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: aspirin / aleve / codeine / depakote attending: chief complaint: altered mental status after dialysis on major surgical or invasive procedure: thoracentesis central line placement (left ij) lumbar puncture picc line placement dialysis history of present illness: 72f h/o t2dm, esrd on hd, gave, htn, mr, cad, chf w/ rv failure and seizure disorder who presented to the ed on after experiencing somnolence at dialysis. it is not known how much fluid was removed during hd. the pt has no recollection of being at dialysis. in the ed, she stated that she felt fine, and denied ha, vision changes, nausea, weakness, or sensory changes. she also specifically denied any f/c/ns, abdominal pain, or cp. she did report a non-productive cough for several days and gradually worsening shortness of breath. . ed course: vs: 97.4, 121, 104/68, 14, 91ra ms. mental status cleared throughout her course in the ed. she had no leukocytosis, and chem 7 was notable for k 2.7, mg 1.5, phos 0.5, with new mild elevations in her transaminases, alk phos and tbili. ct head was negative. cxr with improving effusion but satting 91% ra. ruq u/s was done given elevated lfts: there was a negative son sign, and echogenic focus within gb wall c/w sludge, unchanged from . levaquin was given for possible pna. pt also received gentle ivf (1l ns), potassium and d50 as her bg was in the 60s and her k was 2.7. hr improved slightly to the 100s at admission. of note, shortly after being transfered to the floor, she developed . she was triggered and transfered to the micu. past medical history: * chronic gastric angiodysplasia (gave)and consequent chronic low-grade ugib, and has therefore been advised not to take aspirin or other antiplatelet agents. * dm type ii: c/b nephropathy and neuropathy - currently not on diabetic meds, has hypoglyemia poor nutritional stores * esrd: hd mwf has fistula l arm * cad * chf, r-sided, ef 50-55% with 4+ tr 2+ mr tte, and in icu with this admission * anemia: multifactorial (esrd + iron deficiency gib) * colon polyps (hyperplastic) colonoscopy * gastritis and duodenitis egd * gout * pleural effusion s/p thoracentesis negative cytology, chemistry c/w exudate * seizure disorder -dose not know how seizures manifest social history: pt lives at . no etoh, tobacco, or drugs. pt has four children, all involved in her care. there were several family meetings during this admission with all her children. they are very supportive and close family. no health care proxy is assigned at this time (). she is aware that she needs to choose one. . family history: son and daughter have dm. her son also has htn. her mother had an mi in her 80s. physical exam: at time of admission: physical exam: vs: 97.3 102/palp 118 16 972l gen: elderly female in nad. heent: ncat. sclera icteric. perrl, eomi. no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp not elevated. cv: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. decreased bs about way up left field w/ dullness to percussion. abd: distended but soft. no hsm or tenderness. +bs, small reducible umbilical hernia ext: no c/c/e. good pulses, no asymmetry. skin: no rashes. neuro: non-focal, a&ox3, moving all ext's, 4-5/5 strength, 1+ reflex b/l, following commands . at time of transfer from icu to med floor: vs: tm-97.2, tc-96.7 bp: 113/45 (85-132/31-50) hr: 81 (63-84) rr: 20 sao2: 100% 2l nc gen: elderly female, only resposive to some simple commands, some moans heent: ncat. + scleral ictertis, mucous membranes slightly dry neck: supple, no jvd, bandage from central line on the l neck cv: irregular regular rhythm, normal rate, normal s1, s2. unable to ascultate a murmur (pt making noise) chest: breathing comfortably, rhonchi bilaterally. abd: soft, nt/nd. no hsm or tenderness. +bs, umbilical hernia ext: pitting 1+ edema to the knees, peumatic compression devices in place, 2+ dps bilaterally skin: no rashes, or bed sores neuro: 1+ reflex b/l, will squeeze fingers bilaterally, peerl, unable to test other cn, pt does not move toes or open eyes to command., pt moans occasionally, gcs of 9 lines: picc on rt arm, ngt, rectal tube (liquide dark green stool) pertinent results: admission labs: 04:12pm glucose-66* lactate-1.7 k+-2.7* 04:12pm hgb-12.5 calchct-38 04:00pm glucose-66* urea n-8 creat-1.8*# sodium-142 potassium-2.7* chloride-100 total co2-35* anion gap-10 04:00pm estgfr-using this 04:00pm alt(sgpt)-43* ast(sgot)-95* ck(cpk)-205* alk phos-249* tot bili-3.8* dir bili-2.3* indir bil-1.5 04:00pm lipase-112* 04:00pm ctropnt-0.17* 04:00pm ck-mb-4 04:00pm albumin-2.5* calcium-7.8* phosphate-0.6*# magnesium-1.5* 