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: keflex attending: chief complaint: seizure major surgical or invasive procedure: endotracheal intubation history of present illness: 55 y/o f with h/o of migraines and depression who was presented to with seizure. stablized, intubated for airway protection and transferred to . the patient was found at 12:30pm by her husband having seizures in bed. he called ems who noted the patient to be having a tonic-clonic seizure with eyes deviated to the left and left arm/leg convulsing and administered 2mg ativan and narcan without improvement. brought to where seziure was broken with 8mg of ativan and 1500mg of dilantin. ct head (-). utox (+) for amphetamine, barbituates, and opiates. lactate elevated. intubated for airway protection and trsnferred to . in discussion over the phone with the patient's husband she has been very depressed recently. unclear if taking all of her meds. at , vs 102 157/84 tv 500 rr 14 60% fio2 5 peep. an ogt was placed and drained 300ml of dark fluid that was hemmocult (+). started on iv pantoprazole and ocreotide and admitted to the micu. on arrival to the mciu, vs 99.3 77 160/69 99%. intubated and sedated. past medical history: - sleep apnea - tobacco abuse - migraines - bronchitis - hypothyroidism - depression - back surgeries - hl - htn social history: long h/o smoking. lives with her husband and two daughters. does administrative work. has had a live-in "friend" named who has been supplying the pt. with opiates such as heroin and presciption pills. family and pt. have voiced their wishes that he does not visit in the hospital. family history: long h/o migraine physical exam: admission exam: vitals: 99.3 77 160/69 99% intubated general: intubated and sedated. opens eyes to voice. heent: sclera anicteric, mmm, oropharynx clear, eomi, perrla but sluggish neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: somewhat coarse bs b/l abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: (+) foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: pupils reactive but sluggish. sedated. discharge exam: vs: t 98.3 bp 128/80 hr 88 rr 16 o2sat 96% ra gen: nad, comfortable neuro: mental status: alert, oriented, conversing appropriately with normal f l u e n c y /comprehension/naming/repetition//writing/prosody/thought process/affect; digit span 6 forward, 3 back; misspells "world" backwards but otherwise no evidence of attentional deficits. excellent recall of recent events. cn: eom intact, vf full, face symmetric. pertinent results: imaging studies: cxr impression: 1. there has been interval appearance of mild to moderate pulmonary and perihilar edema. no pleural effusions or pneumothorax. overall, cardiac and mediastinal contours are stable. mri head findings: study is limited due to motion-related artifacts on multiple sequences. within this limitation, on the diffusion sequences, there is no focus of slow diffusion to suggest an acute infarct. there is asymmetry in the size of the lateral ventricles, with the left being slightly larger than right. on the flair sequence, there are several areas of hyperintense signal, involving predominantly the cortex, in the frontal, parietal, and the occipital lobes as well as in the left medial temporal lobe. small areas of involvement in the adjacent white matter are also seen. there is no abnormal enhancement noted in these areas. there is no focus of negative susceptibility to suggest hemorrhage allowing for the areas of mineralization. patient is intubated. there is mildly increased signal intensity in the mastoid air cells on both sides from fluid/mucosal thickening. the major intracranial arterial flow voids are noted. mr angiogram of the head: the left vertebral artery is dominant. the major arteries of the intracranial circulation are patent, without focal flow-limiting stenosis. the a1 segment on the left side is diminutive. there is contour irregularity related to atherosclerotic disease at multiple levels. a tiny outpouching is seen from the lateral aspect of the left cavernous carotid segment and also the right, question artifactual related to pulsation artifacts/small outpouchings. the p1 segment on the left side is diminutive, with prominent posterior communicating artery. impression: 1. several areas of flair hyperintense signal in the cerebral parenchyma, - the etiology of these findings is uncertain, a broad differential diagnosis including encephalitis, seizure-induced changes either reactive or inflammatory changes or related to medication/toxic etiology. clinical and lab correlation and close followup can be considered to assess stability. 