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: iodine / codeine / reglan / ketorolac / oxycodone / hydromorphone hcl attending: chief complaint: chest pain major surgical or invasive procedure: upper endoscopy with attempted balloon dilatation of nissen fundoplication / gastroesophageal junction. history of present illness: is a 41 yo woman with a history of dm type 2, htn, hl, stroke, osa, spinal stenosis, arthritis, asthma, and gerd here with left sided chest pain radiating to her left arm. the patient was in her usoh until 3 months prior to this admission when she noted intermittent palpitations and chest discomfort. the patient was not concerned about this chest discomfort until about 2 weeks prior to this admission when she noticed increasing left sided chest pain accompanied by worsening dyspnea and wheezing causing her to decrease her mobility, which is low at baseline. 2 days prior to admission, the patient noted worsening of the left sided chest pain growing from to pain, continued radiation down the left arm, and associated diaphoresis and decrease in her peak flow from 350 at baseline to 170s even after using albuterol nebulizers. of note, patient typically uses 3 albuterol nebulizers as need for wheezing over the course of the day. over the past 2 days, she required up to 4 nebulizers in one morning and noticed minimal improvement of her symptoms. the patient's chest pain was constant and distinct from the symptoms of reflux associated with gerd. of note, the patient has been hospitalized in the past for this type of chest pain. . the patient was brought by ems to the ed. en route she received ntg, aspirin with only minimal improvement of chest pain. in the ed she was afebrile, but tachycardic to 100s. she received iv fluids, morphine for pain control with good effect. she also received iv dilaudid and had an allergic reaction which was treated with benadryl with good effect. she was admitted to the medicine floor for further workup . on ros, patient denied headache, changes in vision, fever, chills, night sweats, abdominal pain, changes in her chronic back pain or changes in her neuropathy, left sided weakness. remainder of ros as per hpi past medical history: -dm2, diagnosed in , on insulin -asthma -htn -nissen fundoplication -osa -ganglion cyst removal -left ankle stabilization -right ankle stabilization -cva in with residual left sided weakness -eczema -mitral valve prolapse -deafness, left ear -hl -diabetic peripheral neuropathy -oligomenorrhea - seasonal, drug, and food allergies. food allergies to oats, wheat, rice, green beans, chocolate, ketchup. social history: patient denies tobacco, etoh, ivdu. patient is a former pre-k teacher who has been on disability since . currently lives on apartment and uses a walker to get around. is being evaluated by housing for placement in a single level apartment. married, no children. family history: significant for 7 aunts on her mother's side with type 2 dm with significant insulin resistance. mother with htn and dvt. sister and brother in good health. does not know about her father's health. physical exam: vitals: 97.9 bp 103/66 hr 103 rr 22 o2 sat:98% on ra general: obese woman, lying in bed with moderate work of breathing. skin: warm, eczematous rash visible on face, some excoriations visible on forearms bilaterally. heent: ncat, mmm, oropharynx clear. perrl neck: supple, no masses, no lad heart: rrr, normal s1, s2, no murmurs, gallops or rubs lungs: expiratory and inspiratory wheezes throughout lung fields bilaterally. chest: patient with tenderness to palpation over left parasternal chest wall. abdomen: obese, soft, nontender, nondistended. no hsm extremities: no lower extremity edema, tenderness to palpation of calf muscles up to knee bilaterally. dp pulses 2+ bilaterally. no ulcerations. neuro: a&o x 3, strength decreased on left leg and arm, cn 2-12 intact pertinent results: hematology and chemistries 10:10am blood wbc-8.3 rbc-4.19* hgb-10.4* hct-33.6* mcv-80* mch-24.8* mchc-31.0 rdw-15.5 plt ct-499* 10:10am blood neuts-54.1 lymphs-37.4 monos-5.3 eos-2.6 baso-0.5 06:37pm blood lactate-3.5* 02:04am blood pt-11.7 ptt-33.7 inr(pt)-1.0 10:10am blood plt ct-499* 10:10am blood glucose-368* urean-11 creat-1.0 na-135 k-4.3 cl-98 hco3-24 angap-17 07:00am blood wbc-10.0 rbc-3.42* hgb-8.5* hct-27.9* mcv-82 mch-24.8* mchc-30.3* rdw-16.1* plt ct-422 07:00am blood glucose-207* urean-8 creat-0.7 na-139 k-4.2 cl-101 hco3-28 angap-14 . venous blood gas 06:37pm blood type- temp-35.6 po2-55* pco2-37 ph-7.37 caltco2-22 base xs--3 intubat-not intuba . cardiac