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: amoxicillin / haldol attending: chief complaint: depressed loc/seizures major surgical or invasive procedure: hd tunnelled line placement picc line placement central venous line placement intubation lumbar puncture history of present illness: reason for consult: altered ms, evaluate for ncse most of the history was obtained by review of osh records and ed resident communication. no family was at bedside to corroborate details. hpi: the patient is a 45 y/o woman with history of dm, ckd, htn, depression who was transfered from for evaluation of multiple generalized seizures. she was seen earlier in the day after having had a seizure at home. she evidently took her insulin without eating anything. on arrival to the ed the first time, she was noted to be hypoglycemic and was treated with amp d50 with good response. she then chose to leave ama instead of being admitted for observation. at some point later that evening, she was found by family members having generalized seizures. she was brought by ems back to the ed where nchct was done and was negative for acute bleed or mass. subsequent investigation of electrolytes, utox screen, and infectious workup was negative. around 10pm, she again had 2 witnessed generalized convulsions and was loaded with 1000 mg dilantin and given 5 mg valium. clinical seizure activity stopped around that time, and she was transfered here for further workup. on arrival to our ed, she appeared rigid in b/l upper extremities and reportedly had some lipsmacking movements with attempted gag reflex testing. because there was concern for ncse, she was given 2 mg iv ativan, and we were then called to consult. past medical history: dm chronic kidney disease (unknown baseline), now off hemodialysis htn depression social history: unknown family history: unknown physical exam: admissionphysical exam: vitals: t: 37.8 p: 60-72 r: 16 bp: 189-193/94-121 sao2: 100% on 2lnc general/ms: comatose, no spontaneous eye or limb movements. does not arouse with painful stimuli heent: ncat, +lip laceration with dried on r lower lip, dry mucous membranes neck: no nuchal rigidity pulmonary: ctab, no crackles audible anteriorly cardiac: rrr, nl. s1s2, hyperdynamic precordium, but no murmurs/thrills abdomen: soft, obese, ntnd, vertical laparotomy scar, well healed. extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: several acne pustules noted on face, shoulders, some have ruptured. +taught shiny skin on le. wwp. cn: perrl 3mm to 2mm and sluggish b/l; l pupil slightly irregular. does not regard examiner. f oculocephalic reflex intact, but does not blink to threat. face grossly symmetric motor: does not withdraw to nailbed pressure in all exremities. no grimace to pain. -dtrs: tri pat ach l 3 2 3 0 0 r 3 2 3 0 0 plantar response was flexor bilaterally. discharge exam: vs: 128/72 hr 68 rr 18 97% ra heent: slight periorbital right edema cv: rrr, normal s1, s2 pulm: clear lungs bilaterally abdomen: benign neuro: cns ii - xii grossly intact, ambulates without difficulty, although requires supervision pertinent results: initial osh data: osh- chem: na 140, k 4.1, cl 104, co2 21, bun 50, cr 2.1, glu 147 ca8.0 abg: 7.29/53/214/25.5/-1 (on 10l nonrebreather) utox: negative lactate 2.5 cxr: pneumonitis ua: +100 glucose, neg nit, leuk esterase, wbc. radiologic data: non-contrast ct of head: somewhat limited by motion artifact, but no acute hemorrhage or mass effect. 04:00am wbc-9.5 rbc-4.29 hgb-13.5 hct-43.8 mcv-102* mch-31.5 mchc-30.8* rdw-14.4 04:00am neuts-82.5* lymphs-13.2* monos-3.8 eos-0.2 basos-0.4 04:00am plt count-274 04:00am phenytoin-11.3 04:00am albumin-3.0* calcium-7.9* phosphate-5.0* magnesium-2.1 04:00am ck-mb-7 ctropnt-0.07* 04:00am alt(sgpt)-18 ast(sgot)-42* ck(cpk)-595* alk phos-352* tot bili-1.5 09:03am urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 04:00am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 10:59pm cerebrospinal fluid (csf) wbc-3 rbc-208* polys-89 lymphs-3 monos-8 10:59pm cerebrospinal fluid (csf) wbc-12 rbc-560* polys-92 lymphs-2 monos-6 10:59pm cerebrospinal fluid (csf) protein-91* glucose-95 csf: hsv pcr negative ebv negative enterovirus negative mr w/o contrast findings: there are extensive t2/flair confluent hyperintensities involving bilateral white matter in both the supratentorial and infratentorial brain. there are few foci of increased signal on the dwi images, with no definite adc correlate in bilateral frontoparietal lobes at the vertex. there is relative sparing of the matter. ventricles and sulci appear age appropriate. major intracranial flow voids are preserved. visualized orbits and mastoid air cells are unremarkable. mild mucosal thickening is seen in bilateral maxillary sinuses. impression: extensive confluent bilateral diffuse white matter signal abnormalities as described above. imaging appearances are nonspecific and the differentials include but are not limited to pres, toxic metabolic encephalopathy, osmotic demyelination syndrome, hypoxia. final report study: ct of the abdomen and pelvis without contrast. indication: 45-year-old female with history of poorly controlled diabetes, hypertension, renal insufficiency, presented in comatose condition following prolonged seizures from unknown etiology. the patient has history of