2. patent major intracranial arteries as described above, with evidence of mild contour irregularity related to atherosclerotic disease. echocardiogram results measurements normal range left atrium - four chamber length: 5.0 cm <= 5.2 cm left ventricle - ejection fraction: >= 75% >= 55% left ventricle - lateral peak e': 0.11 m/s > 0.08 m/s left ventricle - septal peak e': 0.10 m/s > 0.08 m/s left ventricle - ratio e/e': 9 < 15 aortic valve - peak velocity: *2.2 m/sec <= 2.0 m/sec aortic valve - pressure half time: 519 ms mitral valve - e wave: 0.9 m/sec mitral valve - a wave: 1.0 m/sec mitral valve - e/a ratio: 0.90 mitral valve - e wave deceleration time: *128 ms 140-250 ms findings left atrium: normal la size. right atrium/interatrial septum: ra not well visualized. the patient is mechanically ventilated. cannot assess ra pressure. left ventricle: normal lv wall thickness, cavity size, and global systolic function (lvef>55%). suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. no resting lvot gradient. right ventricle: rv not well seen. aortic valve: no valvular as. the increased transaortic velocity is related to high cardiac output. significant ar, but cannot be quantified. mitral valve: normal mitral valve leaflets with trivial mr. tricuspid valve: tricuspid valve not well visualized. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. general comments: suboptimal image quality - poor echo windows. conclusions the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. significant aortic regurgitation is present, but cannot be quantified. the mitral valve appears structurally normal with trivial mitral regurgitation. there is an anterior space which most likely represents a prominent fat pad. impression: suboptimal image quality. normal biventricular cavity sizes with preserved global biventricular systolic function. aortic regurgitation - ? mild. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. eeg impression: this telemetry captured no pushbutton activations. it showed a mildly slow background throughout with frequent epileptiform spike discharges in the left temporal region. the discharges, however, did not occur repetitively in short segments nor were they rhythmic or prolonged. the slow encephalopathic background was unchanged from the previous day's recording. there were no periodic discharges or electrographic seizures. echo left ventricle: hyperdynamic lvef >75%. aortic valve: mild (1+) ar. conclusions left ventricular systolic function is hyperdynamic (ef>75%). mild (1+) aortic regurgitation is seen. compared with the findings of the prior study (images reviewed) of , the findings are similar. cxr the left perihilar component of pulmonary abnormality has improved substantially over approximately 48 hours suggesting the diagnosis of asymmetric edema or acute aspiration. there is new opacification at the base of the right lung, at least some of which is due to atelectasis given progressive elevation of the hemidiaphragm and ipsilateral mediastinal shift. nevertheless findings could also be explained by aspiration to that side. clinical correlation advised. previous pulmonary vascular engorgement has improved indicating improved cardiac or hemodynamic status. pleural effusion is minimal on the right, if any. micro/path labs: admission labs: 06:26pm blood wbc-22.1* rbc-5.26 hgb-13.5 hct-43.3 mcv-82 mch-25.7* mchc-31.2 rdw-14.6 plt ct-302 06:26pm blood neuts-91.6* lymphs-4.5* monos-2.9 eos-0.9 baso-0.1 06:26pm blood pt-12.8* ptt-28.1 inr(pt)-1.2* 06:26pm blood glucose-147* urean-8 creat-1.1 na-141 k-3.4 cl-101 hco3-25 angap-18 06:26pm blood alt-9 ast-18 alkphos-100 totbili-0.6 06:26pm blood albumin-4.2 06:26pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 06:55pm blood type-art temp-36.1 rates-14/5 tidal v-500 fio2-60 po2-67* pco2-44 ph-7.41 caltco2-29 base xs-2 -assist/con intubat-intubated 06:25pm blood lactate-1.2 mri brain w/ & w/o contrast : findings: extensive t2/flair hyperintensities in bilateral white matter, thalami, left medial temporal lobe have significantly improved since exam. increased flair signal persists in bilateral parietal, occipital regions and right frontal lobe (4:20), predominantly in white matter distribution. no diffusion abnormality is seen to suggest acute infarct. no abnormal parenchymal, leptomeningeal