, she was concerned because he "seemed to get worse" every day. she reports that he was seeing things, including people, "a committee of ten people." regarding his previous history, per his wife, his previous doctors had suspecting lyme disease in him for some time now. she says that given his muscle aches, feeling tired, they suspected lyme could be playing a role as well. he in fact had a rash a few years ago at and nothing was ever found. ros: unable to obtain given intubated and sedated past medical history: hypertension fibromyalgia erectile dysfunction copd without acute exacerbations mi s/p stent to rca atrial fibrillation hyperlipidemia social history: lives at home with wife. is a current smoker, trying to quit. dependent on his wife for most activities of daily living. no alcohol use. family history: unable to obtain physical exam: admission physical exam: vs: temp: 96.3 bp: 168/76 hr: 53 rr: 16 o2sat 100% on peep 5, fio2 100% gen: intubated, sedated, nad, non-arousable, not withdrawing to painful stimuli heent: perrl, anicteric, mmm, op without lesions neck: right subclavian line in place, no jvd, no carotid bruits cvs: bradycardic, regular rhythm, s1 and s2 wnl, no murmurs resp: comfortable on vent, cta b/l anteriorly without wheezes or crackles abd: +nabs, nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: slightly cool, dry, no , purplish lesion on left 5th metatarsal skin: no rashes/no jaundice, ~1cm erythematous skin breakdown on right forearm neuro: intubated, sedated. pupils equal, round, reactive. does not withdraw to pain. 2+ biceps, patellar 2+ r dtr, 3+ l. beats clonus bilaterally discharge physical exam: vs: tmax 98.3 tc 96.6 bp 138/73 hr 89 rr 18 o2 sat 94% 2l nc gen: pale appearing man in nad. heent: perrl, anicteric, mmm, oropharynx without lesions, conjunctiva pale neck: supple, no jvd, no carotid bruits cvs: rrr, s1 and s2 wnl, no murmurs resp: faint bibasilar crackles l>r, no increased wob, no cyanosis abd: +nabs, mildly distended, soft, nt, no masses or hepatosplenomegaly ext: slightly cool, dry, no c/c/e, 1+ pulses bilaterally skin: no jaundice, extensive senile purpura and abrasions, erythematous macular rash on superior back neuro: a/o x3, cn ii-xii intact, ab/adductors in bues, flexion/extension in bues, flexion/extension in bles. pertinent results: admission labs: 08:32pm blood wbc-15.5* rbc-4.24* hgb-10.2* hct-31.8* mcv-75* mch-24.1* mchc-32.1 rdw-18.5* plt ct-292 08:32pm blood neuts-78* bands-0 lymphs-15* monos-5 eos-0 baso-0 atyps-0 metas-2* myelos-0 08:32pm blood pt-12.7 ptt-25.3 inr(pt)-1.1 08:32pm blood ret aut-2.0 08:32pm blood glucose-119* urean-27* creat-1.9* na-143 k-4.9 cl-113* hco3-17* angap-18 05:51am blood glucose-147* urean-25* creat-1.6* na-144 k-4.5 cl-115* hco3-21* angap-13 04:48am blood glucose-165* urean-13 creat-1.2 na-140 k-3.3 cl-112* hco3-21* angap-10 08:32pm blood alt-25 ast-43* ld(ldh)-268* ck(cpk)-363* alkphos-82 totbili-0.3 08:32pm blood albumin-3.5 calcium-8.8 phos-3.8 mg-2.2 iron-51 08:32pm blood caltibc-346 hapto-257* ferritn-29* trf-266 05:51am blood vitb12-1206* 05:51am blood tsh-0.49 05:51am blood cortsol-22.9* 08:02pm blood tobra-2.3* 08:36am blood vanco-38.7* 08:32pm blood phenyto-10.9 08:36am blood phenyto-10.3 05:51am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg 05:02am blood type-mix temp-38.3 10:29am blood type- temp-37.8 po2-44* pco2-43 ph-7.34* caltco2-24 base xs--2 06:10am blood type-art po2-74* pco2-37 ph-7.36 caltco2-22 base xs--3 09:47pm blood type-art rates-16/ tidal v-500 peep-5 fio2-50 po2-148* pco2-41 ph-7.30* caltco2-21 base xs--5 -assist/con intubat-intubated 08:55pm blood type-mix ph-7.25* comment-green top 08:55pm blood lactate-1.1 05:43am blood wbc-10.4 rbc-3.70* hgb-8.9* hct-27.7* mcv-75* mch-24.0* mchc-32.0 rdw-20.5* plt ct-354 05:43am blood glucose-112* urean-19 creat-1.3* na-141 k-4.7 cl-105 hco3-26 angap-15 05:43am blood calcium-9.1 phos-2.8 mg-2.1 discharge labs: micro: blood cx : no growth urine cx : urine culture (final ): gram negative rod(s). ~8ooo/ml. lyme serology (final ): no antibody to b. burgdorferi detected by eia. 10:17 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in chains. smear reviewed; results confirmed. respiratory culture (final ): moderate growth commensal respiratory flora. legionella culture (preliminary): no legionella isolated. fungal culture (preliminary): no fungus isolated. wound culture catheter tip(final ): no significant growth. 