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: oxycontin / morphine attending: chief complaint: "swollen tongue" major surgical or invasive procedure: lp x2 history of present illness: 74 yo f with chronic low back pain s/p multiple procedures, urinary incontinence, and dementia who presented to the ed with tongue swelling after falling onto her face. per report she was walking and fell forward. no apparent loc or preceeding symptoms. she appeared to loose her balance. she sustained a right orbital hematoma and bit her tongue. she did not require sutures. she is being admitted to the for airway monitoring given her swollen tongue. . she was seen at today for a pre-op assessment prior to a urinary sling procedure. her husband reports increasing confusion and frequent falls over the last two weeks. she was treated for a uti with amoxicillin 1 month ago. he reports she is forgetful at baseline. she has been on several different medications for urinary incontinence over the last 2 yrs including detrol and vesicare. her recent confusion appears to correlate with starting vesicare on . she also discontinued her fluphenazine on after 40 yrs of use. . in the ed a head ct revealed chronic microvascular angiopathy without acute fracture or hemorrhage. her ua was negative. . she is alert and oriented to self only. she denies pain, dysuria, or sob. husband reports her wt has been stable and she has a good appetite. past medical history: - ?dementia - urinary incontinence since - chronic low back pain/degenerative disk disease s/p failed back surgery, epidural steroid injections, nerve blocks, facet injections, trigger point injections - hyperlipidemia - hypertension - major depression social history: she lives at home with her husband. she is independent of her adl's. she quit smoking tob in ; ~10 pack year history. occasional etoh. denies illicit drug use. husband, , is hcp (). son . family history: mother died of . two sisters are healthy. youngest child with mental retardation; lives in group home. physical exam: admission: tc 98.6 bp 170/100 hr 96 rr 18 sat 95% ra gen: appears comfortable, nad hennt: swollen tongue, multiple ecchymoses and abrasions over right orbit, lips, and cheeks. mmm, anicteric, perrl neck: no lad, no jvd cv: rrr, nl s1s2, ii-iii/vi systolic murmer heard best at apex lungs: ctab abd: soft, nt/nd, +bs, no hsm ext: no peripheral edema, strong dp/pt pulses bilaterally neuro: a&o to self, moving all extremities pertinent results: 09:25pm blood wbc-10.5 rbc-4.27 hgb-14.0 hct-37.8 mcv-89 mch-32.7* mchc-36.9* rdw-13.7 plt ct-267 09:25pm blood neuts-88.9* bands-0 lymphs-4.3* monos-5.0 eos-1.3 baso-0.6 09:25pm blood pt-11.6 ptt-19.1* inr(pt)-1.0 09:25pm blood glucose-116* urean-18 creat-1.1 na-139 k-3.7 cl-102 hco3-25 angap-16 09:25pm blood ck(cpk)-201* 05:55am blood alt-23 ast-26 ld(ldh)-192 ck(cpk)-171* alkphos-95 amylase-50 totbili-0.4 09:25pm blood ck-mb-6 ctropnt-<0.01 05:55am blood ck-mb-4 ctropnt-<0.01 05:55am blood lipase-22 09:25pm blood calcium-9.5 phos-3.5 mg-1.7 05:55am blood tsh-0.63 05:55am blood vitb12-1012* folate-greater th . ecg: sinus rhythm prior inferior myocardial infarction no previous tracing available for comparison . ct head: 1. no intracranial hemorrhage or mass effect. 2. chronic microvascular angiopathy. 3. right supraorbital facial swelling. 4. no fracture identified. . : ct c-spine: no evidence of acute fracture or listhesis. multilevel degenerative changes as described above. . ct orbits/face: 1. soft tissue swelling over the right orbit. 2. no evidence of acute fracture. note added at attending review: there is a fracture of the tip of the coronoid process of the right mandible. . mri head: significantly limited mri of the brain due to motion artifact. extensive chronic periventricular microvascular ischemic changes. scattered old lacunar infarcts within the brainstem. no acute territorial infarcts are seen within the brain. . most recent head mri: this study, slightly degraded by patient motion artifact, is compared with recent contrast-enhanced mr examination dated ; the overall appearance is unchanged. there is mild-moderate cortical atrophy. there is severe, confluent flair-hyperintensity in bihemispheric periventricular and subcortical white matter, representing extensive chronic microischemic change. however, there is no focus of restricted diffusion to indicate acute infarction. there is no evidence of acute hemorrhage. there are a few punctate foci of blooming susceptibility artifact, unchanged, likely representing hemosiderin from past petechial hemorrhage, related to small vessel infarction. again noted is a prominent developmental venous anomaly ("venous angioma") in the right paramedian cerebellar vermis, with no associated cavernous angioma or hemorrhage. there is no other pathologic focus of parenchymal, leptomeningeal or dural enhancement. impression: 1) no acute process and no significant interval change since the examination. 2) severe chronic micro-ischemic change in bihemispheric white matter. 