enzymes 10:10am blood ck(cpk)-132 09:15pm blood ck(cpk)-113 05:50am blood ck(cpk)-81 10:10am blood ck-mb-3 10:10am blood ctropnt-<0.01 09:15pm blood ck-mb-3 ctropnt-<0.01 05:50am blood ck-mb-notdone ctropnt-<0.01 . iron studies 10:10am blood iron-28* 05:50am blood calcium-9.5 phos-3.0 mg-1.9 11:29am blood d-dimer-1436* 10:10am blood caltibc-463 ferritn-33 trf-356 . endocrine studies 05:58pm blood %hba1c-9.0* 10:10am blood glucagon-pnd . urinalyses 10:25am urine color-yellow appear-clear sp -1.034 10:25am urine blood-neg nitrite-neg protein-neg glucose-1000 ketone-tr bilirub-neg urobiln-neg ph-6.5 leuks-neg 05:19am urine color-yellow appear-clear sp -1.022 05:19am urine blood-lg nitrite-neg protein-neg glucose-100 ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg 05:19am urine rbc-* wbc- bacteri-few yeast-none epi- . microbiology 5:34 pm mrsa screen (final ): positive for methicillin resistant staph aureus. urine culture: (final ) no growth. 4:35 am urine culture (final ):<10,000 organisms/ml. 5:45 am blood culture(final ): no growth. 3:34 am stool clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. . cardiac studies ekg: sinus tachycardia. left ventricular hypertrophy with associated st-t wave changes, although myocardial ischemia and myocardial infarction cannot be excluded. compared to the previous tracing the axis has shifted minimally. intervals axes rate pr qrs qt/qtc p qrs t 110 118 100 324/411 70 -29 72 . imaging . cxr: impression: low lung volumes with bibasilar atelectasis, but no superimposed acute cardiopulmonary abnormality. . lower extremity doppler ultrasound: impression: no evidence of dvt of bilateral lower extremities. . ventilation perfusion scan: impression: limited study with normal perfusion and ventilation. no evidence of pe. . barium swallow:impressions: 1. limited exam, but no gross abnormalities of the esophagus or proximal stomach. 2. intact gastric fundoplication, with moderately delayed passage of barium through the distal esophagus intothe stomach. 3. no gastric emptying seen during 10-minute exam. . : frontal and lateral chest radiograph to evaluate for fever after esophagogastroduodenoscopy. the cardiomediastinal silhouette is stable. the lung volumes remain low, with no pleural effusion or pneumothorax as well as with no focal consolidation to suggest pneumonia. mild volume overload cannot be excluded. . abdominal plain films: the current study that includes seven views of the abdomen including the decubitus view demonstrate significant amount of stool within the colon with dilated right flexure up to 10 cm and no significant dilatation within the sigmoid and descending colon. the transverse colon is also dilated up to 11 cm and full of stool. there is contrast material in left colon and rectosigmoid most likely related to upper gi series obtained on . the decubitus view demonstratesair-fluid level within the stomach and otherwise are unremarkable. overall, the picture is consistent with excessive amount of stool in the colon with no evidence of obstruction. . endoscopy . upper endoscopy: mild gastritis, otherwise unremarkable. attempt made to dilate ge junction with 18mm balloon was unsuccessful. . pathology: antral mucosal biopsy: antral mucosa with chronic inflammation and changes consistent with chemical gastritis. brief hospital course: this is a 41 year woman with a history of dm type 2, htn, hl, osa, spinal stenosis, arthritis, stroke, asthma, and gerd who presented with left sided chest pain and worsening dyspnea of 2 weeks duration. . # chest pain - patient's chest pain was unlikely to be secondary to an acs given the reproducibility of her chest pain, including radiation to left arm with palpation on the chest wall. she also had no concerning st changed on her ekg and had three sets of negative cardiac biomarkers. she was monitored on telemetry without event. the lack of consolidation on cxr, the absence of fever, sputum, or elevated wbc on admission, made pneumonia an unlikely cause of chest pain. her pain was most likely musculoskeletal in origin given her chronic arthritis. on the floor the patient was initally on ketorolac for pain control, but this was later stopped due to concern for stomach irritation. there was also concern about about possible pe given her family history of dvt, patient's limited mobility and an elevated d-dimer in the ed. she was started on lovenox on admission, but a subsequent ventilation/perfusion scan, albeit limited due to problems with patient compliance with holding her breath, showed normal perfusion and ventilation and no