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: bradycardia major surgical or invasive procedure: none history of present illness: hpi: the patient is a 80y/o m with a pmh of cad, htn, pvd, copd admitted to neurology service for new onset seizure now transferred to micu following bradycardic arrest. per admission note, the patient lives at a nh and was found to have leftward eye deviation after eating breakfast this am, followed by generalized tonic-clonic activity. unclear duration of symptoms. he was given 1mg ativan, was noted to have incontinence of bowel and bladder, however this is his baseline. reported to be post-ictal for approx 10 minutes with minimal verbal output. there was question of l sided weakness at this time. there is no previous history of seizure. . he was admitted to neurology service with preliminary workup including head ct negative. on the evening of transfer, code blue was called at approx. 2am for asystole. chest compressions were briefly administered ~1min prior to code team arrival. per report the patient had bradycardia followed by asystole with spontaneous return of circulation. the patient was intubated for agonal breathing. 2piv and l femoral line were placed. he received ativan 2 mg without response. the patient was given 1mg atropine for bradycardia to rate of the 30s with improvement in hr to 70s. bp stable throughout. ecg without ischemic changes. he is now transferred to the micu for further management. past medical history: cad copd b/l hip fx and r hip replacement bph w/ obstructive uropathy mood d/o pvd osteoporosis htn gerd anemia mild dementia social history: (+) tobacco, 5 cigarettes per day x 60 years, quit 1 yr ago. social etoh. no drugs. formerly in marines. now lives at . family history: per admission note denies including specifically any hx of seizure physical exam: vitals: 98.6, bp 126/58, hr 63, rr 14, o2 100% on fi02 50% gen: intubated and sedated heent - pupils pinpoint and reactive cv: bradycardic, regular, no mrg resp: ctab, no wrr abd: soft, nt/nd, nabs ext: no le edema neuro: withdrawals all extremities to painful stimuli, moving all ext. spontaneously . examination on transfer from the icu : . general: mildly agitated heent: normocephalic, atraumatic. + conjunctival erythema. no scleral icterus. mm dry. op clear. neck supple, no lad, no thyromegaly. no nuchal rigidity cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: scattered upper and lower extremity ecchymoses. . neurologic: -mental status: alert, but inattentive. ", , " unable relate history. stated dow forward but got stuck on wednesday when going in reverse. language is dysarthric with intact repetition. speech was dysarthric but patient was notably adentious. able to follow simple one step commands but was easily distracted from a given task. no evidence of neglect. . -cranial nerves: i: olfaction not tested. ii: pinpoint but errl 1.5 to 1mm and reactive. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : unable to test do to exam cooperation xii: tongue protrudes in midline. . -motor: moves all extremities spontaneously but too inattentive to test strength. . -sensory: no apparent deficits to light touch. . -dtrs: tri pat ach l 3 3 3 1 1 r 3 3 3 1 1 plantar response was flexor bilaterally. . -coordination: pt with bilateral action tremor r>l. unable to attend to fnf testing. . -gait: pt in restraints; gait deferred exam at time of discharge: general: nad, pleasant but disoriented to place pulm: cta b/l, except at decr. sounds at right base cv: s1,s1 nl, no g/m/r abd: soft, nt, nd, peg in place, no drainage, c/d/i dressing. the t-fasteners will fall out on their own in approximately six weeks. ext: warm, dry, no edema neuro: mse: please note, this exam will fluctuate based on time of day (early am - patient may present w/ somnolence that resolves to exam listed below by late morning) alert, awake. oriented to year, and month, but not date. normal speech allowing for dentures. no aphasia. anomia to low frequency objects (watch band). able to perform dow backwards, but not backwards. knows some current events: . death. no paraphasic errors, no l/r confusion. cn: vf intact to threat. perrl 2-1.5mm b/l. no nystagmus. face symmetric allowing for lack of dentures. hearing impaired to finger rub b/l. palate midline, tongue midline, shoulder shrug intact. motor: strength 4+/5 in ues throughout, including fes. les 4-/5 at r ip (site of prior hip replacement), l ip . 