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: ms changes major surgical or invasive procedure: intubation/extubation history of present illness: ms. is a 71 year old female with a complicated medical course over the past year, who is being transferred from osh on her son's request. she was transferred to the osh from nursing home after low grade temperature and agitation. her past medical history includes storke, seizure disorder, atrial fibrillation, type 2 diabetes mellitus, recent hospitalization for enterococcal uti, frequent ms change, for enterococcal urinary tract infection, moraxella bacteremia, altered mental status, subdural hemorrhage, acute renal failure thought secondary to dehydration, pyelonephritis, c-diff colitis. her baseline mental status is aox1 per reports. she had an icu stay for status epilepticus, requiring iv midazolam. upon presentation to the osh she was reported to have had low grade fevers, and vomiting. she was found to have uti per ua, and was given levofloxacin and ceftriaxone. flu swab was reportedly negative. per notes, ct head was obtained and neg. ms difficult to assess. unclear baseline. a+ox0-1. not trully verbal, alert. uncooperative with exam. in our ed, t 95.6 150/70 88 16 100ra, ct abdomen was obtaine to work up elevated lfts, and prelim report negative except for dilated rectum due to fecal load. past medical history: 1. stroke 30 years ago (? location-images not available) with residual right hemiparesis, dysarthria, and difficulty to express herself 2. type 2 dm, insulin dependent 3. hlp 4. atrial fibrillation, not on coumadin 5. h/o recurrent uti 6. seizure disorder, unspecified 7. h/o angina 8. pvd 9. chronic thrombocytopenia 10. anemia 11. depression 12. osteoporosis 13. dementia with delusional features 14. obesity 15. bilateral cataract surgery . prior admit for b chronic sdh and acute parafalcine sdh. social history: home: lives in nursing home. son is hcp, niece is training to be a nurse and is involved in her care. etoh: none drugs: none tobacco: none family history: could not obtain full family history due to patient's baseline dementia and altered mental status physical exam: exam on admission to medicine service: vitals: t: 97.4 bp: 150/70 p: 88 r: 20 o2: 94% general: lethargic, poorly arousable, responds to painful stimuly, does not follow commands heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally anteriorly cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: cold and clamy, no clubbing, cyanosis or edema neurological exam by neurology resident: mental status: not alert or arousable to voice; eyes closed during exam; grimaces to noxious stimuli. does not follow commands. cranial nerves: i: not tested; ii: pupiles symmetric 4mm; reactive to light. does not blink to visual threat. iii, iv, vi: gaze was upwards initially; then moved to midline; l exotropia v, vii: right facial weakness. viii: hearing appears intact to voice ix, x, , xii: tongue midline. motor: increased tone r arm and leg. no observed myoclonus or tremor ; retracts both legs and arm l>>r to noxious stimuli. sensation: withdraws from painful stimuli bilaterally l>>r, localizes pain by moving bilateral upper extremities, making moaning sounds. reflexes: b t br pa pl right 1 1 1 0 0 left 1 1 1 0 0 r upgoing toe coordination and gait not assessed exam at time of discharge: pertinent results: 06:15am blood wbc-5.9 rbc-3.98* hgb-12.2 hct-38.2 mcv-96 mch-30.6 mchc-31.8 rdw-14.6 plt ct-123* 06:15am blood neuts-71* bands-0 lymphs-18 monos-9 eos-1 baso-1 atyps-0 metas-0 myelos-0 06:15am blood pt-14.5* ptt-27.2 inr(pt)-1.3* 06:15am blood glucose-120* urean-41* creat-0.9 na-145 k-4.8 cl-106 hco3-26 angap-18 01:55am blood glucose-145* urean-7 creat-0.5 na-140 k-3.4 cl-109* hco3-24 angap-10 06:15am blood alt-300* ast-307* ck(cpk)-59 alkphos-142* totbili-0.4 03:00am blood alt-73* ast-35 alkphos-83 totbili-0.2 06:15am blood lipase-33 04:55am blood albumin-3.5 calcium-8.7 phos-3.5 mg-1.7 03:00am blood albumin-3.1* calcium-7.3* phos-2.9 mg-1.7 06:15am urine color-straw appear-hazy sp -1.010 06:15am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-mod 06:15am urine rbc-0-2 wbc-* bacteri-mod yeast-none epi- microbiology: urine culture (final ): obtained after patient had already received 2 days of ceftriaxone escherichia coli. 10,000-100,000 organisms/ml.. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ 8 i meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ 4 s trimethoprim/sulfa---- =>16 r c.diff - negative x2 bcx - pending imaging: eeg : impression: this is an abnormal portable eeg due to four non-convulsive electrographic seizures as detailed above. the interictal activity was slow and disorganized consisting of a mixed alpha/theta activity. continuous eeg monitoring is recommended to ensure resolution of these ictal events. : impression: this telemetry captured multiple periods of activity described above without clinical correlate. the interpretation of this is unclear. it may represent electrographic seizure activity, but each event had a gradual onset and evolved gradually, with a gradual offset. the slower progression and evolution is not typical of electrographic seizures, but cannot be excluded. patterns like this can also be seen with electrographic arousals, and the patient's known structural abnormality involving the left hemisphere (left mca stroke,) may be the cause of the asymmetry of progression. there were no interictal discharges seen in this recording. the background activity was slow suggestive of a moderate encephalopathy. cxr - impressions: no acute cardiopulmonary abnormality. low lung volumes. ct abdomen/pelvis: impression: 1. massively fecal impacted rectum. 