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: nsaids attending: chief complaint: seizure major surgical or invasive procedure: -lumbar puncture -extubation (was intubated at an outside hospital) history of present illness: patient is an 82 year old female with history of cad, pvd (s/p left aka), htn, chf, afib with pacemaker, carotid stenosis, and hypothyroidism who initially presented to with right inguinal pain and right foot pain. in the ed, right foot was initially cold and pale but warmed up by itself. she received dilaudid for pain. . per discharge summary from , patient was doing well until her second day when she had 2 witnessed seizures (tonic clonic on right side of body) lasting about 10 minutes each. hr 160s, bp 150s at the time. patient was intubated for airway protection. she was given 2 mg ativan. patient had stat head ct which showed old lacunar infarcts. her ekg showed sinus tachycardia at depressions diffusely different from her old ekgs. initial cardiac enzymes were elevated with troponin of 0.33. troponin peaked here at 0.55 but trending down to 0.37. cardiac index normal. she was transferred to for management of seizures. . patient could not have mri because of pacemaker. she had lp which was negative for meningitis. per neurology, they think cause of seizures is toxic-metabolic vs. pres as she was noted to have pressures 190-200 systolic when the propofol was weaned. no history of seizures in her or her family. patient was extubated at 11 am on successfully. . patient denies any headache, dizziness, chest pain, sob, cough, abdominal pain, nausea, vomiting, leg pain or any other symptoms. she asked multiple times when she would be able to leave the hospital. she does not remember the events of her hospitalization at . per family, she complains of chest pain at rest intermittently at home. . cardiology was consulted while she was in the tsicu and felt her troponin rise was due to demand ischemia in setting of seizure and tachycardia. given her multiple medical problems and since her enzymes were trending down and she was not having any current symptoms, cardiology recommended ongoing medical management of cad and no interventions. they recommended stopping heparin gtt and holding amiodarone (started in tsicu) and sotalol (takes at home) because of long qt. also recommended starting her home lopressor dose which was being held. . given her multiple medical issues and seizure thought to be related to htn, neurology requested medical transfer. neurology recommended eeg, carotid ultrasound, and echocardiogram/tte. she was on dilantin 100 mg tid at time of transfer. neurology to follow her on the consult service. past medical history: 1. coronary artery disease; s/p rca stent at in , r coronary artery occlusion , and lad stent ' at mt aubrun, after she had acs with a trop of 2.5 2. peripherial vascular disease, s/p left below knee amputation; right leg: aorto-bifemoral bypass and right femoral popliteal bypass 3. hypertension 4. hyperlipidemia 5. afib 6. chf (diastolic dysfunction, lv function 60% in ') 7. carotid stenosis (not sure of the side) 8. phantom leg pain in the left leg 9. hypothyroidism 10. anixety 11. osteoporosis 12. iron deficiency anemia 13. gerd 14. chronic constipation 15. possible type 2 dm 16. pacemaker 17. psoriasis social history: lives in an facility in ma. an ex-smoker, 40 pack years. worked in a metal factory. denies alcohol intake. her daughter lives in and she has three adult children. according to her daughter's husband, she is non-compliant with many of her medications. wheelchair bound at baseline due to her left aka from severe pvd. family history: no family history of seizures, premature cardiac disease or cancers per patient. physical exam: vs: t 96.7, r 18, bp 150/78, p 71, o2 sat 97% ra. gen: elederly female, soft voice, a & o, bent over in a ball, sidways on bed, poor eye contact : , anicteric, no injections, perrla, eomi, op clear, dry mm, pealing skin on lips cor: rrr, s1s2, no murmur lungs: bibasilar crackles b/l, prominent kyphosis abd: +bowel sounds, soft, nontender, nondistended, + hematomas on abdomin, no hsm extrem: aka left leg, no edema of right leg,, pulses faintly paplpapble, cool upto mid calf skin: multiple ecchymosis neuro: cn 2-12 intact, strength symmetrical but poor effort, normal sensation pertinent results: initial labs: 09:33pm blood wbc-16.2* rbc-4.66 hgb-15.8 hct-44.5 mcv-95 mch-34.0* mchc-35.6* rdw-14.0 plt ct-261 06:15am blood wbc-9.7 rbc-3.59* hgb-12.3 hct-35.1* mcv-98 mch-34.1* mchc-34.9 rdw-14.0 plt ct-250 09:33pm blood