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: patient recorded as having no known allergies to drugs attending: chief complaint: seizure, brain mass major surgical or invasive procedure: intubation, central line placement and removal, arterial line placement and removal, tracheostomy placement and removal, peg placement, lumbar puncture x 2, picc placement, bronchoscopy x 2, laryngoscopy history of present illness: patient is a 60 year old female with auto-immune hepatitis who was found to be unresponsive by her family, and seizing after a fall. . she was first seen for evaluation of her liver disease in and in . at that time she had recently returned from a trip to from to . during that travel she developed severe itching associated with extremity swelling and edema. these subsequently subsided but when she returned she sought medical attention. on laboratories she was noted to have elevated liver function tests and subsequently progressed to "near fulminant liver failure." in mid her inr was 1.6 (peaked at 2.0), bilirubin was 23 and her transaminases were 300-400. her wbc count was 6.8, hct 31.2, platelets 125, total bilirubin 23, ast 441, alt 306 alkaline phosphatase 297, albumin 2.5, inr 1.6. her electrolytes were within normal limits. her lipase was 367. her was positive at 1:80. her hepatitis b surface angigen, hepatitis c antibody, hepatitis a igg and igm were negative. she underwent a liver biopsy on which showed reactive hepatocytes, cholestasis, and inflammatory infiltrate. the biopsy was felt to be consistent with autoimmune hepatitis, drug reaction or extra-hepatic obstruction. she was started on immuran and prednisone on for presumed autoimmune hepatitis with plans to also undertake an mrcp to assess for sclerosing cholangitis. per osh notes she did have an mrcp but report not available to us at . between and her total bilirubin decreased from 21 to 17 (direct 9.8) with a decrease in her transaminases to ast 176 and alt 223 with alkaline phosphatase of 213. lipase at that time was 595 and inr was 1.7. she was scheduled to complete a prednisone taper starting at 30 mg and tapering over one month to 10 mg daily. she was also started on ursodiol in late . there are no additional laboratory values between then and her admission here on although per the patient's family she was under the care of a naturopath while in in who was administering a number of naturopathic supplements (including iron) to help with her liver disease, and laboratory work was taken. the patient reported that despite improvement in her laboratory values she continued to feel fatigued and had swelling of her legs. . the patient lives in but immediately prior to this admission was visiting family in . per family report, over the last several days the patient was lethargic, had difficulty with movement, swelling, foot numbness, and fatigue. on the day prior to admission, she complained of fever and chills and had a recorded temperature of 102. on the morning of admission on , her family found the patient on the floor with reported seizure activity. ems responded and administered valium, which did not break the seizure fully. in the field, she had a hr of 120s and was breathing spontaneously. she was taken to an outside hospital, where her seizure was broken with fosphenytoin and ativan. due to concerns over airway protection and unresponsiveness, she was intubated at that time. a ct of head, by report, demonstrated a left frontal mass and left frontal subarachnoid hemorrhage. she was transferred to for further management. in the emergency room, she was given vitamin k, 2 units of ffps, and decadron 10 mg iv. upon arrival to , she was found to be hypothermic and hypotensive, and was placed on pressors. a repeat head ct confirmed the above findings. she was initially admitted to the neurosurgial icu, when decision was made not to operate she was transfered to the medical service for continued work up and treatment. past medical history: 1. autoimmune hepatitis - diagnosed . 