04:00pm wbc-5.5 rbc-3.62* hgb-11.9* hct-36.7 mcv-102* mch-33.0* mchc-32.5 rdw-20.0* 04:00pm neuts-75* bands-0 lymphs-9* monos-16* eos-0 basos-0 atyps-0 metas-0 myelos-0 04:00pm hypochrom-normal anisocyt-occasional poikilocy-normal macrocyt-normal microcyt-normal polychrom-occasional 04:00pm plt count-117*# . discharge labs: . . reports: cxr - ap upright and lateral views of the chest are obtained. cardiomegaly is again noted with large tapering left pleural effusion. right lung is essentially clear and unchanged. there is no evidence of pneumothorax. osseous structures reveal a compression fracture in the upper- to-mid thoracic spine which is new since . ct head - impression: no hemorrhage, edema, or fracture. us liver - moderate ascites with gall bladder wall thickening and edema, unchanged from prior study, likely due to third spacing. no evidence of acute cholecystitis. echogenic focus within the gall bladde possibley adherent sludge. ct chest - conclusion: 1. no pulmonary embolism or aortic dissection. extensive atherosclerosis is present in the coronary arteries and there is an aberrant origin of the right coronary artery which traverses between the aortic root and the pulmonary artery. 2. cardiomegaly, pleural and pericardial effusion as well as ascites could represent congestive cardiac failure. there has been significant interval increase in the right pleural effusion with almost complete collapse/atelectasis of the left lung. 3. enlarged mediastinal lymph nodes are unchanged since the prior examination and may be assessed further to exclude indolent lymphoma. echo - a small secundum atrial septal defect is present (cine loop #34). there is mostly left-to-right shunting, but after injection of aerated saline into the right atrium, right-to-left bubble transit is seen, as well. the estimated right atrial pressure is 10-20mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%) the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular volume overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets fail to fully coapt. severe tricuspid regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: dilated and hypokinetic right ventricle. preserved left ventricular systolic function. moderate mitral regurgitation. severe tricuspid regurgitation secondary to annular dilation. small secundum asd with bidirectional flow. . ct of head - impression: no acute intracranial abnormalities. old infarct of the left frontal lobe and insula as well as the left thalamus. . ct chest/abd/pelvis - impression: 1. no acute intra-abdominal process is seen. there is no evidence of ischemic bowel. 2. moderate free intraperitoneal fluid is seen. 3. reflux of contrast into the hepatic veins and intrahepatic ivc does suggest right heart failure. 4. dilated common bile duct without evidence of an obstructing lesion. this has in fact progressed in diameter since a prior torso imaging. therefore, an mrcp is recommended for further evaluation of this finding. 5. bilateral pleural effusions, decreased in size since the prior exam. 6. areas of consolidation at the lung bases as detailed above. 7. endotracheal tube extends into the main stem bronchus. . mri/mra brain - mri of the brain: the -white matter differentiation of the brain is well preserved. the ventricles and extra-axial csf spaces appear normal. there are old lacunar infarcts in the centrum semiovale bilaterally visualized with adjacent view of this. there is no evidence of an acute infarct. there is no evidence of intracranial edema, mass effect, shift of normally midline structures, or hydrocephalus. the posterior structures appear unremarkable. the major vascular flow voids are well preserved. there is hyperintensity visualized in both mastoid air cells suggestive of fluid within the mastoid air cells. there are multiple susceptibility artifacts visualized in the left temporal lobe, right aspect of the pons, and in both cerebellar hemispheres, which may represent multiple cavernomas or dystrophic calcifications. visualized orbits and paranasal sinuses appear normal. . mra of the brain: the anterior circulation including the intracranial internal carotid artery, anterior and middle cerebral arteries bilaterally appear normal. the vertebrobasilar system and both posterior cerebral arteries appear normal. there is no evidence of an aneurysm (greater than 3 mm), flow-limiting stenosis, or occlusion. . cxr - increased consolidation of left lung, which could be compatible with pneumonia or aspiration. . eeg - impression: possibly normal eeg in an extremely drowsy patient. whether this is