neuts-84.7* lymphs-9.7* monos-5.2 eos-0.3 baso-0.1 09:33pm blood pt-13.5* ptt-29.9 inr(pt)-1.2* 06:35am blood pt-12.4 ptt-26.9 inr(pt)-1.0 09:33pm blood glucose-174* urean-23* creat-0.9 na-137 k-3.0* cl-100 hco3-24 angap-16 09:33pm blood alt-21 ast-56* ck(cpk)-374* alkphos-68 amylase-92 totbili-1.2 11:10am blood type-art po2-174* pco2-35 ph-7.38 caltco2-22 base xs--3 . cardiac enzymes: 04:20am blood ck(cpk)-573* 09:31am blood ck(cpk)-562* 06:35am blood ck(cpk)-326* 06:20am blood ck(cpk)-134 09:33pm blood ck-mb-18* mb indx-4.8 ctropnt-0.55* 04:20am blood ck-mb-14* mb indx-2.4 ctropnt-0.37* 09:31am blood ck-mb-12* mb indx-2.1 ctropnt-0.34* . lipid profile: 09:33pm blood triglyc-187* hdl-83 chol/hd-2.1 ldlcalc-58, total cholest-178 . endocrine studies: 09:33pm blood tsh-5.5* 09:31am blood free t4-1.2 . toxicology/drug monitoring: 06:35am blood phenyto-12.5 09:33pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg urine studies : 09:34pm urine color-amber appear-clear sp -1.039* 09:34pm urine blood-lg nitrite-neg protein-500 glucose-neg ketone-15 bilirub-neg urobiln-neg ph-6.5 leuks-neg 09:34pm urine bnzodzp-neg barbitr-neg opiates-pos cocaine-neg amphetm-neg mthdone-neg microbiology: 11:28 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): moderate growth oropharyngeal flora. gram negative rod(s). sparse growth. ..... 12:44 am csf;spinal fluid site: lumbar puncture **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. ..... 6:30 pm sputum source: induced. gram stain (final ): <10 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. ... source: catheter. **final report ** urine culture (final ): escherichia coli. >100,000 organisms/ml. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <= ...... blood cx x2 negative to date c.difficile -negative on stool assay testing ....... additional reports: ekg: sinus rhythm. inferolateral st-t wave changes. cannot rule out myocardial ischemia. modestly prolonged qtc interval. no previous tracing available for comparison. intervals axes rate pr qrs qt/qtc p qrs t 73 144 104 450/472 74 -24 -27 ============================== echo /tte: the left atrial volume is markedly increased (>32ml/m2). left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal and mid inferior segments. diastolic function could not be assessed. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is no pericardial effusion. impression: mild focal lv systolic dysfunction. normal right ventricular systolic function. mild mitral regurgitation. lvef 55-60% ======================== arterial ultrasound findings: right leg was examined. there is monophasic flow pattern on the femoral, popliteal and dorsalis pedis arteries. the segmental limb pressures are markedly reduced on the calf and over dp. the ankle brachial index at rest 0.59. the patient was not exercised. impression: significant right iliac and sfa disease. right posterior tibial artery could not be identified. ========================== impression: 1. less than 40% stenosis of the internal carotid arteries bilaterally. 2. tardus-parvus waveform in the left vertebral artery, suggesting stenosis in the proximal left subclavian artery. ========================== eeg: per neurology attending- demonstrated a few left temporal sharp waves with a mildly encephalopathic pattern, 7 hz background rhythms discharge labs: wbc 6,6, hct 30.1, hgb 10.4, plts 335, na 138, k 4.3, cl 106, hco3 25, bun 8, cr 0.7, glucose 82 . brief hospital course: in summary, mrs. is an 82-year-old female with multiple medical problems transferred from for newly diagnosed seizures status post icu stay with intubation, then extubated transfered to medical floor. she had some atrial tachycardias and dysrythmias as outlined below and some demand ischemia with enzyme elevations earlier in her hospital course which resolved by time of discharge. for full details by problem list format please see below hospital course summary: . # demand ischemia: on initial ekgs she had widespread lateral st depressions different from her previous ekgs. these st changes were felt to be demand ischemia in setting of tachycardia as she had atrial tachycardias up into the 150s-160s at times. normal ck mb index, and her troponins were slightly elevated to .55 soon after admission but gradually tapered down on to .37, .33 and then by her troponins were in the .06 range. cardiology was consulted and agreed with medical management given her multiple comorbidities. stopped heparin drip which was intially started, and sotalol and amiodarone were discontinued. per reports, she had notable long qt which is