2. persistent bibasilar nodular opacities and atelectasis which is again nonspecific. continued followup is recommended. 3. 3.9cm rounded structure in the left adnexa may represent an exophytic fibroid or enlarged ovary. recommend pelvic ultrasound after fecal disimpaction. lenis - impression: no evidence of deep vein thrombosis in either leg. brief hospital course: this is a 71 yo female with complicated medical including a stroke ~ 30 years ago with residual aphasia and right hemiparesis, chronic sdh bilaterally, afib off ac due to sdh, seizure disorder, and recurrent cycles of uti/urosepsis (moraxella bacterimia) and c.diff infections, who had her dilantin discontinued on , and was noted to develop decreased level of alertness and confusion at her nh 2 days pta. she was diagnosed with a uti however did not improve after one day of treatment and was thus transferred to osh, then . she was initially admitted to the medicine service, where cftx was stopped. a neurology service was consulted to determine whether patient was in ncse. her initial exam showed that she does not follow commands, eyes closed, eyes midline, mumbles with pain, and retracts both legs and arms l>r to noxious stimuli. because the initial eeg showed signs concerning for ncse, she was transferred to neurology service for further monitoring and treatment on . her baseline state includes (confirmed with nh staff): awake, alert, interacting with staff (maintains eye contact) and answers in one word, often with intelligible sounds without reproducibly following directions with dense right sided hemiparesis requiring full assisstance with transfers and adls. # ms changes/sz disorder: decreased alertness and responsiveness. etiology was felt to be most likely encephalopathy due to e.coli uti in setting of already compromised neuronal reserve, however, given prior hx of sz/status and discontinuation of dilantin on , ncse evaluation was performed. initial eeg was suggestive of nsce, patient was restarted on dilantin, however for multiple reasons, therapeutic levels of dilantin were not reached until . keppra was increased to 1500mg iv bid. secondary review of eeg suggested continued ncse thus patient was started on midazolam gtt which required temporary intubation. once this was achieved, eeg showed no epiletiform activity. patient was extubated on and midazolam gtt weaned off. her level of alertness improved, but she remained encephalopathic and became somewhat agitated. dilantin levels were maintained in the 18 - 25 (corrected for alb) range. there were no further clear ictal or interictal epileptiform activity seen. of note osh ct head revealed no overall change from prior imaging. the following medications were discontinued toradol, compazine, and methenamine, as these were not indicated and could contribute to patients current presentation. she was started on prn zyprexa for agitation. she was changed to po medications (passed speech as swallow for ground solids, thin liquids). dilantin was changed to 100mg tid and keppra to 1500mg . she should have a dilantin level checked 5 days after discharge and albumin corrected level's goal is . this should be communicated with dr. at . # uti: initially cfx was stopped due to no available ua or cx data and a contaminated ua. following osh records arrival, pt was noted to have a e.coli uti with > 100k colonies. cftx was restarted on . patient received a total of 7 days of iv cftx discontinued on . # hypertension: continued outpatient bp medications. intermittently hypertensive over - due to missing medications (pt refused am/pm doses of medicines). verapamil was increased to 160mg tid. # transaminitis. unclear etiology but suspected due to polypharmacy, incuding use of methenamine. ct of abdomen/pelvis was obtain to evaluate for vascular and ostructive etiologies. hepatitis panel showed negative ab for all hbv antigens and hcv antigens. she received first immunization against hepb vaccine. on initial evaluation with ct abd/pelvis, a 3.9cm rounded structure in the left adnexa was noted that may represent an exophytic fibroid or enlarged ovary. pelvic ultrasound ultrasound was recommended as a follow up examination. toradol, compazine and methenamine were withheld. with this, transaminitis improved and lfts at time of discharge are reported in pertinent results (alt/ast 73/35). one of the reported aes for methanamine is ast/alt elevation. # type 2 dm: continued home lantus and ss. # afib: patient was noted to be in sinus rhythm. she was not on coumadin due to sdh. she was continued on asa and plavix. # communication: #. communication: emergency contact cell # is best way to reach him, home #, work #. medications on admission: actonel 35mg daily amlodipine 10 mg daily asa 81 mg daily lisinopril 40 mg daily plavix 75 mg daily simvastatine 20 mg daily keppra 750 mg tylenol 1000 mg + 325 q6h prn methenamine 1 tab verapamil 240 mg er oral vancomycine 125 mg neurontine 300 mg qhs lantus 25 mg qhs novolin prn ss dulcolax supp 10 mg prn mom prn hydralazine 10 mg po q6h compazine 10 mg q6h prn trazadone 50 -100 mg q6h prn restlessness tramadole 50 mg q4h albuterole q4h prn discharge medications: 1. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 2. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 3. actonel oral 4. amlodipine 5 mg tablet : two (2) tablet po daily (daily). 5. lisinopril 20 mg tablet : two (2) tablet po daily (daily). 6. clopidogrel 75 mg tablet : one (1) tablet po daily (daily). 7. simvastatin 20 mg tablet : one (1) tablet po once a day. 8. levetiracetam 500 mg tablet : three (3) tablet po bid (2 times a day). 9. phenytoin 125 mg/5 ml suspension : one (1) po tid (3 times a day). 10. verapamil 80 mg tablet : two (2) tablet po three times a day: hold for hr < 60, bp < 100 . 11. vancomycin 125 mg capsule : one (1) capsule po q 12h (every 12 hours). 12. gabapentin 300 mg capsule : one (1) capsule po hs (at bedtime). 13. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 14. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 15. insulin glargine 100 unit/ml solution : twenty five (25) units subcutaneous at bedtime. 16. insulin lispro 100 unit/ml solution : per sliding scale subcutaneous three times a day. 17. olanzapine 5 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po bid prn as needed for agitation/distress. 18. metronidazole 500 mg tablet : one (1) tablet po three times a day. 19. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain, fever. 20. hydralazine 10 mg tablet : one (1) tablet po every six (6) hours: hold for sbp < 100. 21. albuterol sulfate 0.63 mg/3 ml solution for nebulization : one (1) inhalation every 6-8 hours as needed for shortness of breath or wheezing. 22. outpatient lab work dilantin level every five days prior to am dose until seen by dr. at . please communicate the level to dr. at discharge disposition: extended care facility: rehabilitation and nursing center - discharge diagnosis: primary: encephalopathy, urinayr tract infection, possible non-convulsive seizures secondary: stroke, subdural hematomas, c.diff infetion discharge condition: neurological examination notable for: awake, alert, communicating unintelligibly with examiner at most times, able to name the names of the five sons. with motor and comprehensive aphasia. unable to follow commands reporducibly. rue is spastic with extensor reaction to noxious, triple flexion to noxious stimulation in rle, while full strenght in lue/lle. upgoing right toe. discharge instructions: you were transferred to from osh after altered mental status. she was confirmed to have a urinary tract infection, this was treated with ceftriaxone. her c.diff infection was treated with vancomycin. there was some concern that she was having continuous non-convulsive seizures, and thus required re-institution of dilantin and temporary treatment with midazolam and intubation. after a dilantin was therapeutic, no more seizure activity was noted and midazolam was dicontinued, patient extubated. her mental status improved. it is suspected that majority of her presentation was due to a urinary tract infection. the following changes were made to her medications: - dilantin restarted at 100mg three times daily - keppra increased to 1500mg twice daily - verapamil increased to 160mg three times daily - vancomycin by mouth decreased to 125mg twice daily - zydis started on as needed basis - toradol, compazine, and methenamine were discontinued - received 1st dose of hepatitis b vaccination. she was discharged with improved mental status and motor examination back to baseline. should she develop any further complications, or symptoms concerning to caretakers (see below), please call the responsible physician and refer patient to the emergency room. followup instructions: neurology: provider: , md phone: date/time: 1:30 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified insertion of endotracheal tube enteral infusion of concentrated nutritional substances diagnoses: thrombocytopenia, unspecified anemia, unspecified urinary tract infection, site not specified toxic encephalopathy unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled atrial fibrillation peripheral vascular disease, unspecified depressive disorder, not elsewhere classified other and unspecified angina pectoris long-term (current) use of insulin osteoporosis, unspecified intestinal infection due to clostridium difficile grand mal status late effects of cerebrovascular disease, hemiplegia affecting unspecified side obesity, unspecified late effects of cerebrovascular disease, aphasia nonspecific abnormal results of function study of liver other impaction of intestine 

Answer: The patient is high likely exposed to