2. bronchitis 3. per report, evaluated at for arthritis in social history: patient lives in and was visiting family members in . per report, there is no history of tobacco or alcohol use. she lives alone, works as an education consultant for a chartered school. she has a law degree. she visited 8 months ago. she has also visited , , and other subsaharan countries for work and as a tourist. she visited in and spent 21 days there. this trip was part of an educational exchange program, for which she serves on the board of directors. as noted elsewhere, she toured various parts of and stayed mainly in hotels; she did visit rural areas, however. family history: non-contributory. no history of liver disease, infections or auto-immune diseases. physical exam: (at time of admission to micu) general: intubated, opens eyes spontaneous at times. nad. heent: nc/at. no scleral icterus. pupils reactive bilaterally. no scleral icterus or conjunctival pallor. no facial asymmetry noted. neck: c-collar in place. ij in place. lungs: rhoncerous sounding bilaterally. no wheezes. bilateral breath sounds. cardiac: borderline tachycardic, regular, no m/g/r abdomen: soft, nt, nd, +bs extr: warm, 2+ pitting edema to just above ankle bilaterally. a-line in place over right radial. neuro: opens eyes occasionally, no purposeful movements noted. withdraws feet r>l to noxious stimuli. reflexes 3+ right patella, 2+ left, 3+ bilaterally at bicesp. perrl. skin: 1 cm erythemaous lesion over left 3rd finger. no other lesions noted. lines appear c/d/i. pertinent results: 08:36am cerebrospinal fluid (csf) wbc-79 rbc-1280* polys-58 lymphs-24 monos-0 atyps-4 macroph-14 08:36am cerebrospinal fluid (csf) wbc-101 rbc-732* polys-57 lymphs-26 monos-0 atyps-4 macroph-13 08:36am cerebrospinal fluid (csf) totprot-257* glucose-8 12:39pm cerebrospinal fluid (csf) wbc-14 rbc-634* polys-2 lymphs-89 monos-0 atyps-3 macroph-6 12:39pm cerebrospinal fluid (csf) wbc-33 rbc-656* polys-1 lymphs-96 monos-0 macroph-3 12:39pm cerebrospinal fluid (csf) totprot-89* glucose-58 ld(ldh)-48 blood culture, routine (final ): reported by phone to -cc6c- @ 14:45 . listeria monocytogenes. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ listeria monocytogenes | ampicillin------------<=0.12 s penicillin g---------- 0.12 s trimethoprim/sulfa---- 0.5 s anaerobic bottle gram stain (final ): reported by phone to @ 1700 on - cc6c. gram positive rod(s). 8:23 pm urine source: catheter. **final report ** urine culture (final ): enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ <=2 s nitrofurantoin-------- <=16 s tetracycline---------- <=1 s vancomycin------------ 2 s 8:36 am csf;spinal fluid source: lp tube 3. **final report ** gram stain (final ): this is a corrected report 2105, . reported by phone to md (#) at 2100 on . 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive rod(s). this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. previously reported as at 1215 on . 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): listeria monocytogenes. sparse growth. sulfa x trimeth <=0.5/9.5 ug/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ listeria monocytogenes | ampicillin------------<=0.12 s penicillin g----------<=0.06 s trimethoprim/sulfa---- s fungal culture (final ): no fungus isolated. 3:51 pm bronchial washings gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. smear reviewed; results confirmed. respiratory culture (final ): oropharyngeal flora absent. acinetobacter sp.. >100,000 organisms/ml.. sensitivity testing performed by microscan. sensitive to levofloxacin <= 2 ug/ml. sensitive to cefepime <= 2 ug/ml. sensitive to meropenem <= 1 ug/ml. yeast. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ acinetobacter sp. | ceftazidime----------- <=2 s ciprofloxacin--------- <=0.5 s gentamicin------------ <=1 s imipenem-------------- <=1 s piperacillin---------- 16 s piperacillin/tazo----- 16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=2 s potassium hydroxide preparation (final ): test cancelled, patient credited. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). fungal culture (final ): yeast. viral culture (preliminary): no virus isolated so far. viral culture: r/o cytomegalovirus (final ): specimen not processed due to: duplicate request. refer to viral culture for results. patient credited. 9:47 am urine source: cvs. **final report ** urine culture (final ): no growth. 