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: ferrlecit attending: chief complaint: fever, headache, neck stiffness major surgical or invasive procedure: flex sigmoidoscopy intubation x 2 thoracentesis x 2 bronchoscopy x 4 central line placement picc placement arterial line placement history of present illness: 47 yof w/ a h/o indeterminate colitis who presents with 4 days of of headaches and neck stiffness and intermittent fevers. reports developed severe global ha abruptly while at work 4 days ago, associated with neck stiffness and pain. subjective fevers at home off and on. +chills. took tylenol with some relief. on wed nite, developed nausea and vomiting and has had poor po intake since, only minimal liquids. generally describes herself as a non-outdoors person, however was in 2 weeks ago and spent time out of doors at a ski resort. did have a mosquito bite at that time, but no known recent tic bites. no recent travel or sick contacts. presented to her gi doctor (dr. 3 days ago with these symptoms. at that time, had from of neck, with tender neck muscles, wbc 10,000 with left shift. called her again yesterday, and was instructed to go to the ed. . in the ed, initial vitals were t 103, hr 80, sbp 115, 98% on ra. she received 1 gram of iv ceftriaxone as empiric coverage for meningitis. an lp was performed which showed protein 28, glucose 74, 0 rbc's, and 3 wbc's in tube 2. csf gram stain was negative. she received zofran, morphine, tylenol, ativan, ketorolac, and demerol in the ed for symptomatic relief. she received a total of 4 liters ivf. . on arrival to the floor, ha is (from on admission). has her usual chronic abdominal pain from her colitis. notes that she has had increased frequency of bloody stools over the past month, due to likely flare of her colitis. past medical history: * intermediate colitis * ulcerative colitis (see above) * arthritis * svt (evaluated by dr. at who recommended cardio ablation but the patient refused) * anemia social history: works as shoe designer with frequent travel to . occasional ethanol. no tobacco or ivdu. single mother of 2 sons age 12 and 16. family history: non-contributory physical exam: vital: t99.3, bp 90/60, hr 99, rr 18, 96% ra gen: thin middle-aged female lying in bed under multiple blankets, rigoring heent: perrl, eomi, op clear, no lesions noted in the oral cavity, mmm neck: limited rom pain and stiffness (able to put chin to chest, can bend neck to left 60 degrees, 45 degrees on r) ln: no cervical, supraclavicular, axillary, or inguinal lad cv: rrr, no m/g/r pulm: ctab, no w/r/r abd: soft, nd, +bs, mildly ttp diffusely without rebound or guarding (chronic per pt) : no peripheral edema skin: blanching erythema at upper chest and back (not new per pt). no rash or evidence of insect bites. neuro: a+ox3, cnii-xii intact, sensation to light touch intact throughout, motor in ue and le bilaterally pertinent results: 02:35am blood wbc-19.1* rbc-3.41* hgb-10.2* hct-30.2* mcv-89 mch-29.8 mchc-33.7 rdw-15.4 plt ct-455* 01:15am blood neuts-87.9* lymphs-6.3* monos-4.3 eos-1.2 baso-0.4 07:18pm blood hypochr-1+ anisocy-1+ poiklo-occasional macrocy-1+ microcy-normal polychr-normal ovalocy-occasional tear dr 02:35am blood plt ct-455* 02:35am blood pt-16.3* ptt-32.9 inr(pt)-1.5* 03:20am blood fdp-0-10 03:20am blood fibrino-692* 03:33am blood parst s-negative 02:35am blood glucose-94 urean-47* creat-1.8* na-136 k-4.3 cl-99 hco3-27 angap-14 02:35am blood estgfr-using this 02:44am blood alt-25 ast-29 ld(ldh)-332* alkphos-234* totbili-0.5 03:33am blood ck-mb-notdone ctropnt-<0.01 10:29pm blood ck-mb-notdone ctropnt-<0.01 02:35am blood calcium-8.0* phos-6.2* mg-1.8 01:12pm blood hapto-541* 03:20am blood triglyc-106 04:40am blood tsh-2.2 09:32am blood anca-positive 07:58pm blood -negative 03:33am blood rheufac-6 03:18am blood c3-64* c4-6* 08:10pm blood vanco-3.8* 04:32pm blood type-art po2-96 pco2-41 ph-7.53* caltco2-35* base xs-10 03:59pm blood francisella tularensis serology-pnd 09:37pm blood miscellaneous testing-pnd 04:26pm blood francisella tularensis serology- 08:35pm blood granulocyte antibodies- 05:40pm blood francisella tularensis serology- 05:40pm blood human monocytic and granulocytic ehrlichia agents igg and igm-test name 09:32am blood confirmatory anca- 03:37pm blood anti-gbm-test 09:32am blood anti-gbm-test 10:56am blood histoplasma antibody, immunodiffusion-test 10:56am blood histoplasma antibody (by cf and id)-test 03:52pm blood coccidioides antibody, immunodiffusion-test 03:52pm blood histoplasma antigen-test name 06:32am blood aspergillus galactomannan antigen- test 04:19am blood b-glucan-test 06:50am blood herpes simplex (hsv) 2, igg-test name 03:52pm blood histoplasma antigen-test name 06:32am blood aspergillus galactomannan antigen- test 04:19am blood b-glucan-test 06:50am blood herpes simplex (hsv) 2, igg-test name 