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: lower extremity weakness major surgical or invasive procedure: dobhoff placement and removal history of present illness: mrs. is a 74 year old woman with history of metastatic pancreatic cancer and distant history of syndrome who is now transferred from an outside hospital with lower extremity weakness. patient is unable to provide any history at present. chart review from the osh and discussion with patient's husband provided history contained here. per husband, the patient had her last chemotherapy about 10 days ago and was feeling well one day following. was able to go shopping with a few friends for an hour or two. the following day the patient complained of generalized malaise, fatigue, then rigoring at home. ems took her to hospital where she was noted to be febrile and she was treated with ceftriaxone and azithromicin for ? rll pneumonia and uti. the patient improved the following day and was ambulatory in the hospital, however the following day (sat. ) the patient was very lethargic and slept most of the day. this continued to sunday and pt was noted to be unable to get out of bed on her own. she could sit at the edge of the bed but her "legs were like a rag doll's," and she was unable to stand. her arms also seemed weak. the patient and her husband had a negative experience with a neurologist at , and they love their gi surgeon here at and requested transfer for further evaluation. the patient underwent mri of her t and l spine without note of cord compression at the osh prior to transfer. vitals at osh t 98--tm 99, bp 98-120/56-82, she was on 2l nc sat 91-93%, prior to transfer nif -30, vital capacity 1 liter. mri t and l spine with no reported compression, ? bone metastsis in t 5, t6, t10. pt was more drowsy than earlier due to ____ she got (for mri sedation?). also given 1g solumedrol earlier in the day. she was treated with ceftriaxone and azithromycine for rll pneumonia and also treated for e. coli uti. in arrival to the trauma icu the patient was hypoxic at 89% and started on 40% facemask. patient is unable to offer a full ros. she denies any pain or discomfort at present. past medical history: 1) metastatic pancreatic cancer- diagnosed with obstructive jaundice d/t pancreatic head mass, mets to liver and ? lung, tumor is inoperable. she is s/p biliary stent placement. pt was undergoing chemotherapy, last dose ~10 days ago, her oncologist is dr. in , ma. 2) syndrome- "gbs approximately 5 years ago a few weeks after receiving a flu shot. she describes being at work (at witchcraft elementary school) when a young boy asked her to help tie his shoe, when she reached to tie the shoe her hands completely passed their mark and she was concerned. she rapidly worsened with total body weakness prompting hospitalization at hospital where she was plasmapheresed x 5 days. she did have a few days of dyspnea but did not require ventilatory support. residual pins and needles sensation in the hands and feet and residual ble weakness. she thought she might have had a recurrence a few years ago (felt weak for 2 days), but these symptoms resolved on their own." 3) hypertension 4) hypothyroidism 5) hyperlipidemia 6) esopageal spasm 7) s/p cck. social history: married with 2 children. worked at elemetary in kitchen; retired after gbs. quit smoking 5 years ago, no recent etoh. no illicits. family history: father died of mi mother died of stroke no history of other neurologic disease or malignancy physical exam: vitals: t 96.7, hr 105, bp 106/70, r 24, 94% on 40% fm gen- ill appearing, drowsy but arouses briefly to voice, appears comfortable. heent- ncat, pale, anicteric sclera, mmm, op clear neck- no carotid bruits. cv- tachycardic, no mrg pulm- scattered crackles throughout. abd- soft, nt, nd, bs+ extrem- no cce. neurologic exam: ms- place= hospital, month=, year=?. she is inattentive. able to name days of week forwards, but when asked to say them backwards she is unable to switch tasks. her naming of "watch" is intact, but with other objects the patient is too inattentive to comply with further testing. she follows simple commands, but is perseverative "open your eyes" but difficulty with "show me two fingers on your left hand" cn- smell not tested, pupils 4mm-->3mm and sluggish to light bilaterally, eom's are full, no nystagmus. blinks to threat bilaterally. funduscopic exam could not be performed due pt uncooperativeness with exam (pulled eyes shut forcibly). face is symmetric with symmetric sensation to lt. no ptosis. hearing intact to fr bilat, unable to view palate with face mask for o2, tongue protrudes at midline. motor- no adventitious