or dural enhancement is seen. there is no intracranial hemorrhage, sulci and ventricles are normal in size and configuration. there is no mass effect or shift of normally midline structures. basal cisterns are patent. orbital and nasopharyngeal soft tissues are grossly unremarkable. paranasal sinuses are clear. principal intracranial flow voids are preserved. impression: in comparison to exam, there is near complete resolution of diffuse bilateral flair hyperintensities. t2/flair hyperintensities remain predominantly in bilateral occipital and parietal white matter, the above findings likely represent resolving pres. the study and the report were reviewed by the staff radiologist. brief hospital course: ms. is a 55 y/o f with admitted to the micu following tonic-clonic seizure and intubation. hospital course --------------- brought to where seizure was broken with 8mg of ativan and 1500mg of dilantin. ct head (-). utox (+) for amphetamine, barbituates, and opiates. lactate elevated. intubated for airway protection and trsnferred to . at , an ogt was placed and drained 300ml of dark fluid that was hemmocult (+). started on iv pantoprazole and octreotide and admitted to the micu. in micu had heavy secretions and leukocytosis 22.1 wbc on , cxr with new left retrocardiac opacity, possibly due to aspiration (possible pneumonia, atelectasis), started on levofloxacin. cxr showed mild/moderate pulmonary edema, gave iv lasix. no seizure activity on continuous eeg. weaned off o2 and extubated . transferred to the floor . required oxygen on the floor. normal mentation and no seizure activity on the floor. restarted home meds and gave gentle diuresis with iv lasix. #hypoxia: likely fluid overload vs. aspiration vs. pna. has remained afebrile, although spikes to 99.0, decreasing leukocytosis. lung exam is remarkable to rhonchi and wheezes with copious secretions. with diuresis has not had robust uop and then drops to 20-30/hour. given this most likely chemical pneumonitis secondary to aspiration. received levofloxacin iv x 3 days, po x 2 days, empirically for aspiration pneumonia vs. cap. - gave scheduled albuterol / ipatroprium; albuterol nebs; prn albuterol inhaler - will discharge home on long-acting bronchodilator (spiriva) - gave iv lasix for pulmonary edema #: seizure - no seizures during hospitalization. got dilantin in the icu and floor. the patient has no obvious findings on ct head to suggest structural abnormality or cva. however, with multiple flair hyperintensities, with an initial differential of pres vs seizure-related changes vs encephalitis. her utox was (+) for , , opiates and amphetamines at osh but here only for opiates/ and the patient is known to be prescribed these medications. could be a withdrawal seizure as, by report, the patient may have abruptly stopped taking her two days ago, also may have recently stopped buprenorphine. also with unclear abuse history (pt denies this). lytes normal. transferred to inpatient neurology for continued management. on neurology service, pt initially displayed some very mild residual cognitive deficits that subsequently resolved. on the day of discharge, her mental status was normal. because of this rapid improvement, no lp was performed, and no empiric treatment for encephalitis was initiated. repeat mri on demonstrated near-resolution of the previously seen flair hyperintensities, thus suggesting that these may have been related to pres. phenytoin was discontinued, and pt was discharged with levetiracetam 750 mg instead. as pt's polypharmacy likely contributed to her episode of unconsciousness, her burden of sedating medications was decreased by discontinuing meclizine, and changing lorazepam 1 mg tid to clonazepam 0.5 mg . pt's other psychiatric medications (quetiapine 50 mg qhs, zolpidem for sleep) were continued. #: depression - contracts for safety, no si, but pt and husband report significant depression, no longer has a psychiatrist. continue citalopram. #upper gi bleed: patient with 300cc dark fluid from ogt in the ed and started on octreotide and pantoprazole. in the micu, hematocrit remained stable. the patient was continued on intra-venous pantoprazole. her hematocrit remained stable throughout her micu stay however she was found to have guiac positive stools. on transfer to the floor, iv pantoprazole was transitioned to po metoprolol. hgb on discharge was 11.3. # dermatophytosis - hand & foot rash - likely fungal. gave miconazole ointment. #hypertension: this is a chronic problem. we continued her home dose of metoprolol, verapamil. outpt adjustments of these meds should be considered as they both risk side effects of bradycardia and hence hypoperfusion-related events. #hyperlipidemia statin was continued. #hypothyroid: this is a chronic stable issue. we continued her home levothyroxine. medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from osh notes. 