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, ams major surgical or invasive procedure: peg tube placement history of present illness: 84f, h/o iddm, dens fx in after fall w/ delayed spinal cord injury (upper extremity weakness) in , s/p halo placement, presents from rehab facility with altered mental status and hypotension. at baseline, per records, she is oriented x2, speaks in full sentences. on admission she was oriented x1 and was not speaking coherently. her systolic blood pressure at rehabilitation was 74, and she wsa started on cipro (day 1 ) for a uti from an indwelling foley. . in the ed, initial vs were: 100.9 103 99/66 18 97%. exam showed no focal neurologic deficits. she received 3l ivf with blood pressure increase to the 100's. dipped down again to 70s, responded to fluids. baseline reportedly around 90-100s. she was noted to have a wbc 14.6, febrile to 100.9. got vanc, zosyn. ct head showed no acute process. creat noted to be 1.7, up from baseline 0.6. had poor urine output in the ed (~100 cc over the last few hours). also noted to have trop 0.17, without chest pain or ekg changes. aspirin given. guiaic negative. heparin drip ok'd by neurosurgery, however ultimately cards decided not to start in the setting of no ekg changes, no chest pain, and flat ck-mb. vs on transfer: 95 96/50 16 98% ra . on admission to the the icu, the patient received a ct chest/spine which showed a non-displaced fracture of the anterior and posterior arches of c1, and showed a type ii fracture of the odontoid process that had improved alightment and healing. her blood cultures came back as gram positive cocci in pairs and clusters, but this was felt to be a contaminent since she did not have any leukocytosis or fever. ortho was consluted for left knee pain, and indicated that they did not feel it was septic arthritis; joint not tapped. renal was consulted as the patient was anuric in the setting of a normal renal u/s. tte showed overall left ventricular systolic function is normal, inconclusive for endocarditis, but did have some mitral regurgitation. renal recommended diuresing with metolazone and iv lasix. g-tube placement complicated by the fact that patient is in halo, and wil lneed anesthia, but is a difficult intubation. family in meeting is ok to rescind dnr/dni one time if needed to place peg tube. they would also be ok with dialysis for short time if needed. recently patient has been even in i/os. the patient has never had leukocytosis and fever, and a source for infection was never locatlized. there was concern from renal for atn after hypotension from ischemia. past medical history: ra gerd htn dm 2 depression social history: married, lives with husband. no tobacco, occas etoh, no drugs. ambulates with walker at baseline. family history: n/c physical exam: general: alert, no acute distress, oriented x 1. unable to answer most questions heent: sclera anicteric, mm dry, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: moving all extremities, cn intact pertinent results: admission labs 04:45pm blood wbc-14.6* rbc-3.96* hgb-11.8* hct-35.0* mcv-89 mch-29.8 mchc-33.7 rdw-14.8 plt ct-356 05:00am blood glucose-90 urean-23* creat-1.9* na-142 k-3.7 cl-115* hco3-18* angap-13 . pertinent labs 05:00am blood glucose-90 urean-23* creat-1.9* na-142 k-3.7 cl-115* hco3-18* angap-13 04:21pm blood glucose-68* urean-28* creat-2.5* na-144 k-4.3 cl-118* hco3-15* angap-15 07:58am blood glucose-160* urean-32* creat-3.1* na-142 k-3.9 cl-112* hco3-20* angap-14 06:18pm blood glucose-166* urean-32* creat-3.4* na-141 k-3.8 cl-110* hco3-21* angap-14 03:34am blood glucose-107* urean-34* creat-3.7* na-141 k-4.0 cl-109* hco3-21* angap-15 05:19pm blood glucose-91 urean-36* creat-4.2* na-142 k-4.1 cl-110* hco3-21* angap-15 03:09am blood glucose-90 urean-38* creat-4.5* na-141 k-3.7 cl-108 hco3-23 angap-14 04:43pm blood glucose-225* urean-42* creat-4.7* na-142 k-3.9 cl-107 hco3-22 angap-17 03:43am blood glucose-122* urean-43* creat-4.7* na-145 k-3.6 cl-109* hco3-23 angap-17 . 04:45pm blood ctropnt-0.17* 11:50pm blood ctropnt-0.18* 05:00am blood ck-mb-9 ctropnt-0.21* 04:21pm blood ck-mb-8 ctropnt-0.22* 05:19pm blood ck-mb-4 ctropnt-0.16* 03:09am blood ck-mb-4 ctropnt-0.14* . 