3) extensive fluid within bilateral mastoid air cells, significantly worse since the previous examination, and bilateral ethmoid mucosal thickening with small amount of fluid in the sphenoid sinus, some of which may relate to protracted supine positioning (is there clinical suspicion of either sinusitis or mastoiditis?). . cxr : the heart size is moderately enlarged, unchanged. there is a prominent mediastinal venous engorgement with no overt pulmonary edema. bibasilar mild atelectasis are unchanged. the tracheostomy and the right subclavian venous line are in good position, stable. see omr for further studies. brief hospital course: mrs was initially admitted to the medicine icu for observation given her chronic tongue swelling and fall on her face with trauma. she was monitored overnight on standard icu monitoring and a 1:1 sitter with no problems or events. dementia work up was initiated, and she completed an mri of the head. the dementia workup was negative and the mri (limited study) was significant for no acute stroke. the pt was noted to have extensive chronic periventricular microvascular ischemic changes and scattered old lacunar infarcts within the brainstem. the pt's electrolytes were checked and repleted. she was disoriented throughout her stay, and agitated and somnolent at times. she was stable the day after admission morning, and transferred to the medical floor as she had a stable respiratory status, and did not require icu level care any longer. on the morning of transfer to the floor the pt has a ct head that showed an isolated fracture of her mandible. the pt was evaluated by the oro-maxillofacial surgery service from the and no intervention was recommended. the pt became increasingly somnolent on arrival to the floor and had decreased responsiveness. she became mildly rousable on her third day on the floor. the pt was noted to be hyperventilating. due to concern for altered mental status secondary to meningitis/encephalitis, an lp was attempted by the anesthesia team and house staff. due to the pt's multiple back surgeries and spine fusions, an lp was not successful. the pt was empirically started on vanc/ceftriaxone/acyclovir and ampicillin. a day after initiation of these medications, there was an interval increase in creatinine from 0.9 to 2.2. due to concern for vancomycin or acyclovir induced nephrotoxicity, these medications were held and cr was rechecked; it normalized within days. . the hospital course was significant for the following problems: . # frequent falls/altered mental status: the pt was noted to have a progressive decline in mental status over the last few years with a significantly accelerated decline over the last 2-3 weeks. the pt's fall did not appear to be a syncopal event and her labs and urinalysis were unremarkable. her head ct revealed chronic microvascular angiopathy likely representing dementia. a metabolic workup was negative. the pt was noted to have a waxing and mental status. during a neurology team evaluation the pt was noted to have ?mild myoclonus of toe. a stat eeg showed markedly abnormal brain activity indicating severe encephalopathy. the pt was started on seizure prophylaxis with phenytoin iv. in light of mental status changes, the pt was also empirically started on ampicillin, vancomycin, acyclovir and ceftriaxone after 4 failed attempts at lp (pt has spine fusions from l3 to s1). the ampicillin was subsequently discontinued. the patient was noted to have tonic extension of her arms thought to be a generalized seizure. her dilantin level was found to be subtherapeutic at 2.5. she shortly after developed tachycardia, tachypnea, elevated bp, and acidemia. she was intubated and transferred to the icu. she was then loaded with dilantin and transferred to the neuro icu on the . blood and urine cultures were ultimately unrevealing. a lumbar puncture was performed and found to be negative. all antibiotics were discontinued. in the neuro icu the patient was placed on continuous eeg monitoring. her eeg showed evidence of a deep encephalopathy. she was started on iv glycerine to treat brain edema related to her fall. she remained minimally responsive. a tracheostomy and g-tube were placed and the patient was transferred to the neurology step down unit. thyroid function tests were repeated and were once again unremarkable; ammonia was sent and was normal. in the stepdown unit, her exam improved slightly - she began to open her eyes and keep them open to sternal rub, and then spontaneously opened her eyes on . initially, she had absent reflexes and no withdrawal to noxious stimuli; she began to regain reflexes and withdrew her lower limbs to nailbed pressure, raising the possibility of resolving critical illness polyneuropathy. dilantin dosing was initially increased, then transitioned to keppra. mri was repeated and showed stable subcortical white matter changes. as she did not follow commands, further workup was pursued, including sending anti-tpo antibody to check for hashimoto's encephalitis. results of this were negative. lp was also repeated to look specifically for signs of limbic encephalitis (anti-), intravascular lymphoma (ldh), and creutzfield- disease (csf for cjd). results were pending at time of discharge for cjd. the ldh was normal as was the anti-. by the end of her course, she had received 4 mris of the head which were all stable and unrevealing of a problem that would explain her encephalopathy. multiple blood and urine cultures were sent which showed no signs of infection. she also had several days of eeg monitoring with no evidence of seizure, and only showing encephalopathy. she also had several routine eegs with similar findings. . # renal - the patient temporarily developed arf on iv acyclovir. the medication was discontinued and the patient received aggressive iv hydration. her creatinine eventually normalized. . # swollen tongue: the pt was noted to have a swollen tongue on admission but this was not noted in admission to the floor; in fact the pt had had a large tongue (per husband) for the last 40 years secondary to chronic fluphenazine use. the pt did not have any evidence of airway compromise. the pt was monitored in the overnight. the pt's husband reported that the pt has h/o tongue angioedema scondary to chronic (>40y) fluphenazine use. she was given decadron 10 mg x1; this resolved. . # thyroid mass pt noted to have