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: sepsis major surgical or invasive procedure: peg placement intubation, tracheostomy central line history of present illness: this is a 31 yo f with a past medical history significant for hemorrhagic cva 3 years ago, with a prolonged post cva course, c/b tracheostomy and residual aphasia and r-sided hemiparesis, aspiration pneumonias, who per her mother has had a recent progressive decline with difficulty swallowing. on the day of admission to the osh, the patient developed abdominal pain and vomiting and was admitted for further work-up. she was found to be tachycardic to the 140's, febrile to 103.8 (rectal), bp 138/114. a femoral line was placed as piv access, and a rij were unable to be obtained. she had progressive respiratory distress and was then intubated for airway protection. she was transferred to the osh icu for presumed aspiration pneumonia, sepsis, arf and respiratory failure. . at the osh, the patient was started levofloxacin/timentin/vancomycin, og tube was placed, was given ivf, and was placed on steroids. per her mother, she has no seizure history, but is maintained on valproate, and was restarted on this at the osh. she was transferred to to the for further management of her renal failure and possible sepsis. . when the patient arrived she was on a propofol gtt, and was having tongue and eyelid fasciculations. she withdrew to pain but was otherwise unresponsive. vitals were stable. past medical history: - diabetes mellitus type 1 (dx at age 3), hx of hypoglycemic episodes - cva (hemorrhagic) at 27 with residual aphasia and r-hemiparesis, tracheostomy post cva now decannulated. - blindness in one eye - history of aspiration pneumonia - although patient is on valproate, no reported history of stroke - depression social history: remote smoking history at age 18, lived in ca and has lived at the greenery since coming to ma. family history: healthy brother/sister. maternal family history of dm. physical exam: vitals: t 99.4 hr 90 bp 138/88 sats 98% on ac 450x16 peep 5 fio2 60% general: intubated, sedated, not responding to voice. heent: left ptosis. perrl. anicteric. neck:supple, jvp elevated 8cmh20 lungs: diffuse rhonchi chest: rrr ii/vi sem at base abd: soft nt, mild distention +bs ext: no e/c/c neuro: withdraws to pain, left-sided facial drooping, left sided ptosis; unclear response. no clonus. pertinent results: admission labs: 06:58pm glucose-123* urea n-16 creat-1.0 sodium-148* potassium-2.9* chloride-114* total co2-25 anion gap-12 06:58pm alt(sgpt)-9 ast(sgot)-16 ld(ldh)-204 alk phos-61 amylase-33 tot bili-0.2 06:58pm lipase-7 06:58pm albumin-2.3* calcium-8.6 phosphate-3.3 magnesium-1.7 06:58pm wbc-11.9* rbc-2.64* hgb-8.8* hct-25.9* mcv-98 mch-33.2* mchc-33.9 rdw-15.4 . imaging: eeg study date of : impression: this telemetry captured six pushbutton activations, but they showed the same background as on routine sampling. overall, the eeg showed a widespread encephalopathy with a slow low voltage background but also with some asymmetry. background voltages were notably lower on the left side, and there was additional focal slowing on that side, as well. the recording indicates a widespread encephalopathy. medications, metabolic disturbances, and infection are among the most common causes. raised pressure and anoxia are other possibilities. the leftsided findings raise concern for a structural abnormality on that side. there were no epileptiform features. . ct head w/o contrast 5:57 pm 1. cystic encephalomalacia of the left basal ganglia extending into the left frontal lobe are likely the sequelae of prior infarct, trauma, surgery. correlate with history. while there is no evidence of recent infarction, evaluation is limited on ct, and mr - weighted imaging is recommended if clinically indicated. 2. extensive paranasal sinus mucosal thickening as described. . ct abdomen w/o contrast 5:58 pm 1. diffuse bibasilar centrilobular nodules and frank consolidation likely represents an infectious process. consider aspiration. 2. extensive atherosclerotic calcification. . echo study date of conclusions: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. a left ventricular mass/thrombus cannot be excluded. overall left ventricular systolic function is moderately depressed (ejection fraction 30-40 percent)secondary to severe hypokinesis/akinesis of the apical half of the left ventricle. tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. there is mild pulmonary artery systolic hypertension. no vegetation/mass is seen on the pulmonic valve. the main pulmonary artery is ,markedly dilated. the branch pulmonary arteries are dilated. there is no pericardial effusion. . lung scan impression: limited evaluation. no large perfusion or ventilation defects. low likelihood pulmonary embolism. . chest (portable ap) 5:09 am report: the patient has a left-sided subclavian line, inserting at the cavoatrial junction. et tube appears in good position well above the trachea. the degree of left basal opacity has probably continued to improve slightly from prior day. lungs otherwise appear grossly clear. there