related to sleep deprivation or medications that the patient is taking or represents an early encephalopathy cannot be determined from this record. no definitive epileptiform abnormalities were, however, seen. . us upper extremity - impression: no evidence of dvt in the right upper extremity. - (done because had erythma around picc site.) . ekg - compared to prior tracing irregular sinus mechanism at rate about 55 has replaced atrial flutter. there are occasional atrial premature beats and ventricular premature beats. generalized low voltage remains. in addition, there is q-t interval prolongation consistent with drug effect and also rightward axis. anteroseptal myocardial infarction of indeterminate age cannot be excluded in either tracing. brief hospital course: 71 yo f with dm, esrd on hd, gave, htn, chf w/ rv failure, who p/w altered ms . admitted to the icu, intubated and on vasopressors. was successfully extubated and had several days of altered mental status, where she was uncommunicative and unable to eat. she was refusing ngt and peg was contraindicated with her ascites. improved, started taking po. had intact mental status with some memory problems upon discharge. . after admission and icu course: admitted to floor after dialysis somnolence. transferred to micu after only a few hrs . pt had a an echo in the icu that showed dilated, hypokinetic rv w/ 4+tr. pt was emperically treated w/ vanc/meropenem, then was switched to cefepime for possible pna (now s/p 10-d course). pt also has a l-sided chronic pleural effusion (exudative), pt is s/p thoracentesis of 1.5 l w/ exudate, but no infection. pt had a possible seizure during thoracentesis, so she was intubated and started on neosynepherine. neuro was consulted and eeg showed no seizure activity. lp was performed w/o evidence of bacterial meningitis, however pt was placed on acyclovir. hsv pcr was negative and acyclovir was stopped.. pt has gone in and out of aflutter, but was transfered to the floor in sinus rhythm with 2-3 beat runs of nsvt. pt was on heparin ggt briefly but this has been stopped. she was extubated on , and has been off pressors since . pt has stayed in icu mental status which waxes and wanes, and at best the pt is resposive to only some simple commands. has ngt and on tube feeds. pt does reportely have some baseline altered mental status, but is signifcantly changed from baseline. pt was transfered to the medicine floor on , with vitals of 113/45, 84 (sinus), 20, 99% on 2l. . on the floor, the patient continued to have significantly altered mental status. she was uncommunicative and would follow some simple commands. she improved quite quickly over several days and returned close to baseline mental status according to her family. her major issue for most of her time on the floor was nutrition status. she had pulled out her ng tube and kept not cooperating for replacement. family did not want to have to restrain her to place it. she was unable to get a peg tube d/t ascites. when she woke up, she was able to take po and start repleting nutrition deficits. she had episodes of atrial flutter with into the 110s/120s. pt also had c.diff infection diagnosed. please see below for specific details of each problem... # altered mental status: at baseline pt able to walk from chair to bathroom, and communicate. pt's mental status declined while in pt when she became hypotensive. the differential consists of seizure (eeg x2 did not show seizure activity) or encephalitis (hsv-but pcr was negative, and csf studies wnl) or a global hypoxia or a metabolic encephalopathy. also possible is adrenal insuffiency, therefore, tx with iv steroids, without change, so stopped steroids. no radiologic evidence of intracranial pathology. pt believed to have seizure during thoracotomy as stated above. pt remained in stuporous state until approximately when her mentation started to improve. likely cause of mental status changes was multifactorial - including metabolic derangements from kidney and liver disease. she was continued on her home dose of keppra her entire stay in the hospital. she is leaving the hospital back at her baselin. . # : unclear etiology, originally thought due to possible pneumonia, as stated above, pt required pressers in icu. cta negative for pe. echo showed no pericardial effusion or tamponade. pt improved in the icu and was successfully weaned from pressors. she maintained appropriate blood pressures, and all her antihypertensive medicines were held, and are still being held upon discharge, sbps are in 140s upon discharge, but often drop lower after . she will be on no antihypertensive