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 / heparin agents attending: chief complaint: mental status changes major surgical or invasive procedure: intubation history of present illness: 69 yo f with history of esrd on hd, dm, recently admitted to for orif for left distal femur fracture (uncomplicated hospital course) referred to ed today after she developed acute change in mental status associated with decreased responsiveness during a dialysis treatment today. history per daughter stated that she last spoke to her mother night pta and she was "fine" (asking her daughter about her finances, etc.). she denies that her mother has ever had a seizure, stroke in the past. denies any baseline weakness or numbness. states the patient was living on her own prior to her recent hip fracture. . per sparse history on dialysis notes, patient was given percocet at approximately 9:55am and at approximately 10:30am developed acute mental status changes, including confusion. patient continued through dialysis with stable vital signs (bp 130's-140's/60's, hr 40's-50's). after completion of dialysis, ems was called for transfer to the hospital. . ems notes were significant for noting "rapid deterioration in mental status", right gaze, dry blood on lips, no response to pain, aphasia. ems noted decreased hr to 30's x 2 on transfer, fsbs = 185. . on presentation to ed at , exam was notable for minimal responsiveness, gcs 13, withdrawl of all extremities to pain, following occasional commands, non-verbal (groans). vss with t 98.8, hr 58, bp 132/102, o2 sat 98%. labs were notable for wbc 9.5 with 86 n and 2 b, cr 5.1 (hx esrd on hd), ast 59, ldh 450, ap 218, t bili 3.9, lactate 2.8. blood cxs x 2 were sent in ed. head ct demonstrated no evidence of intracranial bleed or edema. cxr was wnl. mri/a scan was performed (read pending). evaluation by neuro yielded diagnosis of possible seizure activity. pt was given narcan 0.4mg iv x 1, ativan total of 2mg iv, dilantin load (total of 2gm iv). she was intubated for airway protection (given ffp prior to intubation as inr 1.9, on coumadin as outpt as s/p hip surgery) and transferred to the icu for further managment. past medical history: 1. diabetes type 2 2. esrd on hd q m,w,f 3. s/p infection in left knee 4. h/o mrsa/c.diff 5. nash to tylenol 6. s/p orif for left distal femur fracture on social history: soh: lives at home with daughters. etoh/tob/illicts. family history: fh: non-contributory physical exam: gen- intubated and sedated heent- pinpoint pupils, reactive b/l. 2 cm healed scar of r upper forehead. c/d/i neck- supple, unable to assess jvp chest- cla anteriorly, b/l cv- regular, bradycardic. no m/r/g abd- +bs. soft. nd. no hepatosplenomegaly. no masses - 1+ le edema. 2+ dp pulses. . on transfer to the floor: physical exam: vs: bp 131-143/41-57, hr 74-85 rr 20 o2 92-96% ra gen - lying in bed, slurred speech, intermittently opens eyes, intermittently answers questions heent - perrla. 2 cm healed scar of r upper forehead. anicteric sclerae neck - supple, unable to assess jvp, patient with left subclavian line chest - decreased breath sounds in left base cv - rrr, s1s2 normal, systolic murmur radiating into the axillae abd - +bs. soft. nd. no hepatosplenomegaly. no masses, mild tenderness in ruq on deep palpation. ext - trace le edema. 2+ dp pulses. pertinent results: 02:10pm pt-16.8* ptt-36.5* inr(pt)-1.9 02:10pm plt smr-low plt count-149*# 02:10pm neuts-86* bands-2 lymphs-5* monos-6 eos-1 basos-0 atyps-0 metas-0 myelos-0 02:10pm wbc-9.5# rbc-3.92* hgb-13.2# hct-37.7# mcv-96 mch-33.6* mchc-35.0 rdw-20.1* 02:10pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 02:10pm t4-19.8* 02:10pm tsh-3.6 02:10pm calcium-9.4 phosphate-4.0# magnesium-1.8 02:10pm lipase-524* 02:10pm alt(sgpt)-15 ast(sgot)-59* ld(ldh)-450* alk phos-218* tot bili-3.9* 02:10pm glucose-186* urea n-29* creat-5.1* sodium-131* potassium-3.8 chloride-93* total co2-22 anion gap-20 . imaging: ct head w/out contrast: no evidence of intracranial hemorrhage or edema. cxr: unremarkable chest radiograph. mri brain w/out contrast : no evidence of acute brain ischemia. small arachnoid cyst in the right cerebellopontine angle cistern. limited mr angiography study- the distal vasculature is poorly visualized, which could be secondary to low cardiac output. liver u/s - limited examination. patent hepatic arteries and veins and