4+/5 in the remainder of le m. groups. sensory: intact to lt in ue and le. could not assess reproducibly in remainder due to inattention. coordination: fnf moderate end of movement dysmetria b/l. trace asterixis. can not perform hks. gait: patient in wheel chair at baseline. pertinent results: laboratory studies on admission: 10:35am glucose-140* urea n-16 creat-0.9 sodium-134 potassium-4.0 chloride-97 total co2-30 anion gap-11 10:35am alt(sgpt)-10 ast(sgot)-18 ld(ldh)-241 ck(cpk)-61 alk phos-45 10:35am tot prot-6.2* albumin-3.9 globulin-2.3 calcium-8.8 phosphate-3.3 magnesium-1.7 10:35am ck-mb-notdone ctropnt-<0.01 10:35am tot prot-6.2* albumin-3.9 globulin-2.3 calcium-8.8 phosphate-3.3 magnesium-1.7 10:35am tsh-6.3* 10:35am free t4-1.2 10:35am wbc-4.2 rbc-4.18* hgb-12.4* hct-38.3* mcv-92 mch-29.7 mchc-32.5 rdw-14.8 10:35am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 10:35am pt-12.5 ptt-26.8 inr(pt)-1.1 10:35am plt count-106* laboratory findings at time of discharge aed levels: 10:35am blood valproa-45* 04:24am blood valproa-102* 04:31am blood valproa-75 06:00am blood valproa-93 06:26am blood valproa-63 valproate 04:51am 61 microbiology: bcx , , - pending ucx - no growth csf - smear pending, cx - pending csf: 10:54am cerebrospinal fluid (csf) wbc-1 rbc-2685* polys-58 lymphs-30 monos-9 eos-2 10:54am cerebrospinal fluid (csf) wbc-1 rbc-276* polys-73 lymphs-20 monos-7 10:54am cerebrospinal fluid (csf) totprot-41 glucose-77 lab studies at time of discharge: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:12am 8.5 3.05* 9.2* 28.3* 93 30.1 32.5 15.2 212 hemolytic workup ret aut 07:16pm 3.6* renal & glucose glucose urean creat na k cl hco3 angap 06:12am 73 15 0.6 132* 4.6 95* 34* 8 chemistry totprot albumin calcium phos mg 06:12am 2.8* 8.3* 2.9 2.1 imaging/studies: ct head: - impression: no acute intracranial abnormality. in light of no comparison study, findings may represent normal pressure hydrocephalus versus age appropriate atrophy as described above. clinical correlation is recommended. cxr - bilateral lower lobe atelectasis echo - impression: regional left ventricular systolic dysfunction consistent with coronary artery disease. moderate aortic stenosis. mild to moderate aortic regurgitation. moderate eccentric mitral regurgitation. mri head - impression: 1. ventriculomegaly which is although out of proportion for sulci with dilatation of the temporal horns, is likely due to atrophy in presence of widening of the choroidal fissure. however, the appearances could still be consistent with normal pressure hydrocephalus in proper clinical setting. 2. extensive small vessel disease is seen in the periventricular and subcortical white matter and pons. 3. no evidence of acute infarct or enhancing mass lesion. cxr - opacification involving the lower half of the right hemithorax. this is consistent with elevation of the hemidiaphragm, atelectasis and effusion. at the right base, there is increasing opacification in a somewhat triangular configuration adjacent to the heart border. this most likely represents atelectasis, though the possibility of supervening pneumonia can certainly not be excluded. cxr - findings: ap single view of the chest obtained with patient in sitting semi- upright position is analyzed in direct comparison with a similar portable chest examination of . previously described cardiomegaly and bilateral pleural effusions remain. no new parenchymal infiltrates are identified. pleural effusions obliterate diaphragmatic contours and blunt lateral pleural sinuses. the previously suspected density on the right base () is now seen to include air-filled colonic flexure resulting in diaphragmatic elevation. thus, the previous diagnosis of pneumonia is doubtful. no pneumothorax has developed. ng tube reaches below diaphragm including side port. portions of pigtail catheter are seen in upper abdomen. brief hospital course: micu course: while in the icu the patient was noted to have elevated bp's with low hr during the day. mri was obtained which showed significant atrophy but no evidence of acute stroke. he was extubated on . he was started on a higher dose of depakote for possible seizure activity. on , the patient was noted to be febrile to 102.5 axillary. his cxr showed r sided effusion, but no definitive infiltrate. he was started vancomycin, pip/tazo for empiric treatment of a likely ventilator associated pneumonia. despite his fevers and hypertension, the patient did well overall and was felt to be stable for transfer back to neurology. . on transfer, he was reported to be midly agitated but directable. he denied headache, neck pain, chest pain, or abdomninal pain or any other complaint. neurological examination on transfer was remarkable for mild agitation, with patient alert, but inattentive. ", , ." he was unable to relate history. could not perform dow in reverse. repetition was intact. speech was felt to be dysarthric, but patient was notably adentious. able to follow simple one step commands but was