07:16am blood wbc-3.1* rbc-2.38* hgb-8.5* hct-24.8* mcv-105* mch-35.8* mchc-34.2 rdw-23.3* plt ct-120* 06:01am blood wbc-3.1* rbc-2.40* hgb-8.3* hct-25.0* mcv-104* mch-34.7* mchc-33.3 rdw-23.9* plt ct-107* 06:10am blood wbc-3.8* rbc-2.40* hgb-8.6* hct-24.9* mcv-103* mch-35.6* mchc-34.4 rdw-24.6* plt ct-133* 07:16am blood plt ct-120* 07:16am blood pt-15.9* ptt-39.2* inr(pt)-1.4* 06:01am blood plt ct-107* 06:01am blood pt-15.4* ptt-36.7* inr(pt)-1.4* 06:10am blood plt ct-133* 06:10am blood pt-15.1* ptt-38.7* inr(pt)-1.3* 04:03am blood ret aut-5.4* 04:47pm blood aca igg-22.0* aca igm-11.8 04:47pm blood lupus-neg 07:16am blood glucose-98 urean-9 creat-0.4 na-139 k-3.1* cl-111* hco3-26 angap-5* 10:08pm blood k-3.4 03:20pm blood k-3.1* 06:01am blood glucose-105 urean-10 creat-0.5 na-141 k-2.5* cl-110* hco3-27 angap-7* 06:10am blood glucose-111* urean-12 creat-0.5 na-141 k-2.7* cl-109* hco3-26 angap-9 05:56am blood glucose-117* urean-12 creat-0.4 na-138 k-2.9* cl-108 hco3-27 angap-6* 06:18am blood glucose-100 urean-11 creat-0.4 na-141 k-3.6 cl-112* hco3-27 angap-6* 05:48pm blood k-2.8* 07:16am blood alt-32 ast-33 ld(ldh)-288* alkphos-414* totbili-0.9 06:01am blood alt-35 ast-37 ld(ldh)-284* alkphos-453* totbili-1.1 06:10am blood alt-39 ast-40 ld(ldh)-281* alkphos-528* totbili-1.1 05:56am blood alt-46* ast-47* ld(ldh)-289* alkphos-604* amylase-187* totbili-1.2 06:18am blood alt-55* ast-54* ld(ldh)-262* alkphos-657* amylase-199* totbili-1.0 07:16am blood albumin-2.0* calcium-7.6* phos-2.5* mg-1.9 06:01am blood calcium-7.6* phos-2.9 mg-2.0 06:10am blood calcium-7.8* phos-3.3 mg-2.0 05:56am blood calcium-7.5* phos-2.4* mg-2.0 06:18am blood albumin-1.7* calcium-7.4* phos-2.6* mg-2.2 iron-61 06:18am blood caltibc-146* ferritn-371* trf-112* 04:08am blood hapto-<20* 04:06am blood caltibc-139* ferritn-760* trf-107* 10:05am blood ama-negative 04:47pm blood -positive titer-1:160 04:47pm blood crp-34.3* 03:42pm blood pep-polyclonal igg-2451* iga-441* igm-212 ife-no monoclo 10:05am blood igg-1783* rt approved date: specimen received: spinal fluid specimen description: received 2ml pale yellow fluid. prepared 1 thinprep slide. clinical data: 60 y/o female with fevers, brain lesion. report to: dr. . diagnosis: cerebrospinal fluid: negative for malignant cells. diagnosed by: , ct(ascp) , m.d. cardiology report ecg study date of 7:47:22 am sinus bradycardia. non-specific st-t wave changes. no previous tracing available for comparison. tracing #1 read by: , intervals axes rate pr qrs qt/qtc p qrs t 56 100 110 462/455 13 -55 -1 cxr : indication: 60-year-old woman intubated for subarachnoid hemorrhage and seizure. et tube, ng tube and for pneumonia or chf. comparison: none available. the et tube tip is 2.7 cm from the carina, would recommend pulling back approximately 1-2cms. the ng tube tip is in the stomach. the lungs are clear, without evidence of pneumonia or chf. there is bibasilar atelectasis amd a probable small left basal effusion. there is mild degenerative change in the thoracic spine. impression: no acute intrathoracic process. suggest pulling back et tube cms as discussed with dr . ct head without contrast indication: subarachnoid hemorrhage, with new mass, seizure, for interval change and please compare with outside hospital ct. technique: mdct-acquired contiguous axial images of the head were obtained without intravenous contrast. comparison: outside hospital ct from 5:30 a.m. from the same date. findings: there is a 4.3 x 2 cm area of low attenuation in the left frontal lobe with minimal surrounding edema and mild mass effect. there is bilateral fronto-parietal subarachnoid hemorrhage. there is loss of the adjacent - white matter differentiation without midline shift. there is no intraventricular hemorrhage. there are no fractures. the paranasal sinuses and mastoid air cells are clear. impression: large area of left frontal low attenuation lesion, which may represent acute infarct or tumor. in addition there is bilateral fronto- parietal subarachnoid hemorrhage without significant midline shift this is not significantly changed since the study at 5:30 a.m. from the same date. an mri would be more sensitive for assesment of the left frontal lesion. mri of the head without and with contrast, ; mra of the head, indication: 60-year-old woman with new intracranial mass, hemorrhage, and seizures. for mass or aneurysm. technique: mri of the brain was performed with axial gradient echo, t2- weighted, flair, diffusion-weighted sequences. additionally, multiplanar pre- and post-gadolinium t1-weighted sequences were obtained. mra was performed with 3d time-of-flight imaging through the head. multiple mip reconstructions were created on a separate workstation. comparison: head ct of . findings: within the left frontal lobe, there is a heterogeneous region containing focal regions of peripheral enhancement. centrally, there are regions of blood products. there is surrounding edema. portions of this focus demonstrate restricted diffusion. the focus of abnormal signal encompasses