05:00am blood crp-125.1* . labs on discharge: lactate:1.4 141 103 35 -------------<64 4.2 23 2.6 ca: 8.5 mg: 2.0 p: 4.3 10.4 9.6 >----<399 32.4 pt: 13.7 ptt: 23.1 inr: 1.2 microbiology: blood culture - gram positive cocci in pairs and clusters urine culture - negative, ngtd final 1/10,14,14,15/11 blood culture - pending pertinent reports - chest (pa & lat) study date of 6:11 pm impression: low lung volumes, which accentuate the bronchovascular markings, particularly at the lung bases. given this, patchy left base opacity may relate to atelectasis and overlying soft tissue, although focal consolidation is not excluded. mild blunting of the posterior costophrenic angles on the lateral view could be due to pleural thickening or very trace effusions. . - knee (ap, lat & oblique) left study date of 8:03 pm impression: 1. depression of the lateral tibial plateau in the absence of a joint effusion or overlying soft tissue swelling. recommend clinical correlation for age of fracture, it may be subacute to chronic. recommend clinical correlation for point tenderness to further assess acuity and consider cross section imaging as clinically warranted. . - ct head w/o contrast study date of 9:00 pm impression: severely limited examination secondary to the halo device. no evidence of gross acute intracranial hemorrhage. . - chest (portable ap) study date of 2:58 am findings: as compared to the previous radiograph, there is a newly appeared retrocardiac and platelike left basal atelectasis. no evidence of focal parenchymal opacity suggesting pneumonia, with all limitations given positioning of the patient. borderline size of the cardiac silhouette. no evidence of larger pleural effusions. . - renal u.s. study date of 1:59 pm impression: grossly normal renal ultrasound. . - ct c-spine w/o contrast study date of 2:34 pm impression: 1. non-displaced fracture of the anterior and posterior arches of c1. possible mild interim healing along the left posterior fracture line. 2. type ii fracture of the odontoid process demonstrates improved alignment of the fracture fragments and possible partial interval healing across the fracture line. . - ct chest w/o contrast study date of 2:35 pm impression: 1. kyphosis. compression fracture of t12. 2. bilateral pleural effusions and associated atelectasis with very low likelihood of infectious process. 3. extensive degenerative changes of the thoracic spine. 4. coronary calcifications, hemodynamic significance is unclear. . - tte (focused views) done at 9:35:42 am final overall left ventricular systolic function is normal (lvef>55%). the aortic valve is not well seen. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. mild to moderate (+) mitral regurgitation is seen. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. impression: suboptimal image quality. extremely limited views. study inconclusive for endocarditis. mild to moderate mitral regurgitation. if clinically indicated, a tee may be helpful in evaluating for vegetations. . - chest (portable ap) study date of 2:55 am history: volume overload, evaluate for change. one limited ap view. lung volumes are low and there is motion artifact. an external stabilization device overlies the patient. there is no definite focal consolidation. the retrocardiac area is not well penetrated. mediastinal structures appear stable. impression: very limited study demonstrating no definite interval change. . ekg: low voltage. sinus tach @ 110. lad, normal intervals. twi iii, avf - perc g/g-j tube plmt study date of 3:19 pm final study read pending - c-spine (portable) study date of 8:12 am final study read pending - c-spine (portable) study date of final study read pending brief hospital course: 84f with h/o iddm, s/p dens fracture noted to have altered mental status and hypotension, who was found to have acute renal failure and elevated troponins, requiring admission to the micu for hypotension. # altered mental status: the patient at baseline is believed to be alert and oriented x 2. upon admission, vascular sources of ams were ruled out with a negative head ct, infectious sources were ultimately ruled out with negative blood cultures, urine cultures, a chest x-ray, as well as a surface echo. toxic-metabolic favors certainly could have played a role, with the patient's elevated troponin and cardiac injury leading to poor perfusion of her kidneys, causing an elevation in renal toxins. her mental status improved to baseline during her last few days in the icu, as well as on the floor. the patient is aaox3, but apparently is aaox2 at baseline, and she speaks in full sentences upon her discharge from the hospital. # nstemi - the patient is believed to have undergone an nstemi, based on several factors. one, the patient's troponin rose throughout her admission, peaking on , but subsequently tending down. we ended our tending of troponins as troponin level was 0.17 in the setting of known appropriate medical management of nstemi, in addition to lack of symptomatology of acs in the setting of renal injury which can elevate troponins. medical management was started with asa, statin, and bb. the patient's echo on showed a normal ef, without any obvious wall motion