1. zolpidem tartrate 10 mg po hs 2. lorazepam 1 mg po q8h 3. citalopram 40 mg po daily 4. quetiapine fumarate 50 mg po hs 5. metoprolol succinate xl 200 mg po daily 6. atorvastatin 40 mg po daily 7. albuterol inhaler 1 puff ih q6h:prn wheezing 8. acetaminophen-caff-butalbital tab po q6h:prn migraine 9. migranal *nf* (dihydroergotamine) 0.5 mg/pump act. (4 mg/ml) nu daily migraine 10. vitamin d 50,000 unit po 1x/week (th) 11. hydrochlorothiazide 25 mg po daily 12. levothyroxine sodium 150 mcg po daily 13. meclizine 12.5 mg po q6h:prn ha 14. omeprazole 20 mg po daily 15. ondansetron 4 mg po q8h:prn nausea 16. tramadol (ultram) 50 mg po q6h:prn ha 17. verapamil sr 240 mg po q24h discharge medications: 1. albuterol inhaler 1 puff ih q6h:prn wheezing rx *proair hfa 90 mcg 1-2 puffs inhaled every 6 hours disp #*2 inhaler refills:*0 2. atorvastatin 40 mg po daily 3. citalopram 40 mg po daily 4. levothyroxine sodium 150 mcg po daily 5. metoprolol succinate xl 200 mg po daily 6. quetiapine fumarate 50 mg po hs rx *quetiapine 50 mg 1 tablet(s) by mouth at night disp #*5 tablet refills:*0 7. zolpidem tartrate 10 mg po hs rx *zolpidem 10 mg 1 tablet(s) by mouth at night disp #*5 tablet refills:*0 8. verapamil sr 240 mg po q24h rx *verapamil 240 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*3 9. clonazepam 0.5 mg po bid rx *clonazepam 0.5 mg 1 tablet(s) by mouth twice daily disp #*60 tablet refills:*0 rx *clonazepam 0.5 mg 1 tablet(s) by mouth twice daily disp #*20 tablet refills:*0 10. levetiracetam 750 mg po bid rx *levetiracetam 750 mg 1 tablet(s) by mouth twice daily disp #*60 tablet refills:*3 11. acetaminophen-caff-butalbital tab po q6h:prn migraine 12. hydrochlorothiazide 25 mg po daily 13. migranal *nf* (dihydroergotamine) 0.5 mg/pump act. (4 mg/ml) nu daily migraine 14. omeprazole 20 mg po daily 15. vitamin d 50,000 unit po 1x/week (th) 16. miconazole 2% cream 1 appl tp to both hands rx *dermafungal 2 % 1 application twice daily disp #*1 tube refills:*0 discharge disposition: home discharge diagnosis: seizure pneumonia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital after being found down at home with rhytmic jerking concerning for seizure activity. you were initially admitted to the medicien service in the intensive care unit where you were started on seizure medications. you had an mri which showed non-specific diffuse changes. these resolved on follow-up imaging studies. you were transitioned to a different seizure medication on discharge. we discussed performing a lumbar puncture, but you noted that you were improving in terms of your thinking and that this was not necessary. you were seen by social work during this admission and told them you felt as if you had a safe home environment and would be able to go there on discharge. you cannot drive a car for 6 months. 1. you will need to continue on keppra at 750 mg twice daily until you see your neurologist dr. . 2. we stopped meclizine as this medication was not needed. 3. we switched your ativan to clonazepam which should help with your anxiety. please discuss these changes with your primary care doctor. 4. you were given refills for many of your medications. you should see dr. early next week in order to get refills. you told us you would be able to get an appointment. followup instructions: provider: , md phone: date/time: 10:30 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours diagnoses: obstructive sleep apnea (adult)(pediatric) tobacco use disorder unspecified essential hypertension unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified depressive disorder, not elsewhere classified other and unspecified hyperlipidemia acute respiratory failure pneumonitis due to inhalation of food or vomitus grand mal status hemorrhage of gastrointestinal tract, unspecified other, mixed, or unspecified drug abuse, continuous migraine, unspecified, without mention of intractable migraine without mention of status migrainosus delirium due to conditions classified elsewhere leukocytosis, unspecified 

Answer: The patient is high likely exposed to