4:45 am sputum source: endotracheal. gram stain (final ): >25 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. legionella culture (preliminary): no legionella isolated. fungal culture (preliminary): gram stain of this specimen indicates contamination with oropharyngeal secretions and invalidates results. specimen is only screened for cryptococcus species. new specimen is recommended. studies: cxr ap impression: ap chest reviewed in the absence of prior chest radiographs: small infrahilar regions of peribronchial opacification could represent early pneumonia. followup advised. there is no pulmonary edema or appreciable pleural effusion. heart size is normal. endotracheal tube and right subclavian line are in standard placements respectively. no pneumothorax cxr : the diffuse pulmonary abnormality has worsened slightly, most readily explained by an increasing pulmonary edema, but there is a heterogeneity in the right upper lobe that raises the possibility of concurrent pneumonia. small left pleural effusion is larger. heart size is normal. azygous distention suggests volume overload. et tube ends at the upper margin of the clavicles, standard placement. left subclavian line ends in the svc. no pneumothorax. brief hospital course: 68 year-old man with history of fibromyalgia with chronic pain, mi s/p rca stent, htn, copd, and afib not on anticoagulation who presents from hospital with acute confusional state, concern for serotonin syndrome vs. seizure, intubated for airway protection and hypotension. hypotension initially attributed to medication effect of propofol as bp was intially normal on admission. however, pt developed a fever and hypotension, with concern for septic shock. his repeat cxr showed infiltrate, concerning for pneumonia. cultures were sent and he was started on antibiotics. pneumonia was treated with an eight day course of antibiotics. he had good oxygen saturation on room air both at rest and while ambulating. he did have significant urinary retention with post-void residual of 700cc. a foley catheter was placed, flomax started. pt discharged home with vna services. problem list: # septic shock: initially hypotensive, with possible med effect of propofol vs. sepsis and shock vs. cardiogenic vs. hypovolemic. initially thought to be med effect as pt's bp seemed to drop only after receiving propofol for intubation at osh. however, developed a fever in the icu and hypotension, with concern for septic shock. his repeat cxr showed infiltrate, concerning for pneumonia. cultures were sent and he was started on antibiotics. he was initially on vanc, ceftriaxone (to cover for lyme) and tobramycin (trying to avoid additional cephalosporins that could lower seizure threshold, see below). his lyme pcr from csf at hospital resulted as negative, and serologies here were negative. given that, ceftriaxone was discontinued, and he was started on cefepime, in addition to vancomycin for gram positive coverage and tobramycin for double pseudomonas coverage. tobramycin was discontinued, and he was continued on vancomycin and cefepime for a day course for hcap. # respiratory failure: intubated given inability to protect airway, in setting of possible seizure. therefore, most likely hypercarbic resp distress, though no abg at hospital to support this. cxr on admission with no infilrate, no pulmonary edema. as above, pt developed infiltrate and he was treated for hcap. sbt was attempted once pt clinically improved from septic standpoint as above and he was extubated in the icu without event. # delirium: possible seizure vs. encephalitis vs. serotonin syndrome on initial differential diagnosis. seizure seems to be possible given description from osh with acute change in ms following with what sounds like a post-ictal state. preceding etiology for possible seizure is still unclear. pt has bilateral clonus, suggestive of diffuse process. recent mri at osh with no focal findings. hsv encephalitis much less likely given no temporal changes seen on mri, despite rbc's seen on csf. pt continued on iv acyclovir until hsv pcr resulted as negative. lyme consdiered as well, and pt was continued on ceftriaxone initially, which was discontinued once serologies here and csf lyme pcr there were negative. other etiology considered was serotonin syndrome given reported rigidity at osh, ocular clonus (resolved per notes and not seen here), and hd instability. cymbalta was initially held for this reason. neurology was consulted, and eeg was monitored with no evidence of epileptogenic activity. he was initially continued on dilantin, which was weaned down per neuro recs given no seizure activity. cymbalta was restarted at home dosing. most likely etiology was thought to be toxic metabolic encephalopathy given renal failure (see below) and infection. # acute kidney injury: unknown previous baseline. cr currently 1.9 on admission, trending down from cr at hospital. ddx includes pre-renal, vs. atn vs. ain, vs. post-obstructive etiologies. pre-renal less likely as only mildly improved since recent admission at osh. atn possible given hypotension prior to transfer. possibly pt became hypotensive, worsened by atenolol, in