abnormalities or valvular vegetations. mild to moderate (+) mitral regurgitation was seen. she was discharged on medical management for an nstemi with asa, statin, and bb. . # acute renal failure/atn: on presentation, cr 1.7 from baseline 0.6. cr trended upwards to a zenith of 4.7, but afterwards began to trend down, such that on the day of her discharge, cr was 2.6. the etiology was felt to be atn secondary to kidney injury from hypotension in the context of a presumed nstemi. the renal team was involved in her care, and was diuresed in the icu with metolazone and furosemide. the patient and family were okay with cvvh or hd should renal deem it necessary, but over the course of her admission she auto diuresed, and her creatinine continued to trend down. she will need close follow-up of her kidney injury upon dc; per renal, she will follow-up in 2 week's time with one of their physicians. additionally, her ace-inhibitor can likely be restarted in 2 weeks time, per our renal physicians as well. # hypotension: the patient was noted on presentation in the nursing home to have sbps in the 70s, with a baseline around 90s-100s. upon arrival to our icu, she again dripped into the 70s, but was fluid responsive. she initially received vanc/zosyn as broad coverage for sepsis, but her blood cultures came back positive x 1 for staphylococcus, coagulase negative in bottles, leading the infectious disease team to believe this was a contaminant; antibiotics were dc'ed, and the patient maintained her blood pressure well. upon transfer to the floor, the patient maintained her blood pressures in the 110s-130s. # nutrition: per s&s, patient is not taking in adequate pos to maintain nutrition, and they've recommended a peg tube placement. family is in agreement. peg was placed via ir on . the patient tolerated the procedure well. speech and swallow also recommended a diet consisting of thin liquids, soft solids. the patient recieved her peg placement without issues, and nutrition made recommendations which are included in the patient's discharge instruction as to what her tube feeds should be. neurosurgery came by to cut out parts of the plastic halo such that her g-tube would be able to be visualized and assessed. # dens fracture s/p halo placement: patient remained in a halo per neurosurgery guidelines. they evaluated the patient and signed off, given no neurosurgical intervention required. the patient was recommended to have an appointment in 1 month's time with dr. . neurosurgery also came back to tighten the screws on the halo on the day of the patient's discharge, after finding that her halo was slightly loose. # dm: continue insulin sliding scale per in-house sliding scale, may need to be adjusted at rehab post-tube feeds. # htn: home lisinopril and hydralazine were held in the setting of hypotension/acute renal failure. these medications can be restarted by the pcp if clinically indicated once acute renal failure has resolved. # gerd: the patient was started on famotidine in house, but was discharged on her home dose of ranitidine. # rheumatoid arthritis: pain control with tylenol prn and oxycodone prn. # depression: the patient was continued on her home medication regimen. # left knee pain: the patient has bilateral knee pain, which was felt to be consistent with arthritis; we controlled this pain in-house using tylenol and oxycodone. # pending results blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient - c-spine (portable) study date of 8:12 am : final read pending - perc g/g-j tube plmt study date of 3:19 pm : final read pending - c-spine (portable) final read pending # pcp issues - stress mibi. the patient will require a stress mibi as an outpatient to ascertain if she has underwent an nstemi - follow cr, and restart lisinopril/hydralazine if patient is hypertensive, in the setting of a resolved arf - please ensure patient goes to clinic in 1 month's time (appointment has been made) - please sure that patient goes to her nephrology appointment as well - closely monitor insulin requirements as the patient is starting a new tube feeding regimen, described in the discharge instruction. medications on admission: bisacodyl 10 daily ciprofoxacin 500 colace 100 mg po bid heparin sq / currently on hold for peg placement lisinopril 2.5 mg po daily ranitidine 150 mg po bid senna 10ml daily at bedtime trazodone 12.5mg at hs mvi hydralazine 20mg po q 6 hrs prn snp >160 discharge medications: 1. bisacodyl 5 mg tablet sig: two (2) tablet po once a day. 2. colace 100 mg capsule sig: one (1) capsule po twice a day. 3. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) u injection three times a day. 