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: dizziness major surgical or invasive procedure: picc placement history of present illness: 55 yo with h/o hypothyroidism, mds v.etoh marrow toxicity, frequent falls thought peripheral neuropathy p/w hypotension. the pt reported that for the last several months she had intermittent dizziness predominantly when she was turning or leaning to the right side. she reported that every now and then she falls down when she turns her whole body or only her head to the right side. she never lost consciousness. she stated that the night before admission she fell and hit the back of her head. she usually falls backwards. she also reported a cough over the prior several days that was a little bit more than usual and was productive of yellowish sputum. she denied any sob, cp, myalgias, arthralgias, fever, chills or nightsweats. she also denied any abdominal pain or change in her bowel habits, except for one episode of loose stools yesterday. she denied any dysuria but reported increased urinary frequency. the patient's boyfriend reported also increased somnolence and decreased po intake over the week pta. . ros: negative for cp, sob, abdominal pain, constipation, f/c/ns, weight loss, changes in the color of the urine or stool. . in the ed, 97.5 86 60/50** 84 97 2lnc. pt was given levofloxacin and flagyl. she was started on levophed after receiving 3l ns without significant response in her bp, and she received 4mg of dexamethasone. a cvl was placed, cvp was . ekg was unchanged from prior. a cxr was read as normal, however a repeat one after cvl placing was concerning for pulmonary congestion. ua was positive and suggestive of uti. past medical history: 1. chronic macrocytic anemia w/ mild 2. status post bone marrow biopsy -mds v etoh toxicity pancytopenia > resolved and most likely attributed to etoh toxicity 3. hypothyroidism 4. h/o questionable seizures, but neg 48h eeg and nl mri in past. 5. migraine headaches 6. questionable history of cardiac arrhythmias. of hearts in past showed some tachys to 180s. patient denies. 7. peptic ulcer disease status post nissen fundoplication. remote 8. status-post hemorrhoidectomy. 9. asthma s/p intubation x 1 in past. 10. osteoarthritis. 11. b/l cataracts 12. r knee surgery social history: lives with her boyfriend in . three daughters. tobacco. no drugs/herbals. occasional etoh use, states last drink 2 days ago, glass of wine. used to be a photographer. family history: father died of cad at age 80. mother-alive and healthy. no family with mds or leukemia physical exam: neurology pe on vs- t-98 bp 128/78 hr- 124 r-20 sat- 96%ra fs-137 gen- nad, lethargic, difficult to examine heent- nc/at, no scleral icterus noted, dry mm, no lesions noted in oropharynx neck- supple, no carotid bruits appreciated. no nuchal rigidity lungs- few crackles bil. cv- tachy, nl s1s2, no m/r/g noted abd- soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted ext- 1+ edema in le bil. skin- no rashes or lesions noted . on day of discharge a+ox3, pleasant and interactive, neck contracted to the right but patient can reposition when prompted, able to be moved in all directions ue flexion/extension le flexion/extension. pt with difficulty moving her body weight and transfering. still overall weaker than baseline. eomi perrl mmm, op clear r picc lungs cta heart regular no m/r/g abdomen soft, nt. nd +bs extr no edema, skin with old hypopigmented scars pertinent results: 11:58am blood wbc-4.8 rbc-3.07* hgb-10.5* hct-32.8* mcv-107*# mch-34.3* mchc-32.2 rdw-14.0 plt ct-214 11:58am blood neuts-68.6 lymphs-20.0 monos-5.3 eos-5.8* baso-0.2 05:40am blood wbc-10.3# rbc-2.83* hgb-9.6* hct-30.4* mcv-107* mch-34.0* mchc-31.6 rdw-14.4 plt ct-222 05:50am blood wbc-8.0 rbc-2.51* hgb-8.5* hct-26.4* mcv-105* mch-34.0* mchc-32.3 rdw-15.1 plt ct-218 05:52am blood wbc-7.3 rbc-2.80* hgb-9.5* hct-29.3* mcv-105* mch-34.1* mchc-32.6 rdw-14.3 plt ct-326 11:58am blood pt-12.8 ptt-20.5* inr(pt)-1.1 11:58am blood glucose-112* urean-24* creat-1.2* na-141 k-5.52* cl-108 hco3-25 angap-14 01:01am blood glucose-121* urean-18 creat-0.8 na-141 k-4.2 cl-116* hco3-18* angap-11 05:42am blood glucose-93 urean-3* creat-0.5 na-141 k-4.1 cl-109* hco3-28 angap-8 05:52am blood glucose-86 urean-6 creat-0.7 na-139 k-4.4 cl-106 hco3-26 angap-11 11:58am blood alt-11 ast-35 ck(cpk)-375* alkphos-105 totbili-0.5 11:58am blood ck-mb-5 11:58am blood ctropnt-<0.01 12:45pm blood ck(cpk)-59 11:58am blood ctropnt-<0.01 05:39am blood ck(cpk)-36 12:45pm blood ck-mb-notdone ctropnt-<0.01 03:07pm blood alt-12 ast-14 ld(ldh)-213 alkphos-78 totbili-0.3 11:58am blood calcium-8.5 phos-4.2 mg-1.6 05:45am blood calcium-8.6 phos-2.8 mg-1.3* 05:30am blood calcium-8.6 phos-2.9 mg-1.1* 12:35pm blood mg-2.6 06:05pm blood calcium-8.0* phos-3.0 mg-1.4* 05:50am blood albumin-2.5* calcium-7.8* phos-3.0 mg-2.5 05:58pm blood calcium-8.4 phos-4.1 mg-1.4* 