approximately 4.2 x 2.7 cm. in addition to this dominant focus, there are several punctate foci of high signal on diffusion-weighted sequences, including the right frontal lobe, lateral to the right caudate, left temporal, and right parietal lobes. while no definite low signal can be demonstrated on the adc reconstructions, these foci may also represent small infarcts. septic emboli are a differential consideration. as demonstrated on the recent ct, there is subarachnoid blood layering within the sulci bilaterally. there are bifrontal subdural collections, most prominent in the frontal regions, where they measure up to 6 mm in thickness. there is heterogeneous flair signal intensity, which could suggest the presence of blood products. there is a prominent vessel coursing along the surface of the right frontal lobe, with a prominent parenchymal focus of linear enhancement. this likely represents a developmental venous anomaly. mra: the icas are of normal caliber, course, and contour bilaterally. the right vertebral artery is dominant. there is no significant intracranial stenosis. there is no aneurysm. the major vessels of the anterior and posterior circulation demonstrate normal caliber, contour, and course. there is no midline shift. ventricles and cisterns are patent. globes and orbits and extracranial soft tissues are unremarkable. impression: 1. large abnormality within the left frontal lobe characterized by peripheral enhancement, surrounding edema, blood products, and restricted diffusion. differential considerations for this lesion would include an abscess with associated hemorrhage versus an infarct with hemorrhage. there are numerous punctate foci of abnormal signal bilaterally which may also represent either small infarcts or septic emboli. 2. subarachnoid hemorrhage, as see on the recent ct. 3. bilateral subdural fluid collections, most prominent in the frontal regions, where they measure up to 6 mm in thickness. there is heterogeneous signal within it, which could suggest the presence of acute blood product. 4. right frontal developmental venous anomaly. 5. normal mra. eeg: findings: abnormality #1: focal and lateralized slowing was noted toward the end of the record with 1-2 hz slower theta and faster delta from the left mid-temporal, central, posterior temporal, and parietal regions. no associated sharp or spike activity was seen. the runs of slowing tended to last several seconds. abnormality #2: a slowed and disorganized background was seen both posteriorly and anteriorly. the posterior rhythm was relatively low to moderate voltage and of a pseudoperiodic nature verging on a burst-voltage reduction pattern not as extreme as a burst suppression pattern. the faster rhythms were in the faster delta and slower theta range. the anterior-posterior voltage gradient was not preserved. background: no normal background rhythms for age were seen. hyperventilation: not performed. intermittent photic stimulation: not performed. sleep: not obtained. cardiac monitor: no arrhythmias noted. impression: abnormal eeg due to a burst-reduction and pseudoperiodic record overall with marked slowing in the theta and delta range with additional focal and lateralized slowing in the left mid to posterior head regions without associated spike or sharp discharges. this would suggest a diffuse encephalopathy of a moderate to moderately severe degree with accentuated slowing over the left hemisphere from the mid to posterior regions suggestive of a possible structural or destructive process in that area. no epileptiform abnormalities were noted, however. echocardiogram: the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. there is focal thickening of the right coronary cusp of the aortic valve which measures 0.5 x 0.5 cm; cannot exclude valvular vegetation. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. no mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. impression: focal thickening of the right coronary cusp of the aortic valve without aortic regurgitation. cannot exclude aortic valve vegetation. if clinically indicated, a tee would better assess for endocarditis. preserved regional and global biventricular systolic function. mri impression: 1. increased enhancement and mild increase in surrounding edema in the left frontal lesion, which now demonstrates intrinsic slow diffusion, consistent with an abscess. 2. additional areas of new enhancement are seen in the right frontal lobe and in the region of right caudate head. 3. new small bilateral frontal hypointense effusions. 