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: celecoxib / vioxx attending: chief complaint: altered mental status, fever major surgical or invasive procedure: none history of present illness: pt is an 80 yo f with t2dm, ckd, chf with ef 15-20% (), and asthma with hx of recent diverticulitis in c/b sepsis, has been at home for the last few days, doing well until the family noted her to be altered this morning. per her daughter, pt was doing well for the past few days until this morning. she was complaining of dry cough and appeared confused. she was not taking any fluid, food, and was not speaking. a temperature was taken and was 39c at home. at baseline she is apparently very talkative and has a good appetite. as far as the daughter knows, she was not complaining of any nausea, vomiting, or abdominal pain. she has chronically loose stools, though per the daughter, these have been unchanged. as far as she knows she has had no bloody of black stools. she has been taking all of her except for this morning when she was not taking anything po. . apparently she was in the icu twice in in the last month. once was for weakness and there may have been "fluid on the lungs." she was discharged from the icu there and then readmitted for what sounds like diverticulitis. the daughter does not know much about this course, and is unsure of antibiotics use. she did develop a rash while she was there, which has continued, but not gotten worse. per her daughter, it sounds like she may also have been transfused while in the icu there. . in the ed, initial vs 102.5 102 90/54 20 100%on 10l. serum sodium was notably 118. head ct was negative as was lp, u/a. blood cultures were sent. she was treated with vanc/zosyn. she received 3l ns. vitals at the time of transfer were 99.8, 103/52, 78, 16, 100% 8l. . on the floor, she is somnolent, but arousable. she denies any pain anywhere. she is able to nod and shake her head to simple questions. denies any abdominal pain, chest pain, current cough. . review of systems: (+) per hpi per daughter. unable to obtain complete ros given pt somnolent. (-) denies shortness of breath, chest pain, nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. past medical history: # systolic congestive heart failure (ef estimated at 15-20%) # thrombocytopenia: treated with steroids in the past in setting of asthma exacerbation with clinical response -> likely myelodysplastic disorder as per outpatient heme-onc dr. # asthma # diabetes type ii dx'd ~ # hypothyroidism # hypertension # chronic kidney disease- baseline crt 1.3-1.4; likely secondary to hypertensive nephrosclerosis # anemia # eosinophilia # depression # glaucoma # osteoarthritis # h/o syndrome w/ celecoxib # facial cellulitis tx w/ bactrim in # history of atrial fibrillation social history: from (immigrated ~20yr ago). lives with her son and has a daughter close by. supportive family. has vna coming into the house with rotating family members taking care of her. she does not smoke, does not drink, and does not use drugs. family history: her sister had diabetes, brother has heart disease and stroke in sister. physical exam: admission physical: vitals: t: 97.6 bp: 106/73 p: 81 r: 13 o2: 99%ra general: lying down in bed, somnolent, but opens eyes, follows commands, appears comfortable, nad heent: eomi, sclera anicteric, dry mm, adentulous, oropharynx clear neck: supple, jvp not elevated, no lad lungs: no use of accessory mm of breathing, faint crackles at bases, cleared with deep inspiration 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 gu: no foley ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema, diffuse ecchymoses on on upper extremities, scattered erythematous macular rash, non-blanching, with circular erythema over right anterior shin back: erythema over buttocks, no skin breakdown, no ulcers . discharge physical: - mental status: improved alertness. remains disoriented to time/place (although knows hospital+) - skin: improved rash on lower extremities - general condition : moved to chair with assistance, unable to walk pertinent results: admission labs: . 