evidence of pe. a pe-cta was not done due to patient's allergy to iodine contrast. her lovenox was stopped on . the patient's gerd and dysphagia may also have contributed to her chest pain (see discussion below). . # dyspnea/asthma - patient's dyspnea was likely secondary to asthma exacerbation in the setting of deconditioning due to limited movement. pneumonia was considered unlikely as noted above. she was treated with a four day course of prednisone, 60mg per day, intially as one dose, then later divided 30mg , along with standing albuterol and ipratropium nebulizers. she was continued on her fluticasone/salmeterol and zafirlukast home doses. her breathing improved after her steroid course. she never required oxygen. . # diabetes - patient presented with elevated fsbg above 400 over the past 2 weeks prior to admission. these were likely elevated secondary to cortisol stress response in setting of increased chest pain and dyspnea. the fsbgs were elevated further in setting of steroid treatment of her acute asthma exacerbation. due to bs>500 on the floor, was consulted and the patient transfered to the icu for an insulin drip on . she required over 30 units/hr initially. she was later transitioned to lantus 80 units and an aggressive insulin sliding scale. her metformin and pramlintide were held while in the icu. she was transfered from the micu to the floor on after she had completed her course of prednisone and was no longer on an insulin drip. on the floor, her lantus was titrated down to 40 units with a slightly less aggressive insulin sliding scale. metformin and pramlintide continued to be held. her fsbg ranged from 100s-250s, even though the patient did not fully adhere to a diabetic diet on the floor, frequently eating fast food brought in by friends and family. a glucagon level sent to evaluate for possible glucagonoma causing insulin resistance was pending upon patient departure. . # dysphagia / gerd - s/p nissen fundoplication in . the patient also complained of dysphagia and increased reflux when swallowing solids greater more than with liquids. this was thought to be partially secondary to diabetic gastroparesis as patient has long standing diabetes complicated by peripheral neuropathy. barium swallow showed decreased gastric emptying but no esophageal obstruction. the gi service completed an endoscopy on that showed mild antral gastritis. an attempt was made to dilate the gastroesophageal junction with an 18-mm balloon, but was unsuccessful. the patient was continued on omeprazole 40 mg , and placed on a diabetic, soft mechanical, dysphagic diet. . # arthritis, spinal stenosis, musculoskeletal pain, peripheral neuropathy - the patient was continued on her home pain medications with the exception of her nsaid (due to increased stomach pain / gastritis). this included pregabalin, amytriptiline, acetominophen as needed, and lidocaine patches. she had an allergic reaction to iv dilaudid in the ed, and to oral dilaudid in the icu, so the patient's home prescription of dilaudid was discontinued and her pain managed with oral morphine as needed. . #fever: 1 day following her upper endoscopy, the patient developed fevers overnight to 102.1, so blood and urine cultures were sent and cxrs performed to assess for possible pneumonia, uti, or bacteremia. multiple chest radiographs showed continued low lung volumes, but no evidence of consolidation, and blood and urine cultures showed no growth. the patient's fever resolved, and she was afebrile on the day of her departure. . #facial numbness and tingling - on , the patient developed sudden onset of left facial numbness and tingling and generalized dizziness and increased generalized weakness in the setting of fever. because of a concern for stroke, given the patient's microvascular disease and past history of stroke, neurology was consulted. the patient's symptoms were found to be within the distribution of her previous stroke and thought to be secondary to an elevated blood glucose and possible infection. the patient was continued on cardiac and cerebrovascular risk factor management regimen including her statin, asa 325 mg, and lisinopril end encouraged to adhere to the diabetic diet to help keep serum glucose levels better controlled. the neurology service also recommended obtaining a head ct and carotid us, but this could not be completed as the patient eloped. . #abdominal pain - on , 1 day following her egd, the patient developed diffuse abdominal distention and discomfort but most prominent in the epigastric region. ths was thought to be secondary to insufflation