acute disseminated encephalomyelitis and presents with acute hematocrit drop. evaluate for acute hematoma. comparison: none. technique: mdct images of the abdomen and pelvis were obtained from the level of the lung bases to the proximal femurs without administration of iv or enteric contrast. multiplanar reconstructions were performed and reviewed. dose report: total exam dlp: 809.53 mgy-cm. findings: lung bases: there are plate-like atelectases involving the right lower lobe. patchy atelectasis is also seen in the left lower lobe. small pleural effusions are seen bilaterally. in the abdomen, evaluation of the solid visceral organs and bowel is limited due to lack of iv and enteric contrast. grossly, the liver, spleen, adrenal glands and pancreas appear within normal limits. there is no intra- or extra-hepatic biliary ductal dilatation. focal abnormalities are seen in the kidneys. there is no obvious upper abdominal lymphadenopathy. there is widespread ascites in the abdomen and in the pelvis. there is generalized anasarca. there is no retroperitoneal or pelvic lymphadenopathy. the urinary bladder is collapsed with foley in place. the uterus grossly appears within normal limits. bridging osseous densities between six and seventh, eighth and ninth ribs on the right. there are no acute fractures seen. there are no suspicious osteolytic or osteoblastic lesions. impression: no evidence of intra-abdominal or pelvic hematoma. abdominal and pelvic ascites and widespread anasarca. evaluation of solid visceral organs and bowel is limited due to lack of iv and enteric contrast. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 5:34 pm final report history: diabetic renal failure, to assess for fluid overload. findings: in comparison with the study of , the endotracheal tube has been removed. little overall change in the appearance of the heart and lungs. the study and the report were reviewed by the staff radiologist. dr. dr. approved: mon 9:12 am brief hospital course: 45yow h/o htn, dm, ckd, depression p/w status epilepticus in the setting of hypoglycemia and no prior history of seizures. # seizures - the patient initially presented with recurrent generalized convulsions as well as subsequent lipsmacking concerning the possibility of nonconvulsive status epilepticus. the patient was thought to be initially hypoglycemic at home after taking insulin without eating. she was monitored on ltm cveeg for four days without evidence of epileptiform discharges or further seizures. her eeg showed an encephalopathic pattern. she was initially given a fosphenytoin load and continued on fosphenytoin for seizure prevention. she began transition to keppra due to sedative effect of dilantin on with plan to double keppra on and stop dilantin at that timepoint. # stupor/coma from cerebral leukoencephalopathy - her mri (noncontrast) revealed extensive/diffuse subcortical white matter flair hyperintensities suggesting a demyelinating process, toxic-metabolic encephalopathy, or extrapontine myelinolysis. her na at the osh was normal between two admissions, making epm from rapid hyponatremia correction unlikely. methylprednisolone (1 gram daily) was started to reduce the cerebral edema, and her level of consciousness gradually improved however patient's family reported as of that patient was still not entirely at baseline. as of recent at home she would get out of bed and dress herself but often not leave her home, would be depressed and could not feed herself. prednisone was tapered. # acute kidney injury superimposed on chronic kidney disease - prior to admission, the patient had intermittently required hemodialysis but most recently was told that dialysis probably would not be necessary. aggressive diuresis with furosemide was initially attempted but was not successful in maintaining her renal clearance. renal was consulted and patient received dialysis on . a tunnelled hd line was placed and later removed in the setting of improved gfr and increased urine output. patient may have to initiate dialysis in the future as an outpatient and should follow-up with renal. # diabetes - her sugars were labile on methylprednisolone, was consulted to offer assistance in glycemic management. an insulin sliding scale and long acting were initiated. # anemia: hct noted to drop several days into her admission, down to 22 from a normal hct of 43.8 on admission. it is a macrocytic predominance. b12 and folate wnl. ct scan without evidence of rp bleed. iron studies wnl. thought due to ckd per renal, now on epogen. she was guiaic negative on . fluctuating around 22-24 now. # htn: pt was hypertensive which has required hd while in house. have been exacerbated by the high dose steroids she has been receiving. better control obtained on amplodipine, hydralazine, labetolol, lasix, and metolazone, the hydralazine and labetolol having high holding parameters with holding for sbps <110-120. - anticipate having to down titrate bp meds as steroids are tapered. plan to switch to carvedilol, clonidine as better outpatient options. # alk phos elevation: thought due to secondary hyperparathyroidism due to ckd. # volume overload: likely in the setting of her renal failure. pt with preserved ef on echo, but likely a component of diastolic dysfunction contributing. she also has severe tr and phtn. currently is satting well on ra. she was continued on lasix 100mg and metolazone 5mg po daily. pending studies: transitional care issues: communication: , will need to arrange family meeting given discussion of needed outpatient dialysis shelda - patient remained full code this admission - plan to double dose of keppra on saturday, and stop dilantin at that time - continue steroid taper - follow up with nephrology on as noted above medications on admission: metoprolol xl 50 mg furosemide 40 mg hydralizine 100mg daily nephrocap 1 daily ursodiol 300 mg lantus (unknown dose) phos-d 1334 mg tid possibly celexa and/or lyrica discharge medications: 1. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 2. senna 8.6 mg tablet sig: one (1) tablet po daily (daily) as needed for constipation. 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 4. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 5. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain or t > 99. 6. polyvinyl alcohol-povidon(pf) 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for eye dryness. 7. metolazone 2.5 mg tablet sig: two (2) tablet po daily (daily): please give 30 minutes prior to a.m. furosemide dose. 8. furosemide 40 mg tablet sig: 2.5 tablets po bid (2 times a day). 9. labetalol 200 mg tablet sig: three (3) tablet po tid (3 times a day). 10. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). 11. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 12. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 13. epoetin alfa 2,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 14. prednisone 10 mg tablet sig: three (3) tablet po daily () for 2 days. 15. prednisone 20 mg tablet sig: one (1) tablet po daily () for 3 days: please start after prednisone 30 mg daily finishes. 16. prednisone 10 mg tablet sig: one (1) tablet po daily () for 3 days: please start after prednisone 20 mg finishes. 17. phenytoin 125 mg/5 ml suspension sig: four (4) cc po q8h (every 8 hours) for 5 days. 18. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day) for 5 days. 19. keppra 1,000 mg tablet sig: one (1) tablet po twice a day: start . 20. sertraline 50 mg tablet sig: two (2) tablet po daily (daily). 21. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (mo) for 8 weeks. 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) 1 ml iv prn line flush temporary central access-floor: flush with 10 ml normal saline followed by heparin as above daily and prn. 24. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 25. insulin glargine 100 unit/ml cartridge sig: twelve (12) units subcutaneous at bedtime: in addition to humalog sliding scale, please see attached. discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: secondary diagnosis: discharge condition: mental status: clear and coherent, withdrawn. level of consciousness: withdrawn but arousable. discharge instructions: you were admitted to because of seizures. while you were here, you were initially in the neurology intensive care unit and your seizures were treated with medications. your seizures were thought to be due to acute diseeminated encephalomalacia, a disease which should improve over the coming weeks and which was treated with steroids. you were transfered from the neurology to the medicine service due to kidney problems, high pressure and high sugars. these issues improved with the appropriate medications. while you were here some of your medications were changed. stop metoprolol increase furosemide to 100mg twice a day start metolazone 5mg daily before first dose of furosemide increase hyralazine to 100mg three times a day start labetolol 600mg three times a day start amlodipine daily start tylenol as needed for pain start docusate for constipation start epoetin alfa unit sc qmonwedfri for anemia start heparin injections while you are not mobile start keppra for seizures start dilantin for seizures start prednisone for seizures start miconazole powder for rash nephrocap 1 daily ursodiol 300 mg change insulin to attached sliding scale change celexa to zoloft followup instructions: name: , b. location: health center of cha address: 300 , , phone: please discuss with the staff at the facility a follow up appointment with your pcp when you are ready for discharge. we are working on a follow up appointment for your hospitalization in neurology with dr. . you need to be seen within 1 month of discharge. the office will contact you at the facility with the appointment information. if you have not heard within 2 business days or have any questions please call the office at . department: west clinic when: thursday at 9:30 am with: , md building: de building ( complex) campus: west best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis arterial catheterization central venous catheter placement with guidance diagnoses: chronic kidney disease, stage v acute kidney failure, unspecified depressive disorder, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease long-term (current) use of insulin cerebral edema grand mal status hyperparathyroidism, unspecified diseases of tricuspid valve diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled unspecified causes of encephalitis, myelitis, and encephalomyelitis demyelinating disease of central nervous system, unspecified 

Answer: The patient is high likely exposed to