4. diffuse in meningeal enhancement which could be due to meningeal inflammation. 5. bilateral extensive mastoid middle ear and sphenoid sinus soft tissue changes. echocardiogram the left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. the interatrial septum is aneurysmal. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. overall left ventricular systolic function is normal (lvef>55%). the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant). no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. no vegetation/mass is seen on the pulmonic valve. there is a trivial/physiologic pericardial effusion. impression: no vegetations or clinically-significant regurgitant valvular disease. no pfo, asd, or cardiac source of embolism seen. compared with the prior study (images reviewed) of , the localized lucency in near the crux of the heart is likely a coronary artery. mrcp, indication: 60-year-old woman with history of autoimmune hepatitis. technique: multiplanar t1- and t2-weighted breath-hold independent imaging was performed on a 1.5 tesla magnet, including dynamic sequential images obtained prior to, during, and after the uneventful administration of 0.1 mmol/kg of gadolinium-dtpa. comparison: correlation is made with abdominal ultrasound dated and abdominal ct dated . findings: there is a right pleural effusion. atelectasis is noted at both bases. the liver is nodular in contour. there is multifocal abnormal, patchy, linearly-oriented t2 signal abnormality throughout the liver, in a pattern suggestive of bridging fibrosis. there are no focal lesions. the regions of fibrosis are associated with capsular retraction. there is no intra- or extra-hepatic biliary dilatation. the gallbladder is thick-walled, likely relating to the patient's underlying liver disease. no definite gallstones are identified. spleen, pancreas, kidneys, and adrenals are grossly normal, allowing for limitations of non-breath-hold technique. there is ascites. bowel is normal in caliber. bone marrow signal is grossly normal. subcutaneous edema is noted. note is made of tarlov cysts associated with several sacral nerve roots. impression: morphologic changes and diffuse abnormal signal throughout the liver, in keeping with hepatitic fibrosis. no biliary dilatation. : video oropharyngeal swallow study the study was performed in conjunction with the speech pathology department. continuous fluoroscopic observation was provided during administration of multiple consistencies of barium. the patient displayed moderate to severe oral phase swallow dysfunction with decreased tongue propulsion, and delayed swallow initiation. once swallow initiation was started, however, the pharyngeal phase appeared unremarkable. a single episode of frank aspiration, which was silent was demonstrated during straw sip administration of thin liquid barium consistency which appeared to improve with chin tuck maneuvers. mild residue was also noted within the valleculae bilaterally with nectar and puree consistencies. focused examination of the vocal cords was not possible as no phonation was able to be elicited from the patient. : mri head impression: 1. mild decrease in the size of the small enhancing lesion, in the head of the caudate nucleus on the right side and a few smaller lesions noted in the right centrum semiovale and in the left centrum semiovale adjacent to the largest lesion in the left frontal lobe, which itself has not signficantly changed. no new lesions. 2. bilateral moderate subdural fluid collections are unchanged. 3. unchanged diffuse fluid/mucosal thickening in the mastoid air cells on both sides. cxr (ap) findings: in comparison with the study of , the patient has taken a much better inspiration. there is still mild indistinctness of pulmonary vessels, though the vascular status is certainly improved from the previous examination. picc line remains in place. probable mild atelectatic change in the retrocardiac region at the left base. admission labs 04:34pm ck(cpk)-57 04:34pm ck-mb-notdone ctropnt-<0.01 04:34pm phenytoin-10.8 04:34pm pt-16.4* ptt-33.9 inr(pt)-1.5* 04:11pm type-art po2-223* pco2-33* ph-7.47* total co2-25 base xs-1 12:49pm voidspec-clotted sp 08:09am type- comments-green top 08:09am lactate-1.6 08:00am glucose-129* urea n-12 creat-0.6 sodium-131* potassium-3.2* chloride-105 total co2-22 anion gap-7* 08:00am estgfr-using this 08:00am alt(sgpt)-35 ast(sgot)-45* ld(ldh)-342* ck(cpk)-53 