06:50am blood herpes simplex (hsv) 1, igg-test 11:45am blood vitamin d 25 hydroxy-test 11:45am blood vitamin d dihydroxy-test 10:15am blood mycoplasma pneumoniae antibody igm-test 11:36am blood mycoplasma pneumoniae antibody, igg-test 03:15pm blood anaplasma phagocytophilum (human granulocytic ehrlichia ) igg/igm-test name brief hospital course: ms. is a 47 y/o woman with a hx of colitis and svts who was admitted for septic meningitis on . she developed a gradually worsening cough and dyspnea, with cxrs showing worsening diffuse alveolar opaceification, as well as persistant fevers. she was bronched on , after which the pt developed tachypnea to the 40s with dropping o2 sats despite increasing o2 requirements. she was transferred to the micu for respiratory distress and was started on cefepime, flagyl, and doxycycline. in the micu, her problems were as follows: . # respiratory distress: pt was febrile, tachypnic, leukemic, and hypoxemic when transferred to the micu. she was shown to have pleural effusions. her antibiotic regiment was broadened to include vanc and meropenem. she became increasingly hemodynamically unstable and her wbcs increased, and her cxr showed expanding diffuse opacities. fungal coverage was initiated due to the patient's lack of improvement on other antibiotics. on the morning of , the pt was intubated for respiratory distress. her pressures decreased to maps in the 50s, which led to the initiating of pressors. cxr showed progressive upper predominant disease. an a-line was placed. ms. has a repeat bronch on and many labs were sent. her ct showed moltifocal pna vs vasculitis & ards. that night, pt had 3 runs of svt, as evidenced by ecgs. she was converted with b-blockers and stabilized on amiodarone. solumedrol was initiated for wheezing, possible vasculitis. this was switched to methylprednosone. on , pt was still febrile, intubated, with episodes of hypotension, but off pressers. she was started on acyclovir. . pt is in ards suspected tularemia vs hantavirus vs ppulmonary vasculitis vs pulm-renal disease. for a portion of time, with the anca and decreased complement, vasculitis was considered, but once the tuleremia serologies came back positive, the case was discussed with rheum and the steroids were dc'ed. intubated on for tachypnea/respiratory distress/ards. no fevers x72 hrs. continued bilateral effusions. since tuleremia is the suspected (titers 1:128 x2, moderately positive) and the patient has been afebrile and has improving respiratory funciton with docycline, d/c-ed meropenem on 7.20 since unlikely to be of nosocomial etiology. per id, doxycycline is best treatment for tularemia, fluoroquinolones have good effect in , not really synergistic w/ doxy. equivocal, can be added if clinical sx worsen. patient is being treated with a two week course of doxycycline for tuleremia, this is a second line , but is being used since there is compromised renal function that excludes the use of aminoglycisides. after theraputeic thoras that got about a 1.5l from each lung done on 7.23, the patient's resp status improved and the paitent was extubated on 7.24, however, b/c possible asp pna or reaccumulation of pulm edema had to be intubated a few hours later. she was bronched again on due to lobar collapse. repeat bronch on showed no evidence of obstruction or mucus plug. antibiotics were started for concern for aspiration, but these were stopped after a few days. respiratory status improved with diuresis and she was extubated on . . - id following, completed 14 day course of doxycycline - f/u tularemia convalescent ordered - f/u hantavirus serologies. - changed fentanyl patch to 25 on - d/c valium, clonazepam to 0.5 on , goal to further wean sedation over next few days . # hypotension and fevers: pt presented to the micu with a temp of 102.2. she was hypotensive. was initially thought to be due to sepsis. however, no organism has been isolated and broad spectrum antibiotics did not turn back the fevers or pulmonary process. pt was resuscitated with fluids and pressors. white count has continued to increase over the past several days to 20 on . pt has remained afebrile. no identifiable source of infection has been identified. ruq us was negative for any hepatobilliary disease - monitor cbc - ua/cx and sputum cx sent - culture and treat vap empirically if spikes fever . # ulcerative colitis: improving. pt was on azothiaprine on admission, which was held due to the infections processes. likely to be a factor in pt's anemia. following blood in stool on , uc was again discussed with gi, who felt she was not in an acute flare at that time. recommended colazol 750 mg tid at discharge . # acute renal failure: pt has had steadily increasing cr. baseline cr=0.4-0.5. began increasing on , after pt had several episodes of svt and hypotension. fena was 0.5, indicating