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: penicillins / cipro cystitis / aspirin / nsaids / dicloxacillin / aldomet / motrin / lisinopril / vioxx attending: chief complaint: hallucinations major surgical or invasive procedure: none history of present illness: cc: hpi: (per patient, who is a poor historian given her altered mental status) pt is a 69 yo f with pmh schizoaffective disorder, dm2, cad, dchf, htn, restrictive lung disease, discoid lupus, and vascular dementia who presented to from her facility for altered mental status and hallucinations of 3 day duration. pt states the hallucinations began around the same time that developed sores in her mouth that made it painful/hard for her to eat. visual hallucinations consist of animals and people. the animals are "sometimes scary." also admits to auditory hallucinations in which she hears voices. she cannot recall the specific things the voices tell her, but says they are sometimes bad and sometimes good. she knows the hallucinations are not real. she denies suicidal or homicidal ideation. she also c/o fatigue and weakness for past three days, and reports insomnia and racing thoughts over that time as well. she c/o pain in her left leg and has a history of falls, but denies recent fall (confirmed by facility). ros per hpi plus: (+) headache "like my head is going to bust open," feeling cold, shortness of breath, cough productive of yellow sputum, rhinorrhea, urinary incontinence (at baseline), abdominal pain, constipation, left shoulder pain, and left knee pain. (-) she denies chest pain, nausea, vomiting, dysuria. in ed vs were t 98.6 f, hr 110, bp 148/100, rr 20, o2 sat 98% on room air. ed course: chest x-ray, and head ct without contrast were obtained. no neurologic symptoms were noted. ua was negative. lactate and cpk were found to be elevated. final ed diagnosis: hallucinations past medical history: #. dm2 - oral meds. #. cad s/p mi ' - does not tolerate aspirin or ace -> on plavix #. diastolic chf, ef > 55% 7/08 #. htn #. restrictive lung disease - not on home o2. fev/fvc 108%, fvc 45%, fev1 48% 6/07. #. h/o r le dvt, many years ago per pt #. discoid lupus erythematosus #. h/o cva - mri in w/ moderate microvascular changes in the cerebral white matter #. h/o of svt #. schizo-affective disorder #. dementia #. gerd c/b short segment and hiatal hernia #. h/o cellulitis #. h/o seizures, per pt many years ago, not on medications #. s/p total abdominal hysterectomy #. small bowel obstruction s/p ex lap w/ lysis of adhesions and partial small bowel resection () #. osa, does not use cpap #. oa #. osteopenia social history: resides in facility where she has meals prepared. she dresses and bathes herself. she is able to see her family members frequently. she smoked 2ppd for 20 yrs, but quit in . denies current alcohol. she uses a walker for ambulation. family history: father: died of mi at less than 50 years of age. mother: history of breast ca. physical exam: admission exam: physical exam: vs: 99.4 f, bp 155/98, hr 106, rr 18, 96% on 2l ga: aox3, nad heent: head normocephalic, atraumatic. moist mucous membranes. eom intact. visual field exam limited by pt's limited attention. cards: rrr s1/s2 heard. no murmurs/gallops/rubs. pulm: crackles heard at lung bases bilaterally, diminished lung sounds. abd: soft, obese, nt, +bs. no g/rt. hsm difficult to assess due to body habitus. neg sign. extremities: no edema. dps, pts 2+. skin: hyperpigmented macule present on forehead, hypopigmented patch of skin on left shin, erythema on left foot, midfoot, medial maleolus, 1st mtp joint. neuro/psych: cns iii-xii intact. visual acuity not assessed. strength in u/l extremities, however, pt. is slow to lift her left arm, and strength testing is also limited by pain in knees. dtrs 2+ bl (biceps, brachioradialis). sensation intact to lt. cerebellar fxn (ftn, hts) and gait not assessed. mse findings: flat affect. tangential thought process and content, with perseveration on the topic of her marriage at the age of 17. poor attention (cannot state days of the week in reverse order; gets only from sat. to wed.) . discharge pe: physical exam: vs: 98.6 130/72 87 22 98 on ra gen: aao x2 (not oriented to date), pleasant and conversational, nad, breating comfortably cvs: rrr, no m/r/g, normal s1, s2 pulm: lungs clear to auscultation b/l abd: soft, obese, nt, nd, +bs ext: slight le edema b/l. no ttp, 2+ dp pulses neuro: aaox2, cn 2-12 grossly intact, ue/le strength pertinent results: 12:21pm blood wbc-12.8* rbc-5.07 hgb-13.3 hct-41.5 mcv-82 mch-26.3* mchc-32.1 rdw-16.7* plt ct-350 12:21pm blood neuts-74.1* lymphs-19.9 monos-3.1 eos-1.8 baso-1.0 12:21pm blood pt-12.8 ptt-26.0 inr(pt)-1.1 07:30am blood esr-52* 07:35am blood aca igg-2.2 aca igm-3.2 07:35am blood lupus-neg 12:21pm blood glucose-373* urean-28* creat-1.3* na-133 k-4.7 cl-95* hco3-25 angap-18 12:21pm blood alt-31 ast-46* alkphos-119* totbili-0.6 04:50pm blood probnp-248 07:30am blood ck-mb-3 ctropnt-<0.01 12:21pm blood calcium-10.2 phos-4.7*# mg-2.0 11:40am blood totprot-7.1 albumin-3.7 globuln-3.4 07:35am blood %hba1c-9.7* eag-232* 09:05am blood vitb12-621 folate-13.9 07:35am blood tsh-2.6 08:00am blood ammonia-18 07:30am blood crp-119.2* 07:30am blood -negative dsdna-negative 07:35am blood b2micro-3.4* 11:40am blood pep-no specifi 12:29pm blood lactate-2.7* 03:28pm blood freeca-1.23 images: cxr: mild interstitial edema and cardiomegaly. ct head: no acute intracranial process. lle doppler:no left lower extremity deep vein thrombosis. calf mri:1. no signs of muscle edema or myonecrosis in the left calf.2. subcutaneous soft tissue edema of the left calf may reflect third spacing of fluid and edematous changes or cellulitis in the proper clinical setting. 