alk phos-86 tot bili-2.5* 08:00am lipase-112* 08:00am ck-mb-notdone ctropnt-<0.01 08:00am albumin-2.2* calcium-6.6* phosphate-2.1* 08:00am wbc-3.1* rbc-2.30* hgb-9.8* hct-28.1* mcv-122* mch-42.5* mchc-34.8 rdw-17.7* 08:00am plt count-82* 08:00am pt-20.0* ptt-39.6* inr(pt)-1.9* 08:00am fibrinoge-221 discharge labs: 05:12am blood wbc-3.4* rbc-2.45* hgb-8.6* hct-25.9* mcv-106* mch-35.3* mchc-33.4 rdw-23.4* plt ct-98* 05:12am blood pt-15.3* ptt-37.4* inr(pt)-1.4* 05:12am blood glucose-95 urean-8 creat-0.3* na-138 k-2.6* cl-114* hco3-19* angap-8 02:01pm blood k-3.2* 05:12am blood alt-23 ast-30 ld(ldh)-263* alkphos-312* totbili-0.7 12:41am blood genta-1.0* brief hospital course: patient is a 60 year old female with past medical history of autoimmune disease, who presented on with seizure, found to have listeria bacteremia, meningitis, and likely listeria brain abscess, s/p prolonged intubation, now s/p tracheostomy and removal, now awake and alert and breathing comfortably on room air. . #) listeria bacteremia and meningitis/encephalitis/abscess and resultant altered mental status: . listeria noted in blood and csf cultures from and respectively. her recently immuno-suppressed state secondary to steroid and azathioprine treatment for auto-immune hepatitis may have pre-disposed her to infection. initial imaging revealed small sah and large mass, likely abscess with several satellite lesions. serial head ct??????s and mris have been stable showing large left hemisphere lesion and and interval resoluton of bleed and multiple septic emboli. tte and tee completed as noted (abnormal, but no definite abscess or vegetation). eeg was not suggestive of convulsive status. repeat lp and blood cultures all show no growth. - id service consulted. ampicillin and gentamicin were started on . id recommends 6 week course then repeat head mri to reassess. tentative date of completion of abx is . - neurology service consulted for initial seizure presentation, recommend levetiracetam 1500 indefinitely for seizure prevention. . #) respiratory failure: patient intubated for airway protection in setting of altered mental status, and underwent tracheostomy on due to persistent altered mental status. over her hospital course her mental status improved and she was able to be weaned off trach mask and supplemental oxygen. her trach was decannulated by the interventional pulmonology service on . . #) hemoptysis: patient had episodes of significant hemoptysis and blood around her trach site. bronchoscopy demonstrated an erosion that was felt to likely be the source of her bleeding. cta was negative for fistula. no further bleeding noted. repeat bronchoscopy after latest episode of hemoptysis on found a bleeding lesion in the trachea, which was coagulated with good hemostasis. since then, there have been no repeat episodes and her hematocrit and respiratory status have remained largely stable. . #) pancytopenia: pt was pancytopenic on admission and remained so throughout hospital stay. all cell counts stable at time of discharge. pt admitted on prednisone and imuran for autoimmunie hepatitis, initially immunosuppressants thought to be culprits, but were held throughout admission without resolution of pancytopenia; other possibilities included stress of acute infection, viral process. hematology service consulted. hemolytic work up negative. flow cytometry negative for malignancy, bone marrow bx deferred this admission. tpmt returned positive, consistent with heterozyogous state, which suggests increased risk of myelosuppression with imuran treatment. throughout her stay, the patient's hematocrit was closely monitored, and she did require several blood transfusions. . #) elevated coagulation studies: stable. her elevated inr had been felt to be secondary to nutritional deficiencies and liver disease. per hematology and laboratory values, dic appears to be less likely, but still will continue to monitor for this possibility. the patient was continued on pneumoboots for dvt prophylaxsis given her increased coagulation studies, as well as the uncertainty regarding continued bleeding around her brain heparin sc was deferred. . #) elevated lfts: on admission her lfts were essentially normal. during her stay had an elevation most notable in alk phos as well as a mild elevation in transaminases which are again trending down. the hepatology team was consulted. ruq ultrasound consistent with liver disease, no other concerning pathology (no ductal dilation or