05:40am blood mg-1.9 05:39am blood albumin-2.4* calcium-7.3* phos-2.8 mg-1.4* 06:03am blood albumin-2.7* calcium-8.8 phos-4.0 mg-1.3* 05:52am blood calcium-8.6 phos-3.8 mg-2.3 05:35am blood vitb12-619 05:39am blood tsh-<0.02* 05:39am blood free t4-1.4 12:45pm blood free t4-2.1* 12:20am blood phenyto-7.3* 05:50am blood phenyto-6.2* 05:42am blood phenyto-5.9* 05:40am blood phenyto-5.4* 05:39am blood phenyto-7.0* 06:03am blood phenyto-7.7* 11:58am blood asa-neg ethanol-neg acetmnp-31.2* bnzodzp-neg barbitr-neg tricycl-pos 12:05pm blood type-art temp-37.0 po2-110* pco2-46* ph-7.36 caltco2-27 base xs-0 12:05pm blood lactate-1.1 12:20pm urine color-yellow appear-hazy sp -1.018 12:20pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirub-neg urobiln-1 ph-5.0 leuks-sm 12:20pm urine rbc-0-2 wbc-* bacteri-many yeast-none epi-0-2 12:25am urine color-yellow appear-clear sp -1.016 12:25am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 10:09am urine color-straw appear-clear sp -1.013 10:09am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg 12:20pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg . stool clostridium difficile toxin assay-final neg stool clostridium difficile toxin assay-final neg urine urine culture-final no growth. blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient 8:41 am sputum site: expectorated gram stain (final ): >25 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions.. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. 8:50 pm rapid respiratory viral screen & culture nasopharyngeal aspirate. rapid respiratory viral antigen test (final ): respiratory viral antigens not detected. culture confirmation pending. specimen screened for: adeno,parainfluenza 1,2,3 influenza a,b and rsv. this kit is not fda approved for direct detection of parainfluenza virus in specimens; interpret parainfluenza results with caution. viral culture (preliminary): no virus isolated so far. 12:20 pm urine site: clean catch urine culture (final ): escherichia coli. >100,000 organisms/ml.. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s blood culture blood culture, routine-final neg blood culture blood culture, routine-final neg . studies: non-contrast head ct: no hemorrhage, hydrocephalus, shift of normally midline structures or major vascular territorial infarct is apparent. the -white matter differentiation is preserved. the visualized paranasal sinuses and mastoid air cells remain normally aerated. the surrounding soft tissue and osseous structures are within normal limits. impression: no hemorrhage. . supine radiograph of the chest: the study is somewhat limited as the patient has rotated to the right side. however, the cardiomediastinal silhouette and hilar contours are normal. no focal consolidation, pleural effusion, or pneumothorax is identified. as on prior, linear atelectasis versus scar noted at the right lower lung. soft tissue and bony markings are normal. impression: no acute intrathoracic pathology including no pneumonia or heart failure. . portable cxr study is limited due to rotation. there is again seen a central venous catheter with tip in the cavoatrial junction from a right ij entry. there is atelectasis at the lung bases. no focal consolidation or pulmonary edema is noted . ecg study date of 12:01:54 pm sinus rhythm. borderline low limb lead voltage. st-t wave abnormalities. compared to the previous tracing of the q-t interval is shorter. otherwise, probably no significant change. tracing #1 intervals axes rate pr qrs qt/qtc p qrs t 80 178 84 400/435 53 54 39 . ecg study date of 9:17:20 am technically difficult study sinus tachycardia extensive st-t changes are nonspecific low qrs voltages in precordial leads since previous tracing of , heart rate faster clinical correlation is suggested intervals axes rate pr qrs qt/qtc p qrs t 110 142 80 298/385 46 28 39 . ecg study date of 12:59:32 pm artifact is present. sinus tachycardia. diffuse non-specific st-t wave changes. low voltages in the precordial leads. compared to the previous tracing there is no significant change. intervals axes rate pr qrs qt/qtc p qrs t 100 158 72 330/400 44 31 10 . chest (portable ap) 9:34 am this study is limited due to marked rotation of the patient. cardiac size is top normal. the aorta is elongated. scar or atelectasis in the bases bilaterally are very mild and unchanged. there are no new lung abnormalities. there is no pneumothorax or pleural effusion. . chest (portable ap) 4:31 pm comparison is made with prior study . ng tube tip is out of view below the diaphragm. there are low lung volumes. bibasilar atelectasis are new. cardiomediastinum is unchanged but note is made that the patient is very rotated. . chest (portable ap) 10:08 am opacification at the left lung base has improved, consistent with clearing atelectasis or even earlier aspiration. linear atelectasis persists at the right base. upper lungs