is some mild increased density over the left mid lung parenchyma when compared to the right but this is not as marked as on . . peg placement: procedure/findings: after explanation of the potential risks and benefits of the procedure, written informed consent was obtained from the healthcare proxy (patient's mother). preprocedure timeout was performed to confirm patient and proposed procedure. patient was placed supine on the angiographic table and abdomen prepped and draped in standard sterile fashion. guide wire was advanced through the existing torn gj tube under constant fluoroscopic guidance, and a new 18 french x 45 cm mic gj tube was exchanged over the wire. injection of contrast through the tube confirms the g-tube tip to be within the stomach, and the distal j-tube tip to be within the jejunum. the balloon was inflated with approximately 10 cc of saline and contrast, and the tube was secured to the skin with flexi-trak. final spot fluoroscopic view of contrast confirms positioning of the tube. patient tolerated the procedure well without immediate complication. impression: uneventful exchange over a wire of 18 french x 45 cm mic gj tube. catheter is ready for use. 7/20:07: ct of the chest with contrast: there is a right subclavian central line with its tip in the right atrium. there is a tracheostomy tube in place. the aorta is normal in caliber. there is enlargement of the main pulmonary artery, which measures approximately 3.6 cm in diameter. coronary artery calcifications are noted. there is bibasilar atelectasis with additional more patchy areas of airspace disease, some of which are somewhat nodular and may be infectious in etiology. these findings have improved since the prior study. there is a very prominent right paratracheal lymph node that measures 2.7 x 1.8 cm. several smaller subcentimeter lymph nodes are noted in the prevascular/ap window regions. several prominent lymph nodes are noted in the left axilla which may be reactive in nature. the largest lymph node measures 1.9 cm in greatest dimension. ct of the abdomen with contrast: the liver is mildly enlarged measuring approximately 20 cm in sagittal dimension. there is trace amount of ascites in the abdomen. the gallbladder is not distended. there is trace amount of pericholecystic fluid. there is no definite gallbladder wall thickening. the small and large bowel are unremarkable. a g-tube is again noted. there is no evidence of colitis or diverticulitis. heavy atherosclerotic calcifications are noted in the aorta, renal arteries, splenic artery and mesenteric arteries. there is no evidence for intraabdominal abscess. ct of the pelvis with contrast: the uterus and adnexal regions are within normal limits. the urinary bladder is not fully distended, which limits its evaluation. small amount of air is present in the urinary bladder likely due to a foley catheter in place. there is a rectal tube in place. impression: 1. no evidence of intraabdominal abscess, colitis, or diverticulitis. 2. enlarged main pulmonary artery suggestive of pulmonary artery hypertension. 3. extensive atherosclerotic calcifications involving coronary arteries, aorta, and multiple other intraabdominal vessels. 4. mild hepatomegaly and trace amount of ascites. 5. interval improvement in previously noted pleural effusions. interval improvement in bibasilar airspace disease. residual patchy and somewhat nodular opacities at both lung bases may be infectious in etiology. 6. enlarged paratracheal lymph node measuring 2.7x1.8 cm. a follow- up ct is recommended to assess for interval change if clinically indicated. liver ultrasound: findings: the liver is of normal size with normal echogenicity. there is no extra- or intrahepatic biliary duct dilatation with the common bile duct measuring approximately 4 mm. the gallbladder was slightly dilatated with moderate wall thickness and there was no evidence of stones or sludge. impression: cannot include or exclude cholecystitis. if clinically indicated would consider a hida scan. : cxr: one view. comparison with the previous study done . there is a persistent area of increased density at the left lung base consistent with atelectasis and/or consolidation. the right lung remains clear. the heart and mediastinal structures are unremarkable. the tracheostomy tube and right subclavian catheter remain in place. impression: no significant interval change. discharge labs: wbc: 8.2 hct 23.2 plt 499 gluc 80 bun 14 creat 0.7 na 141 k 3.8 cl 101 hc03 36* ag 8 valproate 24 (from 18) brief hospital course: 31 yo f with h/o dmi, hemorrhagic cva in with residual aphasia and r-sided hemiparesis, and recurrent aspiration pnas who was transferred to the from osh for presumed sepsis, arf, and respiratory failure. now with difficulty extubating. . 