addition to sepsis from hcap as above. fena on admission 2.52, suggestive of intra-renal etiology. creatinine downtrended, and pt discharged with creatinine of 1.3. # microcytic anemia: most likely anemia of chronic disease vs. iron defiecieny anemia. microcytosis and elevated rdw suggest fe deficiency. chronic hemolysis unlikely given elevated haptoglobin. normal tibc makes acd less likely. further workup for this issue can continue as outpatient. # htn: hypotensive on admission, requiring pressors at osh (as above). atenolol was held, esp. in setting of . enalapril was also held and never restarted. pt was started on metoprolol before discharge. # fibromyalgia: held cymbalta, lyrica initially in the icu. pt was given fentanyl while intubated (holding home ms contin, prn oxycodone). cymbalta and lyrica were restarted once pt was extubated. ms contin and oxycodone were restarted. # urinary retention possibly bph. patient had post-void residual of 700cc on the day of discharge. a foley catheter was placed, flomax was started, and patient advised to follow-up with urology within 1-2 weeks. medications on admission: asa 81mg daily atenolol 50mg daily align 4mg daily vitamin d3 units daily coenzyme q10 100mg daily welchol 625mg 3 tabs po bid with meals valium 10mg qhs cymbalta 60 mg daily vasotec 10mg daily advair 500/50 1 puff ms contin 15mg mvi daily oxycodone 5mg q4hrs prn pain pravachol 80mg daily lyrica 75mg 3 times a day zantac 300mg viagra prn discharge medications: 1. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). disp:*30 capsule, ext release 24 hr(s)* refills:*0* 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*0* 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 4. pregabalin 75 mg capsule sig: one (1) capsule po tid (3 times a day). 5. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 6. ms contin 15 mg tablet extended release sig: one (1) tablet extended release po twice a day. 7. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 8. cholecalciferol (vitamin d3) 2,000 unit tablet sig: one (1) tablet po once a day. 9. coenzyme q10 oral 10. welchol 625 mg tablet sig: three (3) tablet po twice a day. 11. advair diskus 500-50 mcg/dose disk with device sig: one (1) inhalation twice a day. 12. pravachol 80 mg tablet sig: one (1) tablet po once a day. 13. duloxetine 60 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 14. ranitidine hcl 300 mg tablet sig: one (1) tablet po twice a day. 15. multivitamin oral discharge disposition: home with service facility: , discharge diagnosis: - encephalopathy, toxic metabolic - hypotension - respiratory failure - healthcare-associated - acute kidney injury - anemia - urinary retention 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: mr. , it was a pleasure taking care of you at . you were admitted to the hospital with confusion. you had difficulty breathing, and required intubation. you developed a pneumonia, which we treated with antibiotics. it will take some time for you to get your strength back. we are also concerned about your bladder not emptying completely. this is probably a result of an enlarged prostate. we are sending you home with a foley catheter to help drain your urine. you will follow up with your primary care doctor who can refer you to a urologist who will help manage your issue of urinary retention. during your hospitalization, the following changes were made to your medications: - started flomax - started metoprolol - stopped atenolol - stopped enalapril followup instructions: name: young, , md. location: core physicians- internal medicine address: . bldg 3a, , phone: when: wednesday, , 9:45am *dr. is covering for dr. while he is out. transitional issues: - follow-up with urology regarding urinary retention - try to wean off fibromyalgia medications as they may increase patient's risk for developing confusion in the future. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances diagnoses: pneumonia, organism unspecified other iatrogenic hypotension anemia, unspecified acute kidney failure with lesion of tubular necrosis toxic encephalopathy unspecified essential hypertension chronic airway obstruction, not elsewhere classified atrial fibrillation percutaneous transluminal coronary angioplasty status other and unspecified hyperlipidemia hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (luts) other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure old myocardial infarction retention of urine, unspecified other and unspecified special symptoms or syndromes, not elsewhere classified ventilator associated pneumonia myalgia and myositis, unspecified intravenous anesthetics causing adverse effects in therapeutic use electrolyte and fluid disorders not elsewhere classified other fluid overload 

Answer: The patient is high likely exposed to