clear. the previous vascular congestion has diminished although mediastinal veins remain dilated. heart size top normal. feeding tube passes to the region of the pylorus or proximal duodenum and, as before i see no weighted tip at the end of the tube which i discussed with the house officer caring for this patient to exclude separation of the tip. . ct brain perfusion 1:21 pm cta head w&w/o c & recons; cta neck w&w/oc & recons non-contrast head ct: there is no evidence of hemorrhage, edema, mass, mass effect, or acute infarction. the calibers and configuration of the ventricles and sulci are normal. no fracture is identified. ct perfusion: the perfusion maps appear normal with no evidence of delayed transit time, reduced blood flow, or reduced blood volume. head and neck cta: the carotid and vertebral arteries and their major branches are patent with no evidence of stenoses. the distal cervical internal carotid arteries measure 5 mm in diameter on the left and 5 mm in diameter on the right. there is no evidence of aneurysm formation or other vascular abnormality. impression: normal study. . eeg study date of object: ee, to . there were three pushbutton activations. routine sampling and spike and seizure detection programs were utilized. the heart was monitored because disorders of heart rhythms produce neurological complaints as described above or neurological disorders such as seizures, when symptomatic, produce cardiac arrhythmias. findings: routine sampling: showed a slow background with most frequencies ranging up to 6.5-7 hz, and there were still frequent bursts of generalized delta slowing. over the course of the recording on the morning of , the background improved, with some 9 hz alpha activity posteriorly when the patient was awake early that morning. no epileptiform features or electrographic seizures were seen in this segment of the recording. sleep: the patient did not appear to have normal sleep progression through the night. cardiac monitor: showed a generally regular rhythm. spike detection programs: showed no clear epileptiform features. seizure detection programs: there were 28 entries in this file. they showed some rhythmic background activity and movement artifact, but there were no electrographic seizures. pushbutton activations: there were three. the first occurred at 21:11 on the evening of . it showed the same moderately encephalopathic background at the beginning. there was no change at the time of the pushbutton activation. video from the time showed no change in behavior. the next event was at 4:13 the next morning. the background was a bit better, but there were some bursts of generalized slowing. there was some movement artifact around the time of the pushbutton activation, but there was no electrographic seizure. by video, the patient appeared to arouse somewhat from sleep and have some head and chest motions as if choking or coughing. the eeg showed movement artifact but no electrographic seizure. the final event was a continuation of the second. impression: this telemetry captured three pushbutton activations for two episodes. they did not show evidence of electrographic seizure. routine sampling and automated detections showed no epileptiform features. it showed a mildly slow encephalopathic background at the beginning, with some improvement over the day. . eeg study date of findings: abnormality #1: the background rhythm was disorganized throughout the record and generally remained with a 6 hz maximum in most areas. there was some superimposed faster activity as well. abnormality #2: there were occasional bursts of generalized delta slowing with a bifrontal emphasis. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: no normal waking or sleeping morphologies were seen. cardiac monitor: showed a generally regular tachycardia with a rate of approximately 110. impression: abnormal portable eeg due to the slow and disorganized background and additional bursts of generalized slowing. these findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. medications, metabolic disturbances, and infection are among the most common causes. there were no clear focal abnormalities or epileptiform features. a tachycardia was noted. . mr head w & w/o contrast 8:25 am brain mri: there is no evidence of mass, midline shift or hydrocephalus seen. mild prominence of sulci is noted. following gadolinium no evidence of abnormal parenchymal, vascular or meningeal enhancement seen. no evidence of acute infarct on diffusion images. impression: no abnormal enhancement or acute infarct identified. mra of the head: the head mra demonstrates an approximately 3-mm aneurysm at the anterior communicating artery. no other aneurysms greater than 3 mm in size are seen. there is no vascular occlusion or stenosis seen. impression: probable 3-mm aneurysm at the anterior communicating artery. the clinical team was notified of