of the gi tract during the procedure, coupled with low gastric motility likely secondary to diabetic gastroparesis, and low intestinal motility given the high narcotic requirements of the patient to control her musculoskeletal pain. an abdominal plain film confirmed findings of constipation and the patient was placed on standing bowel regimen including docusate, senna, and bisacodyl. #psych - the patient was seen by psychiatry who felt that the patient would benefit from starting celexa 10mg qd and decreasing elavil to 50mg qhs. because the patient was already taking a benzodiazepine valium, the patient's ambien for sleep was discontinued. psychiatry stated that they would follow the patient as an outpatient. the patient had problems with management during the last 2 days of hospitalization, including throwing a pitcher of water and threatening staff at 2050 on . security and clinical advisor were involved. the patient wanted to be discharged and to follow up with licensed social worker and psychiatrist as an outpatient. . # disposition: the patient left against medical advice on the morning of before a treatment plan for that day or discharge planning could be finalized. medications on admission: albuterol sulfate nebulization q4h prn sob amitriptyline 75 mg tablet hs ammonium lactate 12 % cream for feet diazepam 10 mg tablet tid epinephrine prn anaphylaxis etodolac 300 mg capsule fluticasone-salmeterol 500 mcg-50 mcg/dose hydromorphone 2mg qday to prn pain insulin detemir pen, 60 units hs insulin glulisine ssi ipratropium bromide 0.2 mg/ml (0.02 %) solution prn ketoconazole 2 % shampoo 2x per week levocetirizine 5 mg tablet qday lidocaine 5 % daily lisinopril 10 mg tablet daily metformin 1,000 mg tablet omeprazole 20 mg capsule 2 capsule(s) x 1 week then qday potassium chloride 20 meq pramlintide 1,500 mcg/1.5 ml pen injector 120 mcg before each meal by 5 to 10 minutes pregabalin 150 mg promethazine 25 mg tablet tid prn simvastatin 20 mg tablet triamcinolone acetonide 0.025 % cream urea 40 % cream for feet zafirlukast 20 mg tablet acetaminophen prn aspirin 325 mg tablet daily calcium carbonate 600 mg cholecalciferol (vitamin d3) 1g qday diphenhydramine hcl 25mg prn multivitamin tablet 1 tablet(s) by mouth discharge medications: 1. ammonium lactate 12 % lotion sig: one (1) application topical (2 times a day). 2. diazepam 10 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for pain. 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) inhalation inhalation (2 times a day). 4. ketoconazole 2 % shampoo sig: one (1) appl topical 2x/week (tu,sa). 5. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical once a day. 6. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 7. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 9. pregabalin 75 mg capsule sig: two (2) capsule po bid (2 times a day). 10. triamcinolone acetonide 0.025 % cream sig: one (1) appl topical qd prn () as needed for itching. 11. zafirlukast 20 mg tablet sig: one (1) tablet po bid (2 times a day). 12. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 13. calcium carbonate 500 mg tablet, chewable sig: three (3) tablet, chewable po bid (2 times a day). 14. cholecalciferol (vitamin d3) 400 unit tablet sig: 2.5 tablets po daily (daily). 15. ipratropium bromide 0.02 % solution sig: one (1) nebulizer inhalation q6h (every 6 hours) as needed for sob. 16. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 17. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 18. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po bid (2 times a day). 19. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulizer inhalation q6h (every 6 hours). 20. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 21. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every 6-8 hours as needed for wheezing, sob. disp:*2 90 mcg/actuation hfa aerosol inhaler* refills:*0* 22. hydroxyzine hcl 25 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for itching. 23. morphine 15 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain. 24. amitriptyline 25 mg tablet sig: two (2) tablet po hs (at bedtime). 25. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 26. insulin glulisine 100 unit/ml cartridge sig: one (1) dose per sliding scale subcutaneous three times a day as needed for controlling blood glucose levels: take after each meal, per sliding scale. 27. acetaminophen 500 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 28. epinephrine 0.3 mg/0.3 ml pen injector sig: one (1) injection intramuscular once as needed for anaphylaxis (severe allergic reaction): please call 911 if needed. 