prerenal disease. differential still wide, including contrast nephropathy and pulmonary-renal ds. after several days, cr began to decline, and pt had massive diuresis for several days. likely etiology now thought to be atn (drug related + hypotensive/pre-renal + contrast induced nephropathy from ct). i/o now more than 12 l negative for , have been approx 5 l positive on admission, so will continue to monitor i/o. renal is following. restarted calcium carbonate tid and aluminumoh on . . # svt: pt had a long-standing hx of svt, including a previous episode during this admission. on the evening of , pt had 3 episodes of svt to the 250s controlled with carotid massage, metoprolol, and amiodarone. she had concurrent hypotension.- - continue amiodarone, consider ablation when other medical issues stable . # anemia: pt has had a consistantly falling hct without a clear source of bleeding. she was transfused on for hct<21. as mentioned above, blood was noted in her stools on , which was accompanied by a drop in her hematocrit.thought be be a consequence of the uc. she received 1 unit prbcs on with a 4.8 increase in hct. conintue to monitor hct daily . # anxiety: pt has no known history of anxiety or benzodiazepam use according to parents. during her stay was very anxious about her condition and had difficulty dealing with her hospitalization. subsequently, she was started on valium tid and clonazepam . changed fentanyl patch to 25 on . valium was d/d'd, left on clonazepam 0.5 . consider zyprexa for continued anxiety/delirium. . # mildly elevated amylase/lipase: ct showed normal pancreas. # pt/ot: consulted, follow up recomendations. medications on admission: azathioprine 150mg po daily balsalazide 750mg 3 tablets po tid (2.25 g tid) vitamin b12 1000mcg monthly (last ) folate 1mg daily synthroid 50mcg daily lopressor 25mg po only with svt ocp tri-previfem discharge medications: 1. levothyroxine 50 mcg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. acetaminophen 160 mg/5 ml solution : 15-30 ml po q6h (every 6 hours) as needed for fever, pain. disp:*120 ml* refills:*0* 3. calcium carbonate 500 mg tablet, chewable : one (1) tablet, chewable po tid (3 times a day). disp:*90 tablet, chewable(s)* refills:*2* 4. amiodarone 200 mg tablet : one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). disp:*30 tablet,rapid dissolve, dr(s)* refills:*2* 6. albuterol 90 mcg/actuation aerosol : four (4) puff inhalation q6h (every 6 hours) as needed. disp:*2 inhalers* refills:*6* 7. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection tid (3 times a day). disp:*90 ml* refills:*2* 8. fentanyl 25 mcg/hr patch 72 hr : one (1) patch 72 hr transdermal q72h (every 72 hours): taper as able. disp:*10 patch 72 hr(s)* refills:*2* 9. clonazepam 0.5 mg tablet : one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 10. balsalazide 750 mg capsule : one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 11. sodium chloride 0.9% flush 3 ml iv prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 12. prochlorperazine 10 mg iv q6h:prn nausea 13. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care facility: - discharge diagnosis: acute respiratory distress syndrome with respiratory failure anemia ulcerative colitis superventricular tachycardia acute renal failure deconditioning discharge condition: fair discharge instructions: you were treated in the hospital for an infection and developed problems with your lungs that required you to have a prolonged intubation. while you were ill, you received iv antibiotics, fluids, medications, and nutrition. you are being discharged to a facility for rehabilitation after a prolonged illness. there was concern for tularemia as the cause of your illness, one of the tests for this is still pending. you received a complete course of antibiotics if it was indeed tularemia. follow up with your primary care doctor as soon as possible. followup instructions: follow up with gastroenterology as soon as possible after discharge. an imaging study showed 3.3 cm cystic lesion in the left adnexa, followup in six weeks with a son is recommended to document resolution of this finding. after medical issues resolved, discuss ablation for h/o svt, as amiodarone can have adverse effects md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube insertion of endotracheal tube fiber-optic bronchoscopy thoracentesis arterial catheterization closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of large intestine transfusion of packed cells diagnoses: acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified septicemia severe sepsis hypopotassemia acute respiratory failure other specified cardiac dysrhythmias septic shock acute diastolic heart failure ulcerative colitis, unspecified nutritional marasmus other specified tularemia 

Answer: The patient is high likely exposed to