this finding. brief hospital course: 55 yo female with hypothyroidisim, mds v. etoh bone marrow toxicity, history of frequent falls and possible seizure disorder who presented with complaint of frequent falls and dizziness and found to have early urosepsis. she was initially admitted to the micu where she was weaned off levophed with iv fluids and was continued on levoquin and ceftriaxone. after being off pressors for 48 hours she was transferred to the floors. on the floors she developed progressive weakness with r arm tremor and l facial droop and worsened mental status, with likely seizure observed with r-sided gaze deviation on . she was given ativan and loaded with dilantin and since then she has had much improved strength and is back to baseline mental status. hospital course by problem: . # frequent falls/weakness/ams- the patient has chronically had frequent falls, and had been evaluated in past and thought her falls were due to peripheral neuropathy from etoh. patient last had a glass of wine 2 days pta. while on the floors she initially had waxing and generalized weakness on exam with intermittent r arm tremor, and intention tremors and possible l facial droop. at that point she was thought to be either encephalopathic from infection, withdrawal and/or electrolyte disturbance (she had low magnesium) or having seizure, but it took some time to obtain an eeg. she was monitored on a ciwa scale but this was discontinued due to low suspicion after a few days. her levoquin was discontinued as it lowers the seizure threshold and as she completed 3 day course for uti. on she had what appeared to be a seizure on with r gaze deviation and brief period of unresponsiveness. she responded to ativan and she was loaded with dilantin. she had a negative head and neck ct/cta w/wout contrast. after being loaded with dilantin her mental status returned to baseline and she regained much of her strength, though she is still well below baseline. mri head/c-spine showed incidental finding of 3mm acom aneurysm, otherwise no focal findings. eeg 24hrs showed no seizures, but some encephalopathic background. however, given her response to dilantin it is felt she has a seizure disorder which likely explains her falls. she has been continued on dilantin. she has been started on keppra ( 1st dose) as this may be a better medication for her as dilantin can worsen her bone marrow toxicity. instructions for rehab: - increase keppra by 250mg every 3 days until reaches goal of 1000mg . once this is reached, her dilantin should be tapered down with the assistance of her neurologist - has outpatient neuro f/u w/ dr / on at 4:30pm, she will arrange outpatient emg if the patient is still profoundly weak at that point - fall precautions, oob to chair - cont thiamine/folate - monitor electrolytes (particularly magnesium) every 2-3 days, replete with iv mag . # neck stiffness/ha: the patient had neck stiffness and ha throughout the hospital course. it appears tension related, and did not improve much with ibuprofen. per neuro recs we added flexeril as well as a soft cervical collar for comfort. her gabapentin can also be increased if necessary. . # urosepsis: the patient's blood pressure improved after 2 hours of levophed and ivfs in the micu. once on floor, she did not need any other inverventions and her bps were 110-120's. urine grew e. coli, pan-sensitive. she was negative for influenza. ceftriaxone was discontinued as pna was not suspected and she completed a 3 day treatment w/levofloxacin for uti (started levofloxacin ). she did spike a fever to 100.6 on evening of , but cxr was negative for pneumonia (was at aspiration risk) and she was not started on antibiotics. this could have been post-ictal fever. blood and urine cultures sent and have been negative so far. she has been afebrile since. one set of blood cultures are pending at this time and should be followed up on by her doctor. . # hyperthyroidism: the patient had tremors and slight proptosis with low tsh and increased free t4. have been contributing to symptomatology. her levothyroxine was decreased. thyroid function should be rechecked in a few weeks and dose adjusted accordingly. . # arf: the patient developed arf on admission which was likely prerenal in the context of early sepsis and poor po intake. cr improved with ivfs. . # elevated tylenol level on admission: the patient reported taking propoxy-n/adat on the day of admission which brought her level outside the range of toxicity, no nac was administered. . # anemia: macrocytic, chronic, baseline 32-34, remained relatively stable. macrocytosis likely due to etoh, recent b12 wnl. continue folate and mvi. . # fen: regular diet. pt has had swallowing difficulties in the past. she had weakness/difficulty swallowing early in hospitalization (failed s+s and triggered after choking on pancakes). she had a ngt placed on . nutrition was consulted