movements, tone appears low throughout. she displays motor impersistence. holds both arms antigravity for 2-3 seconds and they fall to her chest. she spontaneously holds her legs antigravity briefly. when asked to move her legs to command she is unable to do so. she briskly withdraws her legs to noxious stim. sensory- intact to light touch in all extrem, intact to noxious in all extrem. unable to perform detailed sensory testing due to mental status. reflexes: unable to elicit any dtr's in , tri, , patell, ankles. plantar response down on right, up on left. gait- unable to test. pertinent results: chest radiograph ap (): mild cardiomegaly. no vascular engorgement. no lung consolidation or mass. no pleural effusion. metallic stent projects over the right upper quadrant. ct head without contrast (): 1. no evidence of infarction, hemorrhage, of mass effect. 2. mr is most sensitive for evaluation of intracranial metastatic disease. bilateral lower extremity dopplers (): no dvt in the bilateral lower extremities. chest pa/lat (): in comparison with the study of , the patient has taken a somewhat better inspiration and the atelectatic changes at the bases have decreased. some costophrenic angle filling posteriorly suggests small pleural effusions. dobbhoff tube remains in place. specifically, no evidence of acute pneumonia. 06:30am blood wbc-7.9 rbc-2.87* hgb-9.6* hct-28.3* mcv-99* mch-33.4* mchc-33.9 rdw-17.4* plt ct-342 07:55am blood neuts-71.7* lymphs-18.2 monos-6.8 eos-2.6 baso-0.7 07:55am blood pt-14.0* ptt-27.2 inr(pt)-1.2* 06:30am blood glucose-108* urean-6 creat-0.6 na-143 k-4.3 cl-105 hco3-33* angap-9 07:55am blood alt-52* ast-88* ld(ldh)-358* alkphos-120* totbili-0.2 07:55am blood caltibc-157* vitb12-767 folate-17.4 ferritn-334* trf-121* 10:05pm blood tsh-0.069* 01:17am blood free t4-0.89* 12:13am blood type-art po2-84* pco2-37 ph-7.46* caltco2-27 12:13am blood lactate-1.5 brief hospital course: 74 year-old female with pancreatic cancer metastatic to her liver and possibly lung, gbs 5 years ago after a flu shot, hypertension, and hyperlipidemia who intially presented to an osh with a fever after chemotherapy and was found to have pneumonia and e. coli uti, and then was transferred to for neurological evaluation for lower extremity weakness. hospital course was as follows. neuroicu course: her neurologic examination on admission was notable for marked inattention, which further limited detailed motor and sensory testing; however, she was able to hold her legs antigravity. neurologic exam the morning after her admission showed strength in the ips, in the deltoids and quads, and 5-/5- in all other muscle groups. she was areflexic, but this was documented in previous neurology notes from . her inattention was thought to be due to toxic metabolic encephalopathy, likely due to her underlying pneumonia and uti. it was determined that gbs was not the cause of her symptoms, and her encephalopathy improved by the second day (oriented to person, place, and date). head ct showed no evidence of infarction, hemorrhage, of mass effect. ammonia 10, alt 13/ast 31, ldh 489, ap 166, t bili 0.3, alb 2.5, inr 1.6, amylase 14/lipase 8, tsh 0.069, t4 6.0; free t4 0.89. she was continued on asa 325 mg daily, amlodipine 5 mg daily, and levothyroxine 75 mcg daily. her pna and uti were treated with ctx and azithromycin. the medicine team was consulted for her pna and uti, and the patient was called out to the medicine floor with neurology following. medicine course: on arrival to medicine floor, patient appeared well. her breathing felt improved over her baseline and she felt stronger than when she arrived initially. her active issues included resolving mental status changes, ?rul pna (sat's 98% on 60%fm, apparently baseline o2 sat in low 90's), uti, and climbing wbc (12) on antibiotics. as above, the patient's weakness was thought to be secondary toxic metabolic encephalopathy; she continued to improve on antibiotics for treatment of uti and community acquired pneumonia. patient completed a 5 day course of azithromycin and 7 day course of ceftriaxone. blood cultures remained no growth to date of discharge, and patient was unable to provide sputum specimen. leukcytosis resolved. concurrently the patient's hypoxia also improved. of note, patient has history of copd with baseline sats in the low 90's. she was initially kept on standing albuterol and ipratropium nebulizer treatments. patient worked with physical therapy as well. on day of discharge, patient was satting at baseline at rest but requiring oxygen (1 to 2 liters) with ambulation. remained of care was as follows. - hypertension: continued antihypertensives per