portal veins with flow in the appropriate direction. eeg - markedly abnormal portable eeg due to the slow and disorganized background and very frequent generalized sharp wave discharges. these findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. medications, metabolic disturbances, and infection are among the most common causes. the sharp waves were prominent and frequent and suggest an increased risk of seizures. nevertheless, they were not particularly rhythmic or of higher frequency during this recording so as to suggest ongoing seizures at the time of the recording. there were no prominent focal findings although encephalopathies can obscure such findings. if concern for seizures persist clinically, a repeat tracing could be of assistance. mr - severely limited study. no large gross changes identified compared to , but more subtle acute changes will not be discernable on today's study. if indeed there is high clinical suspicion of an acute change from , repeat imaging may be necessary. abdominal u/s - there is no ascites. marked splenomegaly brief hospital course: # mental status change: initial exam was notable for minimal responsiveness, withdrawal of all extremities to pain, following occasional commands, non-verbal (groans). vss with t 98.8, hr 58, bp 132/102, o2 sat 98%. head ct demonstrated no evidence of intracranial bleed or edema. cxr was wnl. mri/a scan was performed and did not show any evidence of ischemia. evaluation by neuro yielded diagnosis of possible seizure activity. pt was given narcan 0.4mg iv x 1, ativan total of 2mg iv, dilantin load (total of 2gm iv). she was intubated for airway protection and transferred to the icu for further managment. she was also covered for possible encephalitis/ meningitis with acyclovir, ctx, vanco and ampicillin. a lp was done but did not show any signs of meningitis or encephalitis. the pt continued to have waxing and mental status. she was found to have elevated lfts and was thought to have a component of hepatic encephalopathy. first eeg supporting seizure activity. repeat eeg showed slowed activity c/w encephalopathy. possible hepatic encephalopathy: ammonia elevated at 65, therefore pt has been started on lactulose to attempt to improve ms. repeat was in 30's. abx were discontinued. on the the pt self extubated and was reintubated to be extubated on the . a ng tube was placed for nutrition. over the following two days the pt was more lucid and stable. she was called out to the floor for further management. the pt continued to improve and became more lucid and oriented x3. dilantin was continued orally at 300mg qd. free dilantin levels were checked and below therapeutic levels and therefore dilantin was increased to 150 tid. free dilantin level should be repeated in three days. lactulose and rifaximin were continued. lactulose should be titrated to three bowel movements. . # liver disease: per pt's daughter the pt had tylenol induced liver damage in past. per daughter no etoh/drug abuse in the past. hep a neg, b surface pos, core neg, hep c neg. serum igg, iga, igm were elevated without any specific pattern suggestive of a disease process. was negative, but anti-sm and ama were mildly positive (titer 1:20). hsv pcr was negative. possible primary biliary cirrhosis also consistent with obstructive enzyme pattern. also possible steatosis hepatis from obesity. ruq u/s showed splenomegaly, no ascites, no focal lesions in liver, no sign of biliary dilatiation. flow in appropriate direction in portal vein. lfts were followed up and were trending down. follow up of lft, cbc and chem 7 should be obtained once in the following week. the pt has follow up arranged for her with dr. on the at 9.40am. a liver biopsy might be considered to investigate the etiology of the problem further. the pt should be given hepatitis a vaccine once she is more stable. she was adviced to avoid hepatotoxic medications. . # transient leukocytosis and intermittent fever spike: urine with wbc, and one time positive urine culture for klebsiella. pt was initially treated for suspected meningitis with ampicillin, vancomycin and ceftraixone. antiobiotics were discontinued five days into her hospital course. the pt was afebrile after discontinuation of the antibiotics and remained with a normal wbc. the pt was found to have a new systolic murmur on exam, radiating into her axilla, most consistent