why sotolol was abandoned. she was continued on asa 325mg daily, plavix 75mg daily, and lopressor which was titrated up to 62.5mg tid by time of discharge with good rate control in the 60-90 range. lisinopril also continued. cardiology followed patient during hospitalization and she was set up for an outpatient follow-up appointment in a few weeks time. . # dysrhythmias: ms. had intermittent atrial tachycardias and atrial flutter noted on telemetry monitoring during her hospitalization. had a rate into the 140s without symptoms early in her admission. along with cardiology team recommendations, the medical team stopped amiodarone and sotolol and gradually uptitrated her beta blocker. she responded well and hrs improved with better rate control. electrophysiology team was consulted for pcm interogation, patient has st. pacemaker which appeared to be functioning. she was only noted to have these newer atrial tachycardia episodes post seizure.from she was slightly refractory and had increased ectopy with atrial flutter and atrial tachycardias becoming more frequent on telemetry. she also had a several runs of asymptomatic nsvt ( beat runs)which were short lived. during this timeframe she spiked fevers and underwent an infectious workup which revealed an e.coli uti and questionable lll infiltrate on cxr which was later felt to be atelectasis on better 2-view cxr. these rapid heart rates were attributed to her dehydration from infection along with her sensitivity to fluid changes given her known diastolic dysfunction. cardiology was re-consulted. tachycardias improved once she was transitioned to tid beta blocker regimen and after she was replenished with ivfs over 2 days time. . # seizures: unclear precipitant. neurology evaluated patient and was not sure of the exact cause but felt the most likely etiology of seizures was toxic-metabolic vs. pres as she was noted to have pressures 190-200 systolic when the propofol was weaned at outside hospital. no history of seizures in her or her family. she had an eeg that showed a temporal spike, that could be source of seizure, although this is not definitive. she also had a carotid ultrasound with <40 stenosis noted. electrolytes were predominantly stable. head ct showed old lacunar infarcts. lp negative for infectious etiology. could not get mri because of pacemaker, and she has no focal deficits on exam making stroke unlikely. kidney and liver function normal. toxicology screens negative. placed on initial dilantin load and then dilantin 100mg tid which was discontinued as she was transitioned to trileptal which was adjusted to ensure she had no dizziness. however, she still had some fleeting complaints of dizziness and nausea likely in setting of starting these medications; all resolved now. trileptal was downtitrated to 300mg with good results and this is her current dose. will have neurology follow up as outpatient. . # hypertension: patient had labile blood pressures initially. blood pressure poorly controlled at admission with sbps into 170-180s range. over the course of her first week her medications were increased. then she had several scattered hypotensive bouts with sbps as low as 80s range with occasional complaints of lightheadedness. this was attributed to poor po intake and dehydration and aggressive medication adjustments. i/os balance typically corroborated this with negative balance tendency. eventally re-established normotensive bp on home dose of lopressor, and addition of lisinopril. then metoprolol tartrate uptitrated for tighter rate control (now 62.5mg tid). currently well controlled with lisinopril 10 mg qd, imdur er 30mg, beta blocker and 10mg daily lasix. lasix had been decreased from her usual 20mg daily dose to 10mg daily dose now as her pressures have been in the 98-130/50-70s range and her po intake is still not optimal. she has been given several small ivf boluses in setting of her uti/dehydration which have helped to stabilize her hemodynamics. intially she was also on hydralazine for bp control, but this was discontinued as it is no longer needed, and since it can contribute to her tachycardias. . # pvd: patient had initial outside hospital presentation for leg pain. on admission leg cool with dopplerable pulses. then within hours overnight her leg rewarmed and pulses easier to palpate per reports. it stayed warm with faint pulses. skin tone normal, no apparent ischemia or cyanotic features. had abi of 0.59 of right leg. she has been set up for an outpatient follow-up in vascular surgery. . # chf: patient now appears euvolemic to low volume