a 4.4-cm mass in the right lobe of the thyroid on ultrasound. thyroid function was normal during the admission. she could be considered for ultrasound-guided biopsy of the mass in the future. . # urinary incontinence. appeared chronic. no evidence of acute infection or retention. sling procedure was planned by urology prior to hospitalization. . # htn. bp was elevated upon arrival to medical icu; this was thought to be likely secondary to agitation. she was started on metoprolol 50 in icu (home dose was atenolol 50 daily). blood pressure stabilized after transfer to neuro icu and finally to sdu. she had no further bp issues while on the floor and was stable on discharge. she did have a small amount of captopril added while she was here and was sent out on this. . # psych. the patient had been on fluphenazine x 40 yrs- initially, this was thought to be related to change in mental status; however, two weeks later when she remained in coma, this was thought less likely. upon further questioning, her husband described a gait that resembled a parkinsonian gait - she likely had an element of drug-induced parkinsonism prior to hospitalization; it is possible that an unsteady gait contributed to her fall. #pulm: the patient had a tracheostomy performed while here and then required oxygen through a trach mask for the remainder of her stay. she had to have frequent suctioning as she makes a significant amount of secretions. she oxygenated well throughout. she did develop a bilateral pna which was successfully treated and subsequent cxrs were clear. she also had an element of mild fluid overload on some of the cxrs. her most recent cxrs did not show this. of note, the patient is tachypneic at times with no other instability with rates of ~30. this comes and goes over days. most recent cxr was normal. #in summary, the patient had a rapidly progressive encephalopathy while in the hospital. she had a fall, then became unresponsive fairly soon after. she was then likely in intermittent status for an unknown period of time. she also developed arf likely due to med effect. she then had a tension pneumothorax requiring chest tube. she later developed a pneumonia which was treated. she recovered from all of this, but failed to wake up. a large work-up, including mrix4, lpx2, and multiple blood tests yielded no reason for her symptoms. the theory as to what is causing her problems is that she has a large amount of small vessel disease at baseline. then, she had these multiple medical problems, including likely several days of seizure. this has resulted in her current unresponsiveness. it may simply take a long time for her to recover in this setting. her exam currently is that she opens her eyes to sternal rub and keeps them open, but only looks midline. she does not track at all or look around. her brainstem reflexes are normal, with normal corneals, gag, cough, ocrs, nasal tickle, and pupils. she also withdraws her extremities to pain much of the time, but not always. she has no spontaneous movement or attempts at speech. her toes are downgoing. medications on admission: home meds: - fosamax 35 daily - niacin 500 daily - atenolol 50 daily - fluphenazine 5 - mvi - ca/vitd - vite - advil prn - alleve prn - tylenol prn - hctz 25 daily (d/c'ed secondary to hypokalemia) - vesicare ( - ) discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 2. alendronate 70 mg tablet sig: 0.5 tablet po qsun (every sunday). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. 4. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 5. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. ranitidine hcl 15 mg/ml syrup sig: one y (150) mg po bid (2 times a day). 7. insulin regular human 100 unit/ml solution sig: as directed units injection asdir (as directed): standard insulin sliding scale. 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day): hold hr<60, sbp<100. 9. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). 10. captopril 12.5 mg tablet sig: 0.5 tablet po tid (3 times a day): hold for sbp < 100 . 11. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 12. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 13. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. discharge disposition: extended care facility: - discharge diagnosis: persistent encephalopathy thought to be due to recent status epilepticus as well as severe small vessel cerebral disease. -- htn thyroid nodule discharge condition: pt is unreponsive, but opens her eyes to sternal rub. she is flaccid otherwise. she has intact brainstem reflexes. discharge instructions: please tell the doctors if there is any worsening of breathing, or apaprent change in her clinical status followup instructions: please follow-up as the doctors arrange. -- you should follow-up with dr in the stroke service at after you are discharged. the staff at can schedule this at discharge. md, procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung spinal tap incision of lung insertion of endotracheal tube enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy diagnoses: pneumonia, organism unspecified acidosis unspecified essential hypertension acute kidney failure, unspecified unspecified fall acute respiratory failure iatrogenic pneumothorax antiviral drugs causing adverse effects in therapeutic use grand mal status other encephalopathy vascular dementia, uncomplicated cerebral atherosclerosis arthrodesis status contusion of face, scalp, and neck except eye(s) other specified conditions of the tongue history of fall nontoxic uninodular goiter contusion of orbital tissues closed fracture of mandible, coronoid process incontinence without sensory awareness 

Answer: The patient is high likely exposed to