home regimen. - hypothyroidism: tsh, ft4 low. given acute illness, no changes to medication regimen were made. patient will require recheck of tfts as outpatient. - anemia: hematocrit slightly lower than baseline on admission. b12 and folate normal. labs consistent with anemia of chronic disease. continued folate, iron per home regimen. - gerd: continued omeprazole per home regimen. - hyperglycemia: patient was started on metformin for persistently elevated blood glucose. blood glucose should be checked at rehab facility and hypoglycemics titrated as needed. - nutrition: patient required dobhoff for short duration in neuroicu. on medicine floor, she was evaluated by speech therapy and was found to be able to take regular food and thin liquids without problem. **code status: dnr/dni **communication: (husband), ( medications on admission: medications on transfer: amlodipine 5mg daily asa 325mg daily azithromycin 500mg daily (day 1 is ??) ceftriaxone 1gram iv daily (day 1 is ??) carbamazepine 200mg folate 1mg daily gabapentin 600mg tid heparin 5000units sc tid synthroid 0.075mg daily mvi nortriptyline 50mg qhs prilosec 20mg daily potassium chloride 20mg po daily albuterol 1puff inh q6h zofran 4mg iv q6h discharge medications: 1. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. calcium 500 with d 500 (1,250)-400 mg-unit tablet sig: one (1) tablet po once a day. 4. ferrousul 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. gabapentin 300 mg capsule sig: two (2) capsule po q8h (every 8 hours). 7. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 8. multivitamin tablet sig: one (1) tablet po once a day. 9. nortriptyline 25 mg capsule sig: two (2) capsule po hs (at bedtime). 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 11. paroxetine hcl 20 mg tablet sig: two (2) tablet po daily (daily). 12. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. ipratropium bromide 17 mcg/actuation aerosol sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. disp:*1 month supply* refills:*2* 14. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. disp:*40 tablet(s)* refills:*0* 15. metformin 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 16. home oxygen 1-2l oxygen by nasal cannula, continuous. goal is to maintain o2 sat greater than 90%. 17. tegretol 200 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: medical center - discharge diagnosis: primary: - toxic metabolic encephalopathy secondary to urinary tract infection, community acquired pneumonia] - hyperglycemia secondary: - history of - pancreatic cancer - hypothyroidism discharge condition: hemodynamically stable. ambulatory. discharge instructions: you were transferred to hospital on for further care of your weakness. you were initially admitted by the neurology team, who felt that your weakness was due to an infection in your bladder or lungs. you were treated with antibiotics for both of these infections and your weakness improved. you also required a feeding tube placed temporarily. you worked with physical therapy and your strength and coordination improved, and you will be going to a rehabilitation facility for more physical therapy. on discharge, you are eating and drinking well. your medication regimen has changed. we added a new medication, metformin, for better control of your blood glucose. other than this change, you may resume your home medications just as you were doing prior to this hospitalization. please be sure to follow-up with your appointments as listed below. please call your physician or return to the emergency department for any worsening weakness, shortness of breath, fevers, or for any other concerns. followup instructions: someone from dr. office (neurology) will call you with an appointment time. if you do not hear from them by monday, please give them a call at ( on tuesday. someone from your primary care physician's office will call you early next week with an appointment date with dr. . if you do not hear from them on monday, please call the office at (. procedure: enteral infusion of concentrated nutritional substances diagnoses: pneumonia, organism unspecified anemia, unspecified esophageal reflux pure hypercholesterolemia malignant neoplasm of liver, secondary urinary tract infection, site not specified toxic encephalopathy unspecified essential hypertension unspecified acquired hypothyroidism obstructive chronic bronchitis with (acute) exacerbation personal history of tobacco use malignant neoplasm of head of pancreas hypoxemia secondary malignant neoplasm of lung secondary malignant neoplasm of bone and bone marrow muscle weakness (generalized) 

Answer: The patient is high likely exposed to