on daily exams. chronic diastolic chf is likely from long-term htn. tte/echo done on showed preserved lvef of 55-60% and mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal and mid inferior segments. she was continued on lasix, lopressor, imdur, and lisinopril with careful holding parameters given her shifting blood pressures as noted above. she will follow-up as an outpatient with cardiology in a few weeks. . # hyperlipidemia: for her entire hospital course she was continued on her usual atorvastatin 80mg daily alongside a daily aspirin. # uti: urinalysis revealed increased bacteria and wbcs and follow-up urine culture showed >100,000 e.coli. she had several fevers in 100-101 range which resolved several days ago after she was started on antibiotics. initially she was placed on broad antibiotics as source of her fevers unknown, and cxr had initial read of a questionable lll so she was on combination of vancomycin and zosyn for 4 days and then this was switched to po bactrim for a complicated uti, she now has 3 days of bactrim ds to continue and she will complete course on . foley catheter has been removed. currently afebrile and denies suprapubic pain. . #pna: patient with lll very questionable infiltrate on a portable cxr done after she spiked some fevers on . follow-up 2 view cxr showed only atelectasis however and she had no productive sputum and no increased cough from baseline, no uri symptoms. therefore, antibiotic regimen tailored to her uti and she was not given additional pna directed antibiotics at discharge as she is clinically stable. . # hypothyroidism: tsh elevated at 5.5, but normal free t4 soon after admission. she was continued on levoxyl 112 mcg qdaily. however, a re-check on still showed a tsh of 7.9 and ft4 was .70. hypothyroidism poorly controlled. therefore her dose of levoxyl was increased to 125mcg daily dose, and she will need her tsh and ft4 followed closely in the days after admission. this may have some bearing on her recent low blood pressures. moreover, poorly controlled hypothyroidism can contribute to diastolic htn as well. . # phantom leg pain in the left leg: continued on neurontin and fentanyl patch for her aka left leg pains. also has chronic right hip pain for which she was continued on percocet q6hrs prn. . #diabetes type ii - patient has mainly diet controlled mild type ii diabetes, noted as questionable and borderline dm in records. during her hospitalization her fsgs were checked and daily glucose levels mainly within normal ranges, well controlled. she should continue on a diabetic/cardiac healthy diet on discharge. . # anxiety: appeared very well controlled on her current medication. she was continued on usual home dose of celexa 10mg daily. . # osteoporosis: after discharge she should continue on calcium/with vitamin d supplementation and she should discuss the option of starting a bisphosphonate as outpatient with her pcp at . . # iron deficiency anemia: she was continued on ferrous sulfate 325 mg , and a bowel regimen was provided to avoid constipation. . # gerd: contined on daily protonix, no symptomatic complaints. . #diet, fluid and electrolytes: as above, additional ivfs provided for intermittent dehydration in setting of infection and fevers. given a cardiac healthy/diabetic po diet and daily electrolytes were checked and repleted as needed. . #code status: patient was maintained as a full code status and this was confirmed with patient. medications on admission: 1. sotalol 80 mg po bid 2. levoxyl 112 mcg po daily 3. lopressor 50 mg 4. asa 325 mg daily 5. lipitor 80 mg daily 6. calcium and vitamin d 500 mg po tid 7. celexa 10 mg daily 8. plavix 75 mg daily 9. colace 10. fentanyl patch 100 mcg every 48 h 11. ferrous sulfate 325 mg 12. advair 500/50, one puff 13. lasix 20 mg daily 14. percocet 1 tablet q6h prn 15. protonix 40 mg daily 16. senna 17. spriva 18. zestril 10 mg qd 19. neurontin 300 mg qhs, 100 mg qam discharge medications: 1. fentanyl 100 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q48 hours (). 2. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. atorvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 8. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 9. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. gabapentin 100 mg capsule sig: one (1) capsule po in the morning. 12. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po bid (2 times a day). 13. furosemide 20 mg tablet sig: tablet po daily (daily). 14. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily): for blood pressure. disp:*30 tablet sustained release 24 hr(s)* refills:*2* 15. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 16. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 17. metoprolol tartrate 25 mg tablet sig: 2.5 tablets po tid (3 times a day). 18. oxcarbazepine 300 mg tablet sig: one (1) tablet po twice a day. 19. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) inhalation twice a day. 20. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) for 3 days. 21. percocet 2.5-325 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain. discharge disposition: extended care facility: care center discharge diagnosis: primary- -seizure, focus in temporal lobe -cardiac ischemia -atrial tachycardia -hypertension secondary- -diabetes, type ii -peripherial vascular disease discharge condition: hemodynamically stable, afebrile, able to use wheelchair. discharge instructions: dear ms. , it was a pleasure taking care of you here at . you were admitted to due to a new diagnosis of seizures at another hospital. you had no seizures after being transferred here to . you required a ventilator due to difficulty breathing on your own but you are now breathing well on room air without difficulty. the seizure put stress on your heart and caused an irregular rhythm and may have injured some of your heart tissue. you had an ultrasound of the heart called an echocardiogram showing slightly less effective pumping of your heart. it is important to control your blood pressure to protect your heart. you were started on a new medication to prevent seizures called trileptal. the dose was adjusted to limit ant dizziness and nausea, but these may be some side effects experienced. if you experience these symptoms they should improve over time. there is also concern about the blood flow in your legs, as it is slightly reduced with poor distal pulses. this issue will need further evaluation as an outpatient by the vascular doctor. please keep your listed follow-up appointments. you will need to see your pcp, neurologist, the cardiologist, and a vascular doctor for your leg as outlined below in more detail. we spoke with your cardiologist, and he agrees to discontinue your sotalol, until you are seen by him and be reevaluated. medication instructions/changes: several changes were made to your medications. 1) your sotolol was stopped 2)hydralizine was stopped 3) you were started on a new antiseizure medication called oxcarbazine (trileptal). 4)neurontin adjusted to once daily dosing at 300mg nightly 5) levoxyl was increased for poorly controlled thyroid disease 6)metoprolol tartrate was increased to 62.5mg three times a day 7)please take 3 more days of bactrim antibiotic for urinary tract infection 8)percocet was restarted at prior home dose for your lower extremity pains 9)lasix was decreased to 10mg daily * otherwise, please continue your other usual medications as prescribed, full list attached. . lastly, if you have chest pain, palpitations, shortness of breath, fainting, loss of bowel or bladder, pain and coldness in your leg, or other concerning symptoms please seek medical attention or go to the er. followup instructions: appointments: 1) md: dr. specialty: pcp phone number: special instructions: dr. was unavailable to schedule a follow up appointment today. the office will work on setting up an appointment for next week and that they will call with the date and time. please contact dr. office after discharge if you have not been contact with this appointment. 2) md: dr. specialty: neurology date and time: 1:00pm location: building room # 457 phone number: 3) md: dr. specialty: cardiology date and time: 2:00pm location: , phone number: 4) md: dr. date/time: 9:30am specialty: vascular sugery, appointment to evaluate the right lower leg phone: procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours spinal tap incision of lung arterial catheterization diagnoses: pneumonia, organism unspecified coronary atherosclerosis of native coronary artery urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension unspecified acquired hypothyroidism atrial fibrillation peripheral vascular disease, unspecified atrial flutter pulmonary collapse occlusion and stenosis of carotid artery without mention of cerebral infarction other specified cardiac dysrhythmias hypotension, unspecified osteoporosis, unspecified iron deficiency anemia, unspecified cardiac pacemaker in situ epilepsy, unspecified, without mention of intractable epilepsy dehydration chronic diastolic heart failure above knee amputation status phantom limb (syndrome) 

Answer: The patient is high likely exposed to