10:45pm glucose-180* urea n-39* creat-1.1 sodium-126* potassium-3.8 chloride-91* total co2-23 anion gap-16 06:02pm type- ph-7.38 06:02pm lactate-2.3* tco2-26 05:53pm glucose-192* urea n-42* creat-1.3* sodium-121* potassium-2.8* chloride-83* total co2-25 anion gap-16 05:53pm alt(sgpt)-16 ast(sgot)-25 alk phos-80 tot bili-0.4 05:53pm calcium-8.2* phosphate-4.0 magnesium-1.8 05:53pm tsh-0.85 05:53pm free t4-1.7 05:53pm wbc-10.7 rbc-3.37* hgb-10.7* hct-29.6* mcv-88 mch-31.8 mchc-36.1* rdw-14.8 05:53pm plt count-143* 05:53pm pt-12.5 ptt-24.2 inr(pt)-1.0 04:55pm urine hours-random urea n-216 creat-31 sodium-52 potassium-33 chloride-60 total co2-less than 04:55pm urine osmolal-267 03:50pm cerebrospinal fluid (csf) protein-20 glucose-115 03:50pm cerebrospinal fluid (csf) wbc-0 rbc-0 polys-0 lymphs-0 monos-0 10:30am urine color-straw appear-clear sp -1.005 10:30am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 10:15am comments-green top 10:15am lactate-2.8* na+-120* k+-3.5 10:05am glucose-209* urea n-47* creat-1.2* sodium-118* potassium-3.5 chloride-78* total co2-27 anion gap-17 10:05am estgfr-using this 10:05am probnp-5116* 10:05am ctropnt-0.01 10:05am wbc-9.6 rbc-3.82* hgb-12.1 hct-33.3* mcv-87 mch-31.7 mchc-36.5* rdw-15.1 10:05am neuts-79.2* lymphs-16.2* monos-2.8 eos-1.3 basos-0.5 10:05am pt-12.8 ptt-23.0 inr(pt)-1.1 10:05am plt count-178. . discharge labs: 06:50am blood wbc-6.0 rbc-3.38* hgb-10.4* hct-30.7* mcv-91 mch-30.7 mchc-33.8 rdw-15.6* plt ct-237 06:50am blood plt ct-237 06:50am blood glucose-128* urean-21* creat-0.9 na-127* k-4.3 cl-96 hco3-24 angap-11 06:50am blood calcium-8.8 phos-4.0 mg-2.1 . . micro: bcx : no growth urine legionella : no growth csf cx : no growth urine cx : no growth ova + parasites (final ): reported to and read back by beaver () at 11:15 am. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. strongyloides stercoralis . c diff : negative resp viral screen : negative dfa flu : negative . studies: cxr : ap chest radiograph: the cardiomediastinal and hilar contours are within normal limits. streaky opacities are seen in both lung apices, with associated right apical pleural thickening are unchanged and may relate to mild chronic fibrotic changes. there is minimal bibasilar atelectasis without focal consolidation. stable blunting of right costophrenic angle is noted. impression: no acute cardiopulmonary pathology. . ct head w/o : impression: no acute intracranial process. . kub : impression: no evidence of small bowel obstruction or ileus. no free air in the abdomen. nonspecific bowel gas pattern. cxr findings: some mild blunting of the left costophrenic angle likely reflects minimal effusion and possibly some minimal atelectasis. heart size appears mildly enlarged. there is no gross acute consolidation or pneumothorax. overall appearance is similar to the prior exam. incidental note is made of a small focus of calcification projecting adjacent to the greater tuberosity which may reflect calcific tendinitis. brief hospital course: hospital course: pt is an 80 yo f with t2dm, ckd, chf with ef 15-20% (), and asthma with hx of recent diverticulitis in c/b sepsis, has been at home for the last few days, doing well until the family noted her to be altered morning, found to be hyponatremic and febrile. . # toxic metabolic encephalopathy: most likely profound hyponatremia. ct head negative for intracranial process. other etiologies such as cns infection possible, but csf fluid does not appear infectious. nothing focal on neuro exam. pt has had previous admissions with ams hyponatremia that resolved after correction of na. her mental status continued to improve as sodium corrected. on discharge she was alert and largely oriented to place (hospital in ) but not time. she was able to talk and carry on short conversation. . # fevers: presented with fever to 102.5 in the ed. met sirs criteria given fevers, tachycardia, and hypotension. possible sources of infection include abdominal process such as diverticulitis, pna, viral uri, uti, and less likely meningitis, or c. diff vs. endocarditis. given history of recent diverticulitis, abdominal source was possible. however, exam is benign without pain, making this less likely. cxr unremarkable for consolidation, and given no cough, this was considered less likely. ua was bland. viral uri or influenza certainly possibly given high fevers. c. diff certainly possibly given diarrhea and recent abx use. however, per recent discharge summary, it was noted that pt has had chronic guaiac positive diarrhea with negative c. diffs previously. per family report, loose stools also unchanged, and normal wbc reassuring. on further testing, she was found to have strongyloides infection. she was treated with 2 day course of ivermectin and her diarrhea improved and fevers subsided. this medication was not continued on discharge and she had been afebrile for many days. . # hyponatremia: chronic