gall bladder abnormalities noted). there was concern that her autoimmune hepatitis could be returning, but the team was hesitant to start her on any immunosupressive therapies given the severe comorbid infection in this patient. hepatology recommended a mrcp, which showed findings c/w cirrhosis, as well as some ascites. hepatology also recommended starting ursodiol, but no imuran or prednisone given her acute infection. she should follow up with her liver team upon completion of antibiotics for consideration of restarting treatment for her autoimmune hepatitis. . #) pt had acinetobacter growing in her sputum sample during icu stay. decision made not to treat due to abscence of clinical disease. as above pt tolerated vent and 02 weaning without addition of antibiotics. . #) during initial decompensated illness, there was concern for systemic fungal infection. a b-glucan test was positive and pt was transiently treated with amphotericin. fungal cultures of blood and csf were persistently negative and this was discontinued. currently it is thought that this may have been a false positive in setting of listeria infection or possibly her ampicillin. our id consultants recommend that this be repeated after completion of antibiotic treatment for confirmation of this. . #) hypokalemia: on the medical floor, the patient was noted to be persistently hypokalemic, with a low of 2.5 on . various causes were considered including medication effects from gentamycin or keppra. of note, her creatinine has consistently been 0.4-0.6. potassium was repleted daily. a ttkg calculated was 10.33, which was inconsistent with the measured hypokalemia and suggestive of renal losses. the patient's potassium will need close monitoring and repletion. she is at risk to develop renal failure due to cumulative gent dosing, her renal function should be monitored closely for this reason and to prevent developmement of hyperkalemia in face of aggressive repletion. on discharge she was ordered for 60 meq of potassium but this dose will likely need to be adjusted and would recommend -tid potassium monitoring. . #) ent - ent service was consulted when pt developed partial vocal cord paralysis after extubation and trach decannulation seen by laryngoscope. it is hoped that this may resolve as pt recovers. the ent team recommends ppi to prevent any gerd associated laryngeal edema complicating her recovery and follow up with their service in months. . #) fen: when the patient was unresponsive, a peg tube was placed, and she was receiving tube feeds on transfer to the floor. these feeds were continued. when the patient had a swallow study on , there was concern for aspiration, so a video swallow study was scheduled for . these results are listed above. at this time, she was cleared to take ground solids, and thin liquids with a chin tuck. her tube feeds were continued, as she was taking in only a relatively small amount po. at time of discharge nutrition services were obtaining calorie counts to assess possibility of peg removal. pt is profoundly malnourished perhaps in part due to her personal dietary choices of an organic diet which has limited her voluntary po in-hospital intake. . on day of discharge vital signs are stable, she has no oxygen requirement. her dense right sided hemiplegia has improved markedly since presentation and she is now able to move and grip with her right hand and wiggle her toes. she is alert and oriented x 3. she does have some persistent attention deficits and difficulty with complex tasks (see neurology consult note for full details of current functional neurologic status). medications on admission: potassium, imuran 50 mg daily, ursodiol, prednisone 10 mg (being tapered). dosages unavailable. "naturopath" supplements started in : (from the d'adamo institute) formula o, b6-b2, b12-b2, folic acid, c, iron, selenium, liver, cod liver oil, nac, bonerneal/support, pancreas, chromium, zinc, magnesium & zinc, adrenal, potassium, whey protein powder, psyllium seed blend, stractan, flax seed oil, kidney herbal tea, liver disease/cc/stomac 601, licorice solid extract, bronchial drops, boswellia. discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily). 2. acetaminophen 160 mg/5 ml solution : ml po q6h (every 6 hours) as needed: do not exceed 4 g acetaminophen daily. 3. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed for constipation. 4. docusate sodium 50 mg/5 ml liquid : ten (10) ml po bid (2 times a day). 