3. probable small bone infarcts involving the posterolateral distal tibia and lateral aspect of the talus correlated with left ankle radiographs 4. mild thickening of the achilles tendon at attachment site with associated enthesopathy at the posterior calcaneus. cta chest: no evidence of pe. moderate cardiomegaly with moderate coronary calcifications. small hiatal hernia. no evidence of aortic pathology. mri head non con:1. no evidence of acute infarct, intracranial hemorrhage, or mass lesion. 2. changes of chronic small vessel ischemic disease. 3. generalized cerebral atrophy. 4. focus of old hemorrhage in right frontal lobe which is unchanged. brief hospital course: 69 yo f with pmh schizoaffective disorder, cad, htn, dm, restrictive lung disease, discoid lupus, and h/o cva, who p/w 3d h/o audio and visual hallucinations, leg pain, and sob with altered mental status. active issues: #alered mental status/hallucinations: given pt's history of schizoaffective disorder and vascular dementia, initial presentation was thought to be related to delirium vs. progressive dementia or primary psychiatric condition. initial work-up for infectious and neurologic causes of delirium were unrevealing. urine analysis was unremarkable, chest xray showed no infiltrate, blood cultures showed no growth. a head ct was negative for an acute intracranial process. a head mri was also obtained to further evaluate for neurologic causes,and showed only chronic changes and no new areas of ischemia. an eeg was obtained and was negative for epileptiform activity. over the course of the work up described above, the pt slowly became more withdrawn, which was different from her initial presentation in which she was talkative and quite labile with religious ideosity and frequent outburts of "hallelujah" and "praise ." she began to answer fewer questions, and began to appear somewhat paranoid. psychiatry saw pt and recommended increasing antipsychotic dosage from short acting seroquel 250mg po qhs, to long-acting seroquel 300mg po qhs and adding on haldol 1mg po bid. this was done, and the next morning () the patient seemed withdrawn and stuporous. she was awake but not responsive to questions verbally, answering only with mild head nodding. at this time, she was found to have a urinary tract infection (see below), seroquel and haldol were discontinued and the urinary tract infection was treated and her mental status improved the following day, returning to a level similar to at the time of admission. on , she appeared ill and was again withdrawn. she was febrile and diaphoretic. antibiotic coverage was broadened to vanc/cefepime/flagyl. pt then developed recurrent svt to the 220s, relieved with carotid massage. she appeared rigid and diaphoretic. she was transferred to the icu for further management. in the unit psychiatry was consulted and atypical presentation for neuroleptic malignant syndrome was considered. she was treated with 2mg cogentin and ativan with mild improvement in her mental status. she was transferred back to the general medicine floor, where her mental status continued to wax and wane but never returned to her initial level of interactiveness on admission. she was responsive to some questions, but refusing to answer others. she did not participate in physical exam commands. she remained stable at this point for several days. given the extensive negative work up for delirium, this was considered to be her new baseline and placement was found for skilled nursing facility for discharge with permission from her health care proxy. at time of discharge, the patient remains aao x2 (unchanged from before); she is alert and talkative; still having delusions that her family is outside waiting for her; gets agitated about wanting to leave hospital and often refuses to sit or stay in bed. throughout hospitalization the patient was convinced that her hallucinations and delusions were real. . # urinary tract infection: patient was febrile and urine analysis suggested urinary tract infection. she was treated with ceftriaxone. urine culture revealed grew out presumptive strep bovis and e.coli grow out in her urine. . # supraventricular tachycardia: patient has a remote hx svt, on metoprolol for rate control. on she developed svt to the 220s, which resolved spontaneously. over the course of the following day, she had 4 more episodes of svt which responded to carotid massage, she was never hypotensive. she was transferred