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 5. senna 8.6 mg tablet sig: one (1) tablet po at bedtime. 6. trazodone 50 mg tablet sig: 0.25 tablet po at bedtime. 7. multivitamin tablet sig: one (1) tablet po once a day. 8. aspirin 81 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 9. atorvastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 11. acetaminophen 650 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*0* 12. clotrimazole 1 % cream sig: one (1) application topical once a day: apply to affected areas. disp:*1 bottle* refills:*0* 13. insulin regular human 100 unit/ml solution sig: one (1) injection injection asdir (as directed): per insulin sliding scale attached. disp:*10 ml* refills:*0* 14. oxycodone 5 mg capsule sig: 0.5 capsule po every four (4) hours as needed for pain. disp:*15 capsule(s)* refills:*0* 15. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. disp:*30 tablet(s)* refills:*0* 16. multivitamin capsule sig: one (1) capsule po once a day. disp:*30 capsule(s)* refills:*0* discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: - non-st elevation myocardial infarction - acute tubular necrosis secondary diagnosis: - rheumatoid arthritis - gerd discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: ms. , it was a pleasure taking care of you. you were admitted to the hospital because you were found to have very low blood pressure; you were in fact so ill that you needed to be in the intensive care unit. while you were there, the doctors noticed that some markers of damage to the heart were elevated, and our concern was that your heart damage led to the heart not pumping blood very well to the kidneys, which subsequently damaged the kidneys. because of this damage we started you on several new medications to help to protect your heart. our speech and swallow specialists also looked at you, and while they thought it was okay for you to continue swallowing the foods that you normally have been, their concern was that you are not taking enough nutrition by mouth. because of this concern, we placed a tube that goes from your skin directly into your stomach, so that we can feed you even if you aren't able to take food through your mouth. our nutritions made recommendations for the type of feeding that should go through your g-tube. . when you leave the hospital - stop hydralazine 20 mg daily every 6 (six) hours as needed for sbp >160 (ask your physician about restarting this if your blood pressure starts to become high) - stop lisinopril 2.5 mg daily (you can consider restarting this medication in 2 weeks) - start aspirin 81 mg daily - start atorvastatin 80 mg daily - start metoprolol tartrate 25 mg twice a day - start insulin sliding scale (see attached, will need to be adjusted as patient starting tube feedings) - start oxycodone 2.5 mg every 4 hours as needed for pain - start tylenol 650 mg every 6 hours as needed for pain - start a multivitamin capsule: take one (1) capsule once a day - start clotrimazole 1 % cream: use one (1) application topical once a day to affected areas we did not make any other changes to you medications, so please continue to take them as you normally have. - when you leave the hospital, you will need a stress mibi (stress test) your primary care doctor can order this for you. followup instructions: you have an appointment to see your primary care doctor, dr. . he is currently on vacation, but his earliest available appointment is at 2:45 pm, please meet him at this time. you have an appointment to see a nephrologist (kidney doctor), on monday at 3 pm with dr. located in the building on the . department: spine center when: thursday at 10:40 am with: , md building: sc clinical ctr campus: east best parking: garage department: radiology when: thursday at 9:45 am with: cat scan building: campus: east best parking: garage procedure: enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] diagnoses: acidosis subendocardial infarction, initial episode of care esophageal reflux mitral valve disorders acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified toxic encephalopathy friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site depressive disorder, not elsewhere classified hypotension, unspecified long-term (current) use of insulin rheumatoid arthritis surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled do not resuscitate status hyperosmolality and/or hypernatremia fall from other slipping, tripping, or stumbling chronic diastolic heart failure infection and inflammatory reaction due to indwelling urinary catheter benign essential hypertension closed fracture of c1-c4 level with unspecified spinal cord injury arthropathy, unspecified, lower leg 

Answer: The patient is high likely exposed to