1. respiratory distress: mostly likely etiology is aspiration pneumonia v. acute pnumonitis. pt had a bronchial lavage culture from that is pending; no organism were seen on gram stain. pt was initially on levofloxacin for 5 days and then changed over to zosym 4.5 g q6h (currently day ) for broader coverage. she was also being diuresed, initially with lasix gtt then boluses) as tolerated by her renal function. unfortunately, she remains +6 l for hospital stay. pt also got a v/q scan that showed low likelihood for pe. she is also on albuterol and atrovent nebs. although pt appeared to be able to be weaned, she failed extubation on . of note, pt tends to have a high rsbi which may not be absolutely indicative of ability to ween. causes for failure to extubate include (aspiration) pneumonia, diaphragm atrophy, neurological (r-sided hemiparesis), excess secretions (stridor heard during extubation), hyperthyroid-induced myopathy?. tracheostomy was placed on and attempts were made to decrease ventilator settings. these were limited by tachypnea and low tidal volumes. however, as the patient's pneumonia was treated and she was diuresed, transition to pressure support was possible. she has been stable on pressure support ventilation. diuresis should be maintained as the patient has persistent lower extremity edema and improved respiratory status with diuresis. however, electrolytes and renal function should be followed to direct diuresis. she had had decreased output to the lasix on last day of admission, and bumex could be considered with thiazide to improve diuresis. pt did pull trach out the night prior to discharge, but it was immediately replaced and there were no complications. 2. persistent fevers: patient started spiking fevers on . the cause was unclear and possibly initially due to infection as patient had pneumonia and then eventually thought to be due to drug fever also. however, despite antibiotics that were tailored to culture sensitivities her fevers were unchanged. therefore other causes were evaluated for persisent fevers. she had serial blood cultures drawn that did not show any growth. she continued to have growth from her sputum cultures. her central line was changed over a wire, and a number of medications were stopped. eosinophilia developed over several days as well as urine eosinophils. this suggested that her persistent fevers may have been due to medications. therefore all medications that were potentially pyrogenic medications were discontinued, with last discontinued medications meropenem and vancomycin. as well her central line was removed. after these interventions, her temperature was less than <101 for greater than 48 hours. 3. dmi: initially despite insulin gtt, pt tends to have labile blood sugars. however, once the patient was on a stable tube feeding regimen, the glucose levels were somewhat better controlled. the patient did have more elevated sugars late in the day. consult directed the care of the patient amd recommended glargine 24 units at bedtime. 4. hypothyroidism (tsh 0.02, ft4 3.9): pt started on methimazol 5 mg po bid on . thyroid stim. ab was sent to assess for recs and level was 100 (normal <125). however with the persistent fevers that the patient sustained, the methimazole was changed to propylthiouracil. her thyroid function tests should be checked to confirm that she is at the correct dosage. additionally she will need follow up with endocrinology after discharge (dr. ). 5. seizure: pt has h/o seizure per osh records. eeg here shows encephalopathy, but did have twitching when level of valproate was subtherapeutic. she was evaluated by neurology and felt not to have signs of seizure activity. based on neurology recommendations she should have a goal level of 40-50. the level has been low and the daily dose has been increased last on to 1g po q6hours. this dose should be continued for now, but levels should be checked daily until she is therapeutic and then after as determined by overseeing physician. . 6. abdominal pain: pt had neg. ct abd (). she again had abdominal pain but a normal ct abdomen, pelvis. she continued to have discomfort and an abdominal ultrasound was inconclusive. lfts were negative. pt was on metoclopramide for gastroparesis dmi, but this was discontinued in the concern that this was causing fevers. however, if the patient is afebrile, it is possible that the metocopramide could be restarted on a trial basis to see if she becomes febrile again. . 7. chronic anemia: she had persistent anemia and occasionally required transfusions to keep her hct above 21. she received a total of 3 units prbcs , , . since then her hematorcit has been stable in the 23-25 range. pt is on ferrous sulfate po. cause of continued anemia is thought due to chronic disease and frequent blood draws (iatrogenic) in the setting of persistent fevers. . 8. arf, now resolved at baseline cr of 1.0: pt's cr had increased during hospital stay with aggressive diuresing. furosemide was held for past 3 days with return of cr to baseline. she was again diuresed and renal function has remained stable. . 9. htn: pt's bp is usually stable but has been intermittently elevated. pt is on metoprolol (increased to 175 ) and diltiazem. pt was also restarted on home dosing of lisinopril 10 qd on that was increased to 20 mg. her systolic blood pressures range in the 120-150s with this regimen. however, if continues to be elevated, would recommended increasing bp meds. . 