5. levetiracetam 100 mg/ml solution : 1500 (1500) mg po bid (2 times a day). 6. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 7. folic acid 1 mg tablet : two (2) tablet po daily (daily). 8. ursodiol 250 mg tablet : two (2) tablet po bid (2 times a day). 9. guaifenesin 100 mg/5 ml syrup : 5-10 mls po q6h (every 6 hours) as needed for cough. 10. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day): give 30 min before breakfast and dinner. 11. cyanocobalamin 100 mcg tablet : 0.5 tablet po daily (daily). 12. lorazepam 2 mg/ml syringe : one (1) mg injection prn (as needed) as needed for seizure activity: to be administered prn seizure activity up to 4 mg over 15 minutes. 13. sodium chloride 0.9 % 0.9 % syringe : three (3) ml injection prn (as needed) as needed for line flush: flush every 8 hours and prn. 14. ampicillin sodium 2 gram recon soln : two (2) gram recon soln injection q4h (every 4 hours): day 1 = . 15. gentamicin 40 mg/ml solution : 200 mg injection q18h (every 18 hours): overall day 1 = , 160 q 12h , then 200 q12h, then 200 mg q 18 hrs . 16. heparin, porcine (pf) 10 unit/ml syringe : two (2) ml intravenous prn (as needed) as needed for line flush: flush with 10 ml ns followed by heparin as above daily and prn per lumen. 17. potassium chloride 20 meq packet : sixty (60) meq po twice a day: this dose will need to be adjusted according to twice daily potassium checks. discharge disposition: extended care facility: hospital discharge diagnosis: primary: listeria brain abscess and cerebritis pancytopenia seizures secondary: autoimmune hepatitis discharge condition: fair, tolerating ground diet and thin liquids with chin tuck, transferring to chair with lift. discharge instructions: you were admitted to the hospital after a seizure. you had a head ct and lumbar puncture which showed that you had an infection around your brain. the neurosurgery team decided that you did not need surgery. you were started on iv antibiotics, which have continued for several weeks. you had a breathing tube, and also a tracheostomy placed to help you breathe. you also were unable to eat, and had a tube placed into your stomach to give you food. you were very ill and stayed in the icu, but eventually recovered to the point were you could be transferred to the medical floor. . take your medications as prescribed. it is important that continue treatment with ampicillin and gentamicin as prescribed. they need to be continued for at least 6 weeks (day 1 , 6 wks on ). you will need to have an mri of your brain performed prior to stopping antibiotics to ensure that your infection has been appropriately treated. whether or not to stop these antibiotics should be discussed with your new infectious disease doctor once you have set up follow up. . please call your doctor or return to the ed for any of the following: - seizures - changes in strength, sensation, or mental status - fever/chills - shortness of breath or coughing up blood - black or bloody bowel movements - any other new or concerning symptoms followup instructions: please call your primary care doctor a follow up appointment. . you will need to be followed by an infectious disease doctor as well as a neurologist. please call your primary care doctor to help appointments with a new neurologist and infectious disease specialist. your pcp or new infectious disease doctor can call dr. at to discuss the case at if there are any questions. . please follow up with your regular liver doctor. . you should discuss with your primary doctor about having flow cytometry checked in months if it is felt to be clinically indicated given your low blood counts. this may also need to be discussed with a hematologist. . please set up a new patient visit with an ent doctor your vocal cord dysfunction if your voice does not improve. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung other endoscopy of small intestine enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] arterial catheterization other intubation of respiratory tract temporary tracheostomy bronchoscopy through artificial stoma transfusion of packed cells replacement of tracheostomy tube transfusion of other serum transfusion of platelets diagnoses: other convulsions other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure hyperosmolality and/or hypernatremia intracranial abscess coma other tracheostomy complications listeriosis autoimmune hepatitis other causes of encephalitis and encephalomyelitis 

Answer: The patient is high likely exposed to