29. insulin detemir 100 unit/ml insulin pen sig: forty (40) units subcutaneous twice a day: please take one dose in the morning and one dose before bedtime. 30. xyzal 5 mg tablet sig: one (1) tablet po at bedtime as needed for itching. 31. promethazine 25 mg tablet sig: one (1) tablet po three times a day as needed for nausea: please do not drive after taking. discharge disposition: home with service discharge diagnosis: primary: asthma flare uncontrolled type 2 diabetes mellitus mild gastritis secondary: arthritis spinal stenosis gerd diabetic peripheral neuropathy obstructive sleep apnea eczema discharge condition: please note: patient eloped against medical advice on . stable, afebrile. discharge instructions: please note: patient eloped against medical advice on without receiving full discharge instructions. dear ms. , it was a pleasure caring for you during this admission. you were admitted for evaluation and management of your left sided chest pain, increased difficulty breathing, and high blood sugar levels. the results of an ekg and several blood tests confirmed that you did not have a heart attack. because you had several risk factors for the development of pulmonary embolism (a clot in the blood vessels in the lungs) and deep vein thrombosis (a blood clot in your legs), we initially treated you with the blood thinner lovenox, but stopped this medication after imaging studies suggested that pulmonary embolism was unlikely. it appeared that your chest pain was related to your chronic arthritis and musculoskeletal pain, so we continued your home pain management regimen to manage this pain. your increased difficulty breathing secondary to an asthma flare was treated with a four day course of the steroid prednisone and you were continued on your home medications of fluticasone-salmeterol, albuterol nebulizers, and ipatropium. you never required supplemental oxygen and your breathing returned to your baseline. on admission it was found that your diabetes was poorly controlled and that you had finger stick blood glucose levels persistently above 500, likely secondary to your body's natural stress response and exacerbated by the additional steroids used to treat your asthma flare. you were transferred to the intensive care unit and started on an insulin drip and then transitioned back to a twice daily basal insulin regimen and a sliding scale insulin regimen and transferred back to the hospital floor. because you complained of difficulty swallowing, you underwent a barium swallow study that showed decreased emptying of your stomach but no blockages in your esophagus (food pipe). you also underwent an upper endoscopy to evaluate your increased difficulty swallowing and to assess your nissen fundoplication (wrap). an attempt was made to dilate the connection between your esophagus and stomach, but was not successful. you were found to have some mild gastritis. on , you developed a fever, increasing abdominal bloating, weakness, numbness, and tingling in your face. you were given acetominophen to control your temperature. urine cultures were negative. blood cultures were drawn and showed no bacterial growth. imaging studies showed that you did not have a bowel blockage, but had lots of stool in your colon consistent with constipation. blood tests showed no problems with your liver or pancreas. your numbness and tingling in your face was thought to be related to your recently elevated blood sugars secondary to poorly controlled diabetes. we have made the following changes to your medications: 1. we stopped your etodolac because of stomach irritation, exacerbation of your gastritis 2. we stopped your hydromorphone because of the allergic reaction that you had to both intravenous and oral forms. 3. we stopped your metformin. 4. we stopped your pramlintide (symlinpen). 5. we increased your insulin detemir (levemir flexpen) dose to 40 units 2 times a day (in the morning and at bed time). 6. we changed your insulin glulisine (apidra) sliding scale (please see attached sheet). 7. we started you on citalopram for depression. 