with a mild mitral regurgitation. follow up echo should be obtained. given the fact that all blood cultures were negative and the pt remained afebrile and no other physical signs on examinations were found consistent with endocarditis the suspicion for endocarditis was considered low and no further workup was obtained. . # esrd: pt continued her outpatient dialysis schedule in house. she tolerated dialysis well. . # hypernatremia: transient. due to lack of free water because of to prolonged initial period without feeding as complicate ngt placement. free water deficit was calculated as about 4l. pt was repleted with free water boluses via ngt 250cc tid. hypernatremia resolved. . # anemia - pt has baseline anemia - about three points decreased from her baseline at around 29. likely sequestration in spleen and possible low grade hemolysis due to liver disease in addition to renal anemia in esrd. hemolysis labs difficult to interpret in the setting of liver disease. iron studies consistent with anemia of chronic disease, no iron deficiency. erythropoetin was administered during dialysis. . # thrombocytopenia & elevated inr: hit ab positive. also with splenomegaly and chronic liver disease, likely sequestering. all heparin containing products were avoided. thrombocytes were consistently above 50,000. . # dm2: endocrinology was consulted and sliding scale was adjusted per recommendations. lantus 20 and riss to be continued as outpatient. pt had a one time episode of hypoglycemia to 49. issc was decreased by unit two days prior to discharge. further fine adjustment should be achieved in the rehabilitation center. . # orif: pt was seen by orthopedics in house. knee xr was obtained. no dislocation of the hardware was seen. the pt should remain not weight bearing on her l leg for 5 more weeks. f/u appointment with ortho was obtained in 5 weeks. medications on admission: 1. colace 100 mg 2. pantoprazole 40 mg qd 3. acetaminophen 500 mg q6 4. metoprolol tartrate 25 mg 5. warfarin 1 mg qd 6. calcium carbonate 500 mg tid 7. hydromorphone 2 mg q6 8. senna 8.6 mg 9. bisacodyl 10 mg tablet, qd 10. sevelamer 800 mg tid discharge medications: 1. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 3. epoetin alfa 10,000 unit/ml solution sig: one (1) injection asdir (as directed). disp:*qs * refills:*2* 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. lactulose 10 g/15 ml syrup sig: fifteen (15) ml po tid (3 times a day). disp:*1350 ml(s)* refills:*2* 6. insulin regular human 300 unit/3 ml insulin pen sig: one (1) subcutaneous as directed. disp:*qs * refills:*2* 7. phenytoin 50 mg tablet, chewable sig: three (3) tablet, chewable po tid (3 times a day). disp:*270 tablet, chewable(s)* refills:*2* 8. insulin glargine 100 unit/ml solution sig: as directed subcutaneous at bedtime. disp:*qs * refills:*2* discharge disposition: extended care facility: - discharge diagnosis: mental status changes eeg with seizure like activity liver failure hepatic encephalopathy ................... diabetes type 2 esrd on hd q m,w,f s/p orif for left distal femur fracture on discharge condition: good, pt 3, mental status changes resolved discharge instructions: please come back to the hospital or see your primary care doctor if you experience any worsening mental status, confusion, headaches, jaundice or any other concerns. . please take all medications as instructed. followup instructions: please follow up with dr. on the at 9.40am for your liver disease. . please follow up with neurology, dr. on the at 11.00am, of building. . please also follow up with your primary care doctor. . and follow up with orthopedics for your fracture: provider: , md phone: date/time: 9:00 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified spinal tap incision of lung insertion of endotracheal tube insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis transfusion of other serum diagnoses: thrombocytopenia, unspecified anemia in chronic kidney disease end stage renal disease urinary tract infection, site not specified cirrhosis of liver without mention of alcohol hyposmolality and/or hyponatremia other convulsions diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled hepatic encephalopathy hyperosmolality and/or hypernatremia other chronic nonalcoholic liver disease aftercare for healing traumatic fracture of hip 

Answer: The patient is high likely exposed to