easily distracted from a given task. no evidence of neglect. . pinpoint pupils but errl 1.5 to 1mm, eomi without nystagmus, facial sensation intact to lt, he had no facial droop, palate was symmetrical and tongue was midline. he moved all extremities spontaneously but too inattentive to test strength. sensation was intact to lt, grossly. he was hyperreflexic in ues symmetrically and hyporeflexic in . toes were downgoing and he had a b/l action tremor. fnf, hts or gait could not be assessed (at baseline patient is wheelchair bound). the following is a summary of patient's course based on each problem. # bradycardia. it was unclear whether patient experienced a bradycardic arrest or a pea arrest, unfortunately no clear documentation exists. he did have bradycardia to 50s on telemetry, reported verbally as 30s, accompanied by loc and possible hemodynamic compromise on . he had a mild qt prolongation though there was no report of ventricular tachycardia/torsades. on the floor at time of transfer, he was persistently tachycardic with high load of atrial ectopy. his ce were wnl and echo showed severe dchf but no valvular changes, no global wall motion abnormality accounting for bradycardia. cardiology was consulted who felt as above. since patient was on atenolol 50 mg po bid, he was switched to acebutolol, a beta-blocker with "intrinsic sympathomimetic activity to control his high load of atrial ectopy without precipitating severe bradycardia." at 200 mg po bid, patient's hr decreased to 60-70s with occasional decrease to high 40s without pauses or symptomatic hypotension. indeed, patient was hypertensive and required increase of lisinopril to 20 mg po. he remained hemodynamically stable thereafter, and unfortunately no clear understanding of the event causing hemodynamic instability was ever established. there were no signficant pauses on telemetry. # ? seizure. patient underwent evaluation (as listed below). there was initial concern for complex partial seizure with secondary generalization and subsequent mild paralysis on admission. there were no clear precipitating factors for the seizure. he has no known epilepsy risk factors. he is on depakote but has no prior history of seizures. by the time he arrived in the emergency room, he seemed to be at his neurologic baseline. his eeg on showed mild encephalopathy and then was normal on . it was presumed that he had a parital complex seizure with secondary generalization this his depakote level was increased (initially used for a mood disorder). his mri showed showed ventriculomegaly mildly out of proportion to diffuse atrophy, extensive small vessel disease in the periventricular and subcortical white matter and pons, and no acute areas of ischemia. his tfts were wnl. his valproate level at time of discharge was 61. he will require treatment with vpa given the suspected seizure, his dosages at 1000mg hs and 750mg qam daily. his goal should be above 55 and below 90. # encephalopathy. pt remained disoriented on transfer to neuroloy floor. his baseline reported by his son included being oriented to time in all three domains, and place. he was able to carry on a meaninful conversation regarding a topic of his choice (i.e. music, television), but has not been able to discuss issues such as politics for over a year (he was a former intelligence data miner for us government). he was independent with feeding and most toileting and was mobile in a wheechair in a . he had some difficulty with memory of current events. the etiology of his dementia was not clear. during - patient continued to have waxing and level of alertness (at times requring gentle noxious stimulation to arouse, at times responsive to voice). he continued to have deficits in attention and had difficulty participating in the motor and sensory exams. he was treated for vap (as noted above), his uas have been negative, as well as bcx and ucx to date. a repeat ct head was performed on due to obtundation, showing no change, with resolution without treatment. it was felt that the cause of his encephalopathy was due to an infectious (vap) source and metabolic derangements (metabolic alkalosis) in setting of hospitalization. however, to rule out aseptic meningitis or pleocytosis as etiology of encephalopathy, lp was perfomed, showing 1 wbc, pmn predominance and rbcs, low protein and nl glucose. his csf fluid cytology was negative. based on this, it was felt that his encephalopathy was most like a delirium in a setting of an underlying dementia with causative agents being an infection (vap) and metabolic abnormalities (metabolic alkalosis and respiratory acidosis). his clonopin and mirtazapine were discontinued due to encephalopathy. his donepezil was restarted