issue, thought to be hypovolemia given fevers and insensible losses. pt appeared on ed exam, though labs not particularly suggestive that she was dry, given cr close to baseline (though bun mildly up). previously has been severely hyponatremic, as low as 114 in , hypervolemic hyponatremia given systolic congestive heart failure. pt received 1l of fluids in the ed. and another 1l in the micu overnight. her tsh/free t4 was normal and patient was continued on her home dose of levothyroxine. renal was consulted. she was thought to have either siadh or reset osmostat and placed on a fluid restriction. her na+ was 127 on discharge. . # hypoxia: pt was on 8lnc in the ed, though unclear what initial o2 sats were. ddx included volume overload given h/o chf, vs. infectious such as pna or viral bronchitis on top of known copd vs. pe. pna thought unlikely given no cough and no infiltrate on cxr. pt may have viral bronchitis in addition to baseline lower o2 sats given copd. pe possible, but given no tachycardia, no chest pain, this was less likely. pt has no o2 requirement on the floor. no evidence of retaining co2 on vbg. she was discharged with normal sats on ra. . # rash: diffuse rash on anterior lower extremities. unclear etiology, possible medication effect. pt has had recent medication changes while in pr. derm was consulted but did not recommend intervention or treatment. the diagnosis was dermatitis nos and the rash subsided over the hospitalization. # chronic systolic heart failure: ef from of 15-20%, she appeared dry on first exam and was given iv fluids. . # ckd: baseline cr 1.3-1.4, and cr on admission is 1.2. bun is slightly up, but likely hypovolemia as above. this issue was stable during hospitalization. . # anemia: chronic. hct above baseline (hct 30 on last discharge), but unknown if recently transfused in . last iron studies suggestive of acd given elevated ferritin, low tibc. on ferrous sulfate and folic acid per home meds. per further discussion with family, she had rectal bleeding in pr, but has had none since returning home. hct was stable on this admission and 30.7 on discharge. . # hypothyroidism: nl freet4 and tsh, she brought in her and her dose was revealed to be 88mcg daily and this dose was restarted on discharge. . # hypokalemia: most likely gi losses, has chronic loose stools. her k on discharge was 4.3 without repletion . # t2dm: on glipizide at home. iss while in the hospital house. she will restart her glypizide on discharge. . # hypertension: normotensive currently, though had been hypotensive in ed. she was normotensive on the day of admission. she will continue on toprol xl 25mg daily + lisinopril 2.5mg daily, ################# transitional issues: 1. hyponatremia: chronic but patient known to have episodes of hyponatremia 110s with obtundation. she was fluid restricted and sodium increased to mid-120s but did not increase beyond that. renal was consulted. there is some debate whether she has siadh vs. reset osmostat but we elected not to persue this with a diagnostic fluid bolus. she will remain on fluid restriction 1l per day. her electrolytes (na+) should be rechecked on follow-up friday. she should not take metolazone or any other thiazide diuretics as this would aggravate her hyponatremia. she will be discharged with 20mg lasix daily. if her hyponatremia persists, she should have siadh workup including ct chest/mri head. 2. nutritional status: pt was seen by pt and recommended for rehab, although family declined. she will have home pt. she is receiving supplementation through low-sodium ensure. her nutrional status should be reassess on follow-up. 3. diarrhea: chronic, thought to be related to strongyloides which was treated with two days of ivermectin (for presumed non-complicated course). if diarrhea ongoing, would repeat stool studies and consider treatment for complicated course (7-10days ivermectin) on admission: per most recent discharge: -fluticasone 50 mcg/actuation spray two spray nasal -omeprazole 20 mg capsule, delayed release(e.c.) po bid -calcium carbonate 200 mg (500 mg) tablet, chewable po bid -vitamin d-3 1,000 unit tablet, chewable po once daily -cyanocobalamin 500 mcg po daily -ferrous sulfate 300 mg (60 mg iron) po daily -multivitamin po daily -simvastatin 10 mg po daily -levothyroxine 75 mcg po daily -lisinopril 2.5 mg po daily -furosemide 40 mg po daily -aspirin 81 mg po daily -latanoprost 0.005 % drops one drop ophthalmic hs -flovent hfa 220 mcg/actuation aerosol two puffs inh -symbicort 160-4.5 mcg/actuation hfa aerosol inhaler two puffs inh -metoprolol succinate 50 mg po daily -albuterol sulfate 90 mcg/actuation hfa 1-2 puffs qid prn -glipizide 2.5 mg tablet extended rel po daily -imodium a-d 2 mg po qid prn for diarrhea. . per most recent list from : -isosorbide 10mg -carvedilol 3.125mg -ferrous sulfate 325mg -furosemide 20mg -neurontin 300mg qpm -lorazepam 1mg prn? -metolazone 10mg qday -folic acid discharge : 1. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for groin rash. disp:*1 bottle* refills:*0* 2. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal twice a day. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 4. calcium antacid 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po twice a day. 5. vitamin d-3 1,000 unit tablet, chewable sig: one (1) tablet, chewable po once a day. 6. cyanocobalamin (vitamin b-12) 500 mcg tablet sig: one (1) tablet po once a day. 7. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: one (1) po once a day. 8. multivitamin tablet oral 9. simvastatin 10 mg tablet sig: one (1) tablet po once a day. 10. levothyroxine 88 mcg tablet sig: one (1) tablet po once a day. 11. lisinopril 2.5 mg tablet sig: one (1) tablet po once a day. 12. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po once a day. 13. latanoprost 0.005 % drops sig: one (1) drop ophthalmic at bedtime. 14. flovent hfa 220 mcg/actuation aerosol sig: two (2) puffs inhalation twice a day. 15. metoprolol succinate 25 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 16. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation twice a day. 17. glipizide 2.5 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. 18. lasix 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: primary: hyponatremia strongyloides infection secondary: generalized deconditioning/failure to thrive discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mrs. , you were admitted to the medical center for fever and low blood pressure and being weak and tired. you were found to have low sodium levels in your blood and this was partially corrected by giving you sodium in your veins. this is a recurrent problem for you. to prevent this from happening, you should limit your intake of fluid to 1 liters per day. you should also follow up with your primary care doctor so that he can check your sodium level. you also found to have significant weakness by our physical therapists. they recommended that you spend some time in a rehabilitation facility but you and your family declined this option. you will have a physical therapist come by and help you regain some strength at home. you will also have a hospital bed send to your home to prevent injury given that you spend a long time in bed every day. it is important that you continue to eat foods containing salt even if you are restricting the amount of fluids per day (1l/day). you also have a parasitic worm infection in your digestive tract and have received a medication called ivermectin. you received enough doses to treat this infection. but you should report ongoing diarrhea or abdominal pain or fevers to your primary care physician. some of your have changed on this admission. please note that you should start: - lasix 20mg every day (please stop taking 40mg tabs) - low sodium ensure 3-4 times per day please stop: - metolazone (do not take this medicaiton again as it worsens your sodium level) -carvedilol weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: primary care name: dr. when: friday at 10 am location: health care, inc. address: , , phone: department: cardiac services when: tuesday at 9:00 am with: , md building: campus: east best parking: garage procedure: spinal tap incision of lung diagnoses: anemia of other chronic disease congestive heart failure, unspecified toxic encephalopathy diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified unspecified glaucoma depressive disorder, not elsewhere classified candidiasis of mouth hypopotassemia chronic kidney disease, unspecified myelodysplastic syndrome, unspecified chronic systolic heart failure osteoarthrosis, unspecified whether generalized or localized, site unspecified dermatitis due to drugs and medicines taken internally chronic obstructive asthma, unspecified hypovolemia other disorders of neurohypophysis adult failure to thrive unspecified drug or medicinal substance causing adverse effects in therapeutic use systemic inflammatory response syndrome, unspecified strongyloidiasis 

Answer: The patient is high likely exposed to