medicines on discharge. . # possible pna, hypoxia: with coughs (though no leukocytosis, no fever). cxr showed worsening pleural effusion and collapse of lll initially. pt treated with empiric vancomycin and meropenem (switched from imipenem due to lower seizure threshold from imipenem)for 10 day course. sputum cx was negative. follow up cxrs showed persisent effusions. pt was breathing well on ra upon discharge. no cough. . # arrhythmia: in icu pt had transient which improved with ivf, pt alternated between sinus tach and atrial tach. improved somewhat w/metoprolol, which was later stoped d/t bradycardia into the 30s. most likely initially reflected hypovolemia, but not compeletly clear. no pe on chest cta. pt was monitored on telemetry and had intermitenty ectopic beats, nsvt up to 3 beats, which may have been related to hypokalemia. while on floor, patient converted into atrial flutter with rates between 110 and 130. pt was started on metoprolol. pt then converted to nsr with hrs in 60s. metoprolol was stopped at this time and she was not discharge . # effusions: large left pleural effusion. prior fluid analysis showed exudative process, w/o identifiable cause, cytology negative as well. currently being followed by pulmonary, dr. . during this stay, thoracentesis was performed but resulted in intubation as stated above. pt continues to have effusions, but not symptomatic. pt breathing well on ra upon discharge. . # transaminitis: likely due to congestive hepatitis in setting of rv failure. pt's lfts trended down during her hospital course. pt does have elevated inr, likely d/t some liver dysfunction. no evidence of liver pathology on any imaging studies. . # hyperlipidemia: statin was held in setting of transaminitis. still held on discharge. . # esrd/hd: on hd mwf. hd was continued while in pt, pt on phoslo, and renal labs were closly monitored. pt will need to continue hd upon discharge mwfs for fluid status management. phoslo had been discontinued during admission. upon discharge phos level was low at 1.2. on the day of admission, pt was given 4 packets of neutrapohs. the renal fellow was called about her level and thought discharge was still appropriate. pt is scheduled for dialysis the day after discharge. her phos level will be checked there. dr. , her nephrologist, will be faxed the results and is aware of the problem. . # hypoglycemia: pt had several episodes of hypoglycemia in icu, likely in setting of npo; got dextrose and fs improved after adjusted riss. continued to have episodes of hypoglycemia while on floor and there was no way to have nutritional support (no ngt or peg and somnelent). was on d10w for several days and still had blood sugars in 60s and 70s. pt then started to have improved mental status. she passed a speech/swallow test and was started on ground food and thin liquids. she will go home on a diet that remains ground. per swallow team, she can have repeat study with her denturs if she is to be made full diet. endocrine team was also following and ruled out insulinoma as possible cause. insulin level was low and c-peptide was likely elevated because it is usually cleared by the kidney. encourage small and frequent meals to maintain blood sugar. can use glucose tabs if needed. . # dm: held all diabetic medicines due to hypoglycemia. see above. . # c.diff - had diarrhea during most of her time on the floor. stool culture was positive for c.diff. on flagyl po tid. needs to complete 14 day course. day 1 of antibiotics was . pt will be given prescription for rest of course upon discharge. she was still having diarrhea at the time, but no white count, fevers or abdominal pain. . # new thoracic compression fracture: pt asymptomatic, no treatment. . # megaloblastic anemia: b12 and folate levels are normal, unclear etiology, was monitored and remained stable throughout admission. . # code: full. had several family meetings during stay. palliative care was consulted and helped us coordinate the meetings and discuss the patients prognosis. family is aware of her end organ failure and fragile state. medications on admission: medications: from dc summary in . isosorbide dinitrate 30 mg po bid 2. pantoprazole 40 mg q24h 3. metoprolol tartrate 75 mg po tid 4. lisinopril 20 mg po daily 5. levetiracetam 250 mg po bid ?? not on list from nh 6. b complex-vitamin c-folic acid 1 mg po daily 7. hydroxyzine hcl 25 mg po q6h as needed. 8. atorvastatin 20 mg po daily 9. cinacalcet 30 mg po daily ?? not on list from nh 10. gabapentin 300 mg po qhd ?? not on list from nh 11. citalopram 20 mg po daily ?? not on list from nh 12. acetaminophen 325 mg 2tbl po q6h as needed. 