on . further evluation showed rpr showed a non-reactive assay. # copd and morning hypopnea. patient has copd at baseline and requires 1-2l nc oxygen at home while in a wheechair. upon intubation, his hypercarbia resolved and when extubated, his ph remained within normal limits and he required intermittent nebulizer treatments. while on the neurology floor, however, it was further noted that patient had morning respiratory acidosis and hypercapnia suggestive of sleep related hypoventillation. this lead to decreased morning alertness with patient requiring a sternal rub for responsiveness. nightime apneas and hypopneas was documented with continuous pulse oxymetry (frequent desaturations and apneic episodes during nighttime). as the day continued and patient became more awake with improving ventilation. his ph subsequently increased to normal range (actually into alkalotic range, see below) and his pco2 decreased to high 40s (felt to be his baseline due to copd), documented with abgs. due to this, patient was placed on bipap with initial settings of . with this treatment, his am alertness improved significantly. # metabolic alkalosis. developed over - . felt to be due to post-hypercapnic metabolic alkalosis (during the code) as well as chronic metabolic alkalosis as compensation for chronic respiratory acidosis in setting of chronic copd (see above). patient required temporary treatment with acetozolamide x 2 days. with this treatment, his hco3 returned to 30-34 range, felt to be his baseline hco3. # hyponatremia. on , patient was noted to have developed hyponatremia to 128 (134 on admission) in setting of post-acetozolamide diuresis. una was < 10 and uoxm was 480 and patient was hypovolemic. however, as his volume was repleted w/ ns, his na improved to 132 temporarily, however returned to 128 despite euvolemia. una was 78 and uosm was 490. given euvolemia, and recent vap and copd, siadh was felt to be the leading diagnosis. free water was withheld tfs as well as ns was withheld. # anemia. normocytic. hct 38 on admission, likely hemoconcentrated. hct decreased to 28-30 during hospitalization and remained at that level during the last 3 days of hospitalization. most likely due to aggressive fluid adminstration and phlebotomy (nearly labs for 10 days). guiac negative. no clinical evidence of ugib or lgib on exams. fe studies showed low tibc but were otherwise normal, making acd most likely underlying etiology, but not responsible for the change during hospital stay. folate, b12 were nl, as was tsh. he will need a repeat hct on admission to ltac and weekly thereafter if maintains hemodynamic stability. due to concern for over-phlebotomy, laboratories were not drawn on . # fen. patient required tf after intubation. he was evaluated by speech and swallow on two separate occasions one week appart, and was noted to have aspiration on both of those occasions. due to this, patient underwent a peg placement on . hi was treated with tf. there were no complications of peg placement. outstanding issues: - speech and swallow reevaluation and nutrition consultation to ensure adequate intake. peg removal when cleared by s and s and po intake improves. - monitoring of hct at time of admission and weekly thereafter, with guiacs of stools for potiential bleed. - monitoring and treatment of hyponatremia, felt to be siadh - monitoring and treatment of am hypopnea with bipap (patient does have am somnolence) - continuing treatment with vpa for seizures. patient will require neurology follow up and weekly cbc and chem 10 for monitoring of aes of vpa medications on admission: actonel 35 mg qweek klonopin 0.25 mg qday depakote 500/750 mg lactulose 30 ml albuterol nebs q6hrs aricept 10 mg qhs flomax 0.4 mg qday mirtazapine 7.5 mg qhs senna 2 tabs qhs zocor 10 mg qday colace 100 mg qday iron 325 mg qday lisinopril 10 mg qday omeprazole 20 mg qday atenolol 50 mg mvi qday flovent 2 puffs bisacodyl prn tylenol prn ntg 0.4 mg sl prn . medications on transfer: clonazepam 0.25 mg po daily divalproex (delayed release) 500 mg po qam divalproex (delayed release) 750 mg po qhs donepezil 10 mg po qhs albuterol 0.083% neb soln 1 neb ih q6h tamsulosin 0.4 mg po daily mirtazapine 7.5 mg po qhs senna 2 tab po qhs simvastatin 10 mg po daily docusate sodium 100 mg po daily ferrous sulfate 325 mg po daily lisinopril 10 mg po daily omeprazole 20 mg po daily atenolol 50 mg po bid multivitamins 1 tab po daily fluticasone propionate 110mcg 2 puff ih bisacodyl 10 mg po/pr daily:prn constipation acetaminophen 325-650 mg po q6h:prn pain, fever nitroglycerin sl 0.4 mg sl prn angina . discharge medications: 1. tamsulosin 0.4 mg capsule, sust. release 24 hr : one (1) capsule, sust. release 24 hr po daily (daily). 