and she received tube feeds. tubefeeds were discontinued and her ngt was pulled on as the patient's strength improved and she was able to swallow per speech and swallow eval. the patient was hypoalbuminemic, no proteinuria, likely due to malnutrition. she may benefit from supplements. her magnesium should be followed periodically as above and repleted. . # ppx: hep sc, bowel regimen, ppi (chronic) . # full code . # access: picc placed . pivs . # contact: (hcp and boyfriend): h , c . # dispo: rehab with outpatient neuro f/u . medications on admission: gabapentin 300mg tid propoxy-n/adat 1tbl q4h carisoprodol 350mg tid allopurinol 300mg qdaily lorazepam 1mg tid cyclobenzaprine 10mg tid meloxicam 7.5mg qdaily metoclopramide 10 w meals nitro sl escitalopram 10mg qdaily omeprazole 20mg qdialy atenolol 25mg qdaily levothyroxine 175mcg qdaily zolpidem 10mg qhs fluticasone nasal spray discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) : two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 3. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection tid (3 times a day). 4. thiamine hcl 100 mg tablet : one (1) tablet po daily (daily). 5. albuterol 90 mcg/actuation aerosol : 1-2 puffs inhalation q6h (every 6 hours) as needed. 6. escitalopram 10 mg tablet : one (1) tablet po daily (daily). 7. folic acid 1 mg tablet : one (1) tablet po daily (daily). 8. gabapentin 300 mg capsule : one (1) capsule po tid (3 times a day): can be increased per neuro if necessary. 9. allopurinol 100 mg tablet : three (3) tablet po daily (daily). 10. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 11. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed. 12. phenytoin sodium extended 100 mg capsule : two (2) capsule po qpm (once a day (in the evening)). 13. phenytoin sodium extended 100 mg capsule : one (1) capsule po qam (once a day (in the morning)). 14. phenytoin sodium extended 100 mg capsule : one (1) capsule po qnoon (). 15. levothyroxine 100 mcg tablet : one (1) tablet po daily (daily). 16. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 17. ibuprofen 400 mg tablet : one (1) tablet po q8h (every 8 hours). 18. levetiracetam 250 mg tablet : one (1) tablet po bid (2 times a day): started . pt should take 250mg for 2 more days, then on should take 500mg for 3 days, then on 750mg for 3 days, then on should take 1000mg indefinitely. 19. cyclobenzaprine 10 mg tablet : 0.5 tablet po tid (3 times a day) as needed for neck stiffness. 20. heparin lock flush (porcine) 100 unit/ml syringe : one (1) ml intravenous daily (daily) as needed: flush for picc qd and prn. discharge disposition: extended care facility: & rehab center - discharge diagnosis: 1. seizure with right gaze deviation 2. urinary tract infection 3. generalized weakness 4. muscle spasm (neck) 5. hyperthyroidism 6. acute renal failure 7. macrocytic anemia discharge condition: afebrile, vitals stable, a+ox3, occasionally neck contracted to r (able to be repositioned) discharge instructions: you were admitted to the hospital because of weakness and frequent falls. you were found to have a fever and uti which was treated for 3 days with antibiotics. you were observed to have a seizure with r-sided eye deviation that resolved with ativan and dilantin. your falls and weakness were likely from seizure and you clinically improved and strengthened while on the dilantin. we have also started you on keppra and are tapering this up. please take these medications as prescribed. please go to your follow up appointment with the neurologist. your neurologist will schedule you for an outpatient emg to test your muscle function. . we decreased your dose of levothyroxine. please have your thyroid function labs checked in weeks by your doctor and adjust the dose accordingly. . your magnesium levels have been low. please have them checked every 2-3 days and replete as necessary. please avoid any sedating medications. . if you develop fever, weakness, gaze deviation, shaking, pain, or any other concerning symptoms, please call your doctor or come to the hospital. followup instructions: neurology provider: md , m.d. phone: date/time: 4:30pm. please call if you need to reschedule appointment. . please make a follow up appointment with your pcp , upon discharge from rehab md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified insertion of other (naso-)gastric tube diagnoses: esophageal reflux urinary tract infection, site not specified unspecified essential hypertension acute kidney failure, unspecified unspecified septicemia unspecified protein-calorie malnutrition unspecified acquired hypothyroidism sepsis epilepsy, unspecified, without mention of intractable epilepsy other disorders of plasma protein metabolism alcoholic polyneuropathy encephalopathy, unspecified unspecified deficiency anemia orthostatic hypotension spasm of muscle other dysphagia 

Answer: The patient is high likely exposed to