13. glipizide 2.5 mg 24hr po once a day. 14. phoslo 667mg po tid with meals discharge medications: 1. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. disp:*1 tube* refills:*0* 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 3. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 10 days. disp:*30 tablet(s)* refills:*0* 4. keppra 100 mg/ml solution sig: two y (250) mg po twice a day: please take 2.5 ml twice daily to get a dose of 250 mg . disp:*150 ml* refills:*2* 5. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 2x/week (mo,th) for 2 months. 6. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day: start after 2 months of 50,000u twice weekly is completed. 7. outpatient lab work please check phosphate level at on and fax result to : fax (. discharge disposition: extended care facility: discharge diagnosis: primary diagnosis: 1. altered mental status of multifactorial etiology 2. chronic liver disease with ascites, likely secondary to r heart failure 3. chronic kidney disease stage v 4. pleural effusions of undetermined etiology 6. c.difficile colitis secondary diagnoses: 1. siezure disorder 2. anemia 3. compression fracture 4. gave syndrome with hx ugi bleed discharge condition: pt was afebrile, stable vital signs. pt was unable to ambulate by herself, she was able to walk a short distance with the help of physical therapy. she was a+ox3. she was having diarrhea at the time of discharge. discharge instructions: you were admitted for being somnulent after a dialysis session. it was thought that you may have had a pneumonia, and there was fluid in your lungs. the medical team tried to get the fluid off of your lung with a procedure called a thoracentesis. during this your blood pressure became very low and you had to go to the icu where they kept your blood pressure high with iv medicine and helped you breathe with intubation. your body started to recover and you were brought to a regular medical floor. on the floor, you remained somnolent and confused. you were unable to eat and we could not feed you through a tube. eventually you started to improve. you passed a swallow test and started eating. we were worried because your blood sugar kept dropping low, probably due to your kidney failure and poor nutritional stores. you need to keep eating at regular intervals to keep your blood sugars up. you also had an irregular heart beat at times. sometimes it was too fast, and sometimes it was too slow. we monitored you on telemetry because of that. when you left the hospital, your heart rate was regular and going about 60 beats per minute (a normal rate). you also were diagnosed with an infection of your bowels call c.diff. you need to take flagyl, an antibiotic for a total of 14 days to treat this infection. we stopped some medicines you had been taking at home before this hospitalization. please see the discharge sheet for what you will take now. you must continue m, w, f or as your renal doctor recommends. you will continue physical therapy in rehab to try to regain your strength. please call or return to the hospital for any chest pain, shortness of breath, worsening diarrhea, or any other concerns. you should see your doctor regularly. call 911 for any emergencies. followup instructions: please make appointment with pcp for two weeks to follow up on c.diff infections: , l. please follow up with your renal doctor . you need to go to dialysis tomorrow. dr. , your nephrologist, will continue to follow you. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified spinal tap incision of lung insertion of endotracheal tube hemodialysis thoracentesis diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified anemia in chronic kidney disease end stage renal disease mitral valve disorders unspecified pleural effusion congestive heart failure, unspecified polyneuropathy in diabetes atrial flutter hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease acute respiratory failure intestinal infection due to clostridium difficile pressure ulcer, lower back epilepsy, unspecified, without mention of intractable epilepsy other ascites encephalopathy, unspecified diabetes with other specified manifestations, type ii or unspecified type, uncontrolled hepatitis, unspecified chronic diastolic heart failure angiodysplasia of stomach and duodenum with hemorrhage diabetes with neurological manifestations, type ii or unspecified type, uncontrolled pathologic fracture of vertebrae diabetes with renal manifestations, type ii or unspecified type, uncontrolled shock, unspecified 

Answer: The patient is high likely exposed to