2. lisinopril 20 mg tablet : one (1) tablet po daily (daily). 3. acebutolol 200 mg capsule : one (1) capsule po bid (2 times a day). 4. valproic acid 250 mg capsule : three (3) capsule po qam (once a day (in the morning)). 5. valproic acid 250 mg capsule : four (4) capsule po qhs (once a day (at bedtime)). 6. donepezil 5 mg tablet : two (2) tablet po hs (at bedtime). 7. trazodone 50 mg tablet : 0.5 tablet po hs (at bedtime) as needed for insomnia. 8. actonel with calcium 35 mg-500 mg (1250 mg) tablets, dose pack : one (1) tablets, dose pack po q mon (). 9. simvastatin 10 mg tablet : one (1) tablet po daily (daily). 10. fluticasone 110 mcg/actuation aerosol : two (2) puff inhalation (2 times a day). 11. ipratropium bromide 0.02 % solution : one (1) inhalation q6h (every 6 hours). 12. nitroglycerin 0.3 mg tablet, sublingual : one (1) sublingual prn chest pain. 13. ferrous sulfate 325 mg (65 mg iron) tablet : one (1) tablet po daily (daily). 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q6h (every 6 hours) as needed for sob, wheezing. 15. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 16. heparin (porcine) 5,000 unit/ml solution : one (1) injection tid (3 times a day). 17. therapeutic multivitamin liquid : one (1) tablet po daily (daily). 18. senna 8.6 mg tablet : one (1) tablet po qhs (once a day (at bedtime)). 19. docusate sodium 50 mg/5 ml liquid : one (1) po daily (daily). 20. acetaminophen 325 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 21. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 22. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 23. 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. 24. lab work cbc and chem 10, lfts on arrival to ltac and weekly thereafter. discharge disposition: extended care facility: & rehab center - discharge diagnosis: primary: possible seizure, cardiac arrest (bradycardic versus pea - unclear based on available data), ventilator associated pneumonia, metabolic alkalosis, nocturnal hypopnea secondary: pvd, cad, htn, dementia, copd, osteoporosis discharge condition: seizure free, mild hospital setting delirium discharge instructions: you were admitted to for evaluation of a possible seizure. while in the hospital, you had a cardiac arrest. you were successfully resuscitated. however your course was complicated by ventilator associated pneumonia, sinus tachycardia, metabolic alkalosis, nocturnal hypopnea and hypercapnea as well as delirium. for your pneunomia you were treated with antibiotics. for your tachycardia your heart rate medication was changed. for your metabolic acidosis you were treated with acetozolamide and for your hopopnea, you required bipap. finally, your delirium was felt to be due to pneumonia, arrest and being hospitalized. investigations of all other causes (including lumbar puncture and eegs) were negative. for your suspected seizure activity, your valproic acid dosing was increased to provide protection from further seizures. there were multiple changes made to your medications, please refer to discharge worksheet for the final list. should you develop further seizures, loss of conscioussness, fevers, cough, abdominal pain, weakness, numbness, difficulty with speech or any other symptom concerning to you, please call the physician on staff or go to the emergency room. followup instructions: please follow up with your primary care provider, ,, please call to make a an appointment for follow up within 2 weeks of discharge from the hospital/rehabilitation facility. please call the office of dr. and dr. to set up a follow up appointment within one month of your discharge, please call (. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified spinal tap incision of lung diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization cardiopulmonary resuscitation, not otherwise specified other gastrostomy diagnoses: anemia, unspecified coronary atherosclerosis of native coronary artery esophageal reflux congestive heart failure, unspecified unspecified essential hypertension chronic airway obstruction, not elsewhere classified other convulsions peripheral vascular disease, unspecified other persistent mental disorders due to conditions classified elsewhere hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (luts) acute respiratory failure cardiac arrest osteoporosis, unspecified ventilator associated pneumonia other disorders of neurohypophysis diastolic heart failure, unspecified delirium due to conditions classified elsewhere hip joint replacement mixed acid-base balance disorder dysphagia, oropharyngeal phase unspecified episodic mood disorder hypoglycemia, unspecified urinary obstruction, not elsewhere classified 

Answer: The patient is high likely exposed to