8. we started you on hydroxyzine tablets for itching 8. we have prescribed an emergency albuterol inhaler for you to use if you have acute breathing difficulties. please take all medications as prescribed and go to all follow up appointments. please adhere to an appropriate diabetic diet. to prevent further diabetic neuropathy, it's important to follow this diet to keep your blood sugars under control. please call your physician or return to the emergency department if you have increased difficulty breathing, chest pain, fever, nausea, vomiting, persistently elevated blood sugars, or any other concerning symptoms. dear ms. , it was a pleasure caring for you during this admission. you were admitted for evaluation and management of your left sided chest pain, increased difficulty breathing, and high blood sugar levels. the results of an ekg and several blood tests confirmed that you did not have a heart attack. because you had several risk factors for the development of pulmonary embolism (a clot in the blood vessels in the lungs) and deep vein thrombosis (a blood clot in your legs), we initially treated you with the blood thinner lovenox, but stopped this medication after imaging studies suggested that pulmonary embolism was unlikely. it appeared that your chest pain was related to your chronic arthritis and musculoskeletal pain, so we continued your home pain management regimen to manage this pain. your increased difficulty breathing secondary to an asthma flare was treated with a four day course of the steroid prednisone and you were continued on your home medications of fluticasone-salmeterol, albuterol nebulizers, and ipatropium. you never required supplemental oxygen and your breathing returned to your baseline. on admission it was found that your diabetes was poorly controlled and that you had finger stick blood glucose levels persistently above 500, likely secondary to your body's natural stress response and exacerbated by the additional steroids used to treat your asthma flare. you were transferred to the intensive care unit and started on an insulin drip and then transitioned back to a twice daily basal insulin regimen and a sliding scale insulin regimen and transferred back to the hospital floor. because you complained of difficulty swallowing, you underwent a barium swallow study that showed decreased emptying of your stomach but no blockages in your esophagus (food pipe). you also underwent an upper endoscopy to evaluate your increased difficulty swallowing and to assess your nissen fundoplication (wrap). an attempt was made to dilate the connection between your esophagus and stomach, but was not successful. you were found to have some mild gastritis. on , you developed a fever, increasing abdominal bloating, weakness, numbness, and tingling in your face. you were given acetominophen to control your temperature. urine cultures were negative. blood cultures were drawn and showed imaging studies showed that you did not have a bowel blockage, but had lots of stool in your colon consistent with constipation. blood tests showed no problems with your liver or pancreas. your numbness and tingling in your face was thought to be related to your recently elevated blood sugars secondary to poorly controlled diabetes. we have made the following changes to your medications: 1. we stopped your etodolac because of stomach irritation, exacerbation of your gastritis 2. we stopped your hydromorphone because of the allergic reaction that you had to both intravenous and oral forms. 3. we stopped your metformin. 4. we stopped your pramlintide (symlinpen). 5. we increased your insulin detemir (levemir flexpen) dose to 40 units 2 times a day (in the morning and at bed time). 6. we changed your insulin glulisine (apidra) sliding scale (please see attached sheet). 7. we started you on citalopram for depression. 8. we started you on hydroxyzine tablets for itching 8. we have prescribed an emergency albuterol inhaler for you to use if you have acute breathing difficulties. please take all medications as prescribed and go to all follow up appointments. please adhere to an appropriate diabetic diet. to prevent further diabetic neuropathy, it's important to follow this diet to keep your blood sugars under control. please call your physician or return to the emergency department if you have increased difficulty breathing, chest pain, fever, nausea, vomiting, persistently elevated blood sugars, or any other concerning symptoms. dear ms. , it was a pleasure caring for you during this admission. you were admitted for evaluation and management of your left sided chest pain, increased difficulty breathing, and high blood sugar levels. the results of an ekg and several blood tests confirmed that you did not have a heart attack. because you had several risk factors for the development of pulmonary embolism (a clot in the blood vessels in the lungs) and deep vein thrombosis (a blood clot in your legs), we initially treated you with the blood thinner lovenox, but stopped this medication after imaging studies