10. depression: stable on fluoxetine initially, as above this was stopped in an attempt to determine the cause of her fevers. however, this should be restarted if patient remains afebrile on a trial basis. . 11. fen: pt is on tfs per nutrition recs at goal. . 12. prophylaxis: patient was maintained on heparin subcutaneous, pneumoboots, proton pump inhibitor and bowel meds . 13. code: full . 13. communication: mother (proxy), medications on admission: medications at home: albuterol aspirin 81 mg avelox buspar 10 mg cartia 240mg catapres 0.2mg/24hours folic acid guaifenesin fluoxetine humalog sliding scale l-carnitine lasix prn for edema lisinopril levemir flexpen metoprolol 150mg mom mvi omeprazole percocet senna terazosin valproic acid . medications on transfer from osh: propofol gtt heparin 5000 unit subcut tid tylenol prn docusate combivent methylprednisolone 60mg qid timentin valproic acid 250mg tid, 750mg hs folic acid fluoxetine diltiazem 240mg buspirone 10mg terazosin 2mg metoprolol 150mg iron 325mg aspirin 81 senna insulin gtt discharge medications: 1. ferrous sulfate 300 mg/5 ml liquid sig: five (5) ml po daily (daily). 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. therapeutic multivitamin liquid sig: one (1) cap po daily (daily). 4. docusate sodium 50 mg/5 ml liquid sig: ten (10) ml po daily (daily). 5. senna 8.8 mg/5 ml syrup sig: five (5) ml po bid (2 times a day). 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. diltiazem hcl 60 mg tablet sig: two (2) tablet po qid (4 times a day): per peg. 8. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 9. polyvinyl alcohol 1.4 % drops sig: 1-2 drops ophthalmic prn (as needed). 10. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 11. ipratropium bromide 17 mcg/actuation aerosol sig: six (6) puff inhalation qid (4 times a day). 12. metoprolol tartrate 50 mg tablet sig: 3.5 tablets po bid (2 times a day): per peg. 13. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for rash. 14. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours): per peg. 15. insulin glargine 100 unit/ml solution sig: twenty four (24) units subcutaneous at bedtime. 16. insulin lispro (human) 100 unit/ml solution sig: as dir subcutaneous every six (6) hours: per sliding scale. 17. propylthiouracil 50 mg tablet sig: two (2) tablet po q8h (every 8 hours): per peg. 18. lidocaine hcl 5 % ointment sig: one (1) appl topical q6h (every 6 hours) as needed. 19. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily): per peg. 20. furosemide 40 mg tablet sig: four (4) tablet po bid (2 times a day). 21. valproate sodium 250 mg/5 ml syrup sig: twenty (20) ml po q6h (every 6 hours): checking levels daily x 1 week. 22. lorazepam 1 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for anxiety. 23. morphine 15 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 24. acetaminophen 160 mg/5 ml solution sig: po q4h (every 4 hours) as needed for fever/pain. discharge disposition: extended care facility: & rehab center - discharge diagnosis: aspiration pneumonia prolonged intubation, tracheostomy secondary: diabetes type i, history of stroke with residual hemiparesis, volume overload, hypothyroidism, depression, anemia, possible seizure disorder discharge condition: afebrile, vital signs stable discharge instructions: patient was admitted with pneumonia that was complicated by prolonged intubation and eventual tracheostomy placement. additionally she had fevers that resulted in extensive workup and were determined to eventually be secondary to medications. she should return to the er if she has chest pain, shortness of breath, persistent fevers, chills, hypoxia or any other concerning symptoms. followup instructions: patient should follow up with both neurology and endocrinology as an outpatient. she should follow up with dr. in endocrinology when able to go to the appointment (with thyroid function tests checked prior the appointment). this should be scheduled by calling . she should also have neurology follow up with previous neurologist or by calling ( to see a neurologist. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung insertion of endotracheal tube fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances other lavage of bronchus and trachea temporary tracheostomy transfusion of packed cells diagnoses: anemia of other chronic disease urinary tract infection, site not specified unspecified essential hypertension acute kidney failure, unspecified unspecified septicemia severe sepsis thyrotoxicosis without mention of goiter or other cause, and without mention of thyrotoxic crisis or storm acute respiratory failure pneumonitis due to inhalation of food or vomitus late effects of cerebrovascular disease, hemiplegia affecting unspecified side personal history of venous thrombosis and embolism other encephalopathy late effects of cerebrovascular disease, aphasia background diabetic retinopathy diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled gastroparesis diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled unspecified sinusitis (chronic) family history of diabetes mellitus 

Answer: The patient is high likely exposed to