suggested that pulmonary embolism was unlikely. it appeared that your chest pain was related to your chronic arthritis and musculoskeletal pain, so we continued your home pain management regimen to manage this pain. your increased difficulty breathing secondary to an asthma flare was treated with a four day course of the steroid prednisone and you were continued on your home medications of fluticasone-salmeterol, albuterol nebulizers, and ipatropium. you never required supplemental oxygen and your breathing returned to your baseline. on admission it was found that your diabetes was poorly controlled and that you had finger stick blood glucose levels persistently above 500, likely secondary to your body's natural stress response and exacerbated by the additional steroids used to treat your asthma flare. you were transferred to the intensive care unit and started on an insulin drip and then transitioned back to a twice daily basal insulin regimen and a sliding scale insulin regimen and transferred back to the hospital floor. because you complained of difficulty swallowing, you underwent a barium swallow study that showed decreased emptying of your stomach but no blockages in your esophagus (food pipe). you also underwent an upper endoscopy to evaluate your increased difficulty swallowing and to assess your nissen fundoplication (wrap). an attempt was made to dilate the connection between your esophagus and stomach, but was not successful. you were found to have some mild gastritis. on , you developed a fever, increasing abdominal bloating, weakness, numbness, and tingling in your face. you were given acetominophen to control your temperature. urine cultures were negative. blood cultures were drawn and showed no bacterial growth. imaging studies showed that you did not have a bowel blockage, but had lots of stool in your colon consistent with constipation. blood tests showed no problems with your liver or pancreas. your numbness and tingling in your face was thought to be related to your recently elevated blood sugars secondary to poorly controlled diabetes. we have made the following changes to your medications: 1. we stopped your etodolac because of stomach irritation, exacerbation of your gastritis 2. we stopped your hydromorphone because of the allergic reaction that you had to both intravenous and oral forms. 3. we stopped your metformin. 4. we stopped your pramlintide (symlinpen). 5. we increased your insulin detemir (levemir flexpen) dose to 40 units 2 times a day (in the morning and at bed time). 6. we changed your insulin glulisine (apidra) sliding scale (please see attached sheet). 7. we started you on citalopram for depression. 8. we started you on hydroxyzine tablets for itching 8. we have prescribed an emergency albuterol inhaler for you to use if you have acute breathing difficulties. please take all medications as prescribed and go to all follow up appointments. please adhere to an appropriate diabetic diet. to prevent further diabetic neuropathy, it's important to follow this diet to keep your blood sugars under control. please call your physician or return to the emergency department if you have increased difficulty breathing, chest pain, fever, nausea, vomiting, persistently elevated blood sugars, or any other concerning symptoms. followup instructions: please note: patient eloped against medical advice on 1. provider: . , pt phone: date/time: 9:00 2. provider: , : date/time: 11:00 3. provider: function lab phone: date/time: 10:40 procedure: non-invasive mechanical ventilation esophagogastroduodenoscopy [egd] with closed biopsy diagnoses: obstructive sleep apnea (adult)(pediatric) other chronic pain anemia, unspecified esophageal reflux mitral valve disorders unspecified essential hypertension polyneuropathy in diabetes constipation, unspecified disturbance of skin sensation long-term (current) use of insulin major depressive affective disorder, single episode, unspecified unspecified hearing loss other chest pain fever, unspecified personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits other postprocedural status spinal stenosis, unspecified region asthma, unspecified type, with (acute) exacerbation diabetes with neurological manifestations, type ii or unspecified type, uncontrolled other specified gastritis, without mention of hemorrhage arthropathy, unspecified, site unspecified edema contact dermatitis and other eczema, unspecified cause arthropathy, unspecified, multiple sites other facial nerve disorders scanty or infrequent menstruation 

Answer: The patient is high likely exposed to