to the micu for closer monitoring. cardiology was consulted who identified the rhythm as atrial tachycardia vs. avnrt. the patient has been stable on metoprolol 200 mg . # hypoxia: on admission, patient was hypoxic with 2lnc o2 requirement. there was no evidence of pulmomary edema or consolidation. she was quickly weaned to room air. as part of a work up, an abg was performed which showed po2 of 58, this corrected to 92 with 2lnc. patient was maintained on supplemental oxygen without improvement in mental status. given significant a-a gradient, and persistent tachycardia, cta was performed and showed no evidence of pulmonary embolism. patient has a 20 pack year history and likely has baseline hypoxia with sufficient compensation to maintain peripheral o2 saturation >92%. at time of discharge, the patient no longer has an oxygen requirement, and is satting mid to high 90s on ra. # ankle pain: initial laboratory analysis was remarkable for ck in the 800s and an elevated esr and crp. given her complaints of left leg and ankle pain, orthopedic and rheumatologic causes were considered, as well as pe. plain films of the left ankle and hip were negative for fracture, but did show an area of possible bone infarct in the distal tibia of unclear significance. rheumatology was consulted who did not believe the presentation was consistent with sle, or gout. amyloidosis was also considered however spep and upep, total protein and globulin levels were unremarkable. statin-induced myopathy was considered, and statin was held however ck had already begun to trend down when the statin was stopped, making statin induced myopathy unlikely. a le doppler was negative for dvt. mri of the leg mri was done to evaluate for myositis, skeletal vasculitis or other inflammatory myopathy, and diabetic myonecrosis. it was negative for any muscle inflammation or necrosis, and showed only edema in the subcutaneous tissues, which had been noted on physical exam. within the first few days of her admission, ankle pain and erythemia resolved, etiology remains unclear. . #cog-wheel rigidity/masked facies/resting tremor - on admission to the micu, the patient developed acute presentation of symptoms concerning for extrapyrimidal symptoms related to antipsychotics. patient had received prn doses of haldol, home seroquel 250 mg. however, all antipsychotics had been d/c'd 2 days prior to symptom onset. antipsychotics were held. the patient was given 1 mg cogentin x 2. psych was consulted, who felt that her symptoms were consistent with eps. the patient was started on ativan 1mg q6 hrs prn agitation. upon transfer back to the general medicine floor, her rigidity had improved and she continued to be treated with prn ativan for agitation, though this made pt quite somnolent. on she was restarted on seroquel 50mg po bid prn agitation in an effort to avoid sedation associated with benzos. then as per psych recommendation, the patient was restarted on low dose, 25 mg, seroquel . all other prn doses of seroquel and ativan were held. the patient seems to be responding well to this regimen. . # hypertension - pt had very difficult bp management while in house. she was still measuring in sbp 170s on several occasions despite being on max dose of numerous bp meds, including metoprolol, losartan, furosemide, and clonidine patch. while in house, hydralazine 10mg po tid was added to pt's regimen, and metoprolol was further increased to 200mg po bid for management of svt. on this regimen, her pressures ranged from sbp 140s - 150s, occassionally in the 170s. # hypercholesterol: because of elevated cks (peaked at 819), the patient's simvastatin was discontinued. ck normalized to 92 by time of discharge. she should have her ck rechecked as outpatient and consider restarting simvastatin as outpatient. inactive issues: # cad - chronic. clopidogrel was continued on admission but simvastatin was discontinued shortly after admission secondary to elevated ck levels. # restrictive lung disease: chronic. patient was continued on albuterol, ipratropium, tiotropium. symbicort was replaced with advair during admission due to formulary. pt is likely compensated at a lower po2 secondary to her lung disease. she was repeatedly hypoxic during admission without complaints of shortness of breath. of note, pulse oximetry measured o2 sats in mid-90s on several occasions in which abg drawn at same time showed hypoxia, so pulse ox is not reliable measure of oxygen status in this patient. # dm - held glyburide, gave ssi while in house # h/o candidal rash: miconazole powder transitional issues: # schizoaffective disorder: the patient was admitted on seroquel 250 qhs and because of the possibility of nms, the patient is being discharged on seroquel 50 mg . her lorazepam was held throughout hospital admission. # please check the patient's ck as an outpatient, as she had elevated ck levels as outpatient. medications on admission: - amlodipine 10mg daily - clopidogrel - 75 mg daily - furosemide - 40 mg daily - glyburide - 5 mg daily - ipratropium-albuterol - 2.5-0.5/3ml one vial neb q6h prn - lorazepam - 0.5mg qhs - losartan - 100 mg daily - metoprolol er - 200 mg daily - pantoprazole - 40 mg - quetiapine - 250 mg qhs - simvastatin - 20 mg daily - calcium carbonate - 500 mg (1,250 mg) tid with meals - ergocalciferol (vitamin d2) - 1000 unit daily - ferrous sulfate - 325 mg (65 mg iron) daily - multivitamin - tablet - 1 tablet(s) by mouth daily - senna - 8.6 mg two tabs daily prn constipation - clonidine patch 0.3mg apply every wednesday - saline nasal spray 1 spray each nostril - spiriva 18mcg cap 1 puff daily - symbicort 160/4.5 mcg hfa two puffs - ibuprofen 400mg po tid prn - nystatin 100,000u powder apply to affected area tid prn - proair hfa inh 90mcg 1-2 puffs q4-6h prn - acetaminophen 650mg po tid discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. glyburide 5 mg tablet sig: one (1) tablet po once a day. 4. combivent 18-103 mcg/actuation aerosol sig: one (1) inh inhalation every six (6) hours as needed for shortness of breath or wheezing. 5. losartan 50 mg tablet sig: two (2) tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. 7. multivitamin tablet sig: one (1) tablet po daily (daily). 8. senna 8.6 mg tablet sig: two (2) tablet po daily (daily) as needed for constipation. 9. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qthur (every thursday). 10. saline nasal 0.65 % aerosol, spray sig: one (1) spray nasal twice a day. 11. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 12. symbicort 160-4.5 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation twice a day. 13. ibuprofen 400 mg tablet sig: one (1) tablet po three times a day as needed for pain. 14. nystatin 100,000 unit/g powder sig: one (1) appl topical three times a day as needed: to affected area. 15. proair hfa 90 mcg/actuation hfa aerosol inhaler sig: puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. acetaminophen 650 mg tablet sig: one (1) tablet po three times a day as needed for fever or pain. 17. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 18. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po tid with meals. 19. ergocalciferol (vitamin d2) 400 unit tablet sig: 2.5 tablets po once a day. 20. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 21. metoprolol tartrate 100 mg tablet sig: two (2) tablet po twice a day. 22. hydralazine 10 mg tablet sig: one (1) tablet po tid (3 times a day). 23. outpatient lab work please check ck on and fax results to dr at 24. seroquel 50 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: center - discharge diagnosis: primary diagnosis: altered mental status, nos extra-pyramidal adverse effect, anti-pyschotics hypertension supraventricular tachycardia discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: thank you for letting us take part in your care at . you came to the hospital because you were having hallucinations, altered mental status, and shortness of breath. you were given a diuretic that removed fluid from your lungs and your breathing improved. you had an extensive work up to identify the cause of your altered mental status and no cause could be found. while you were in the hospital, you developed muscular side effects from your anti-psychotic medications. these were stopped temporarily and your symptoms improved. we restarted you at low doses of your anti-psychotic medications now that your symptoms have been improving. your blood pressure and heart rate were elevated during your admission. you were started on two new medications to manage this. the following changes were made to your medications: started: hydralazine 10mg by mouth three times a day changed: metoprolol 200mg by mouth twice a day seroquel 50 mg by mouth twice a day stopped: lorazepam simvastatin thank you for letting us take part in your care at . you came to the hospital because you were having hallucinations, altered mental status, and shortness of breath. you were given a diuretic that removed fluid from your lungs and your breathing improved. you had an extensive work up to identify the cause of your altered mental status and no cause could be found. while you were in the hospital, you developed muscular side effects from your anti-psychotic medications. these were stopped temporarily and your symptoms improved. we restarted you at low doses of your anti-psychotic medications now that your symptoms have been improving. your blood pressure and heart rate were elevated during your admission. you were started on two new medications to manage this. the following changes were made to your medications: started: hydralazine 10mg by mouth three times a day changed: metoprolol 200mg by mouth twice a day seroquel 25 mg by mouth twice a day stopped: lorazepam simvastatin: please discuss with your primary care doctor when you can restart simvastatin thank you for letting us take part in your care at . you came to the hospital because you were having hallucinations, altered mental status, and shortness of breath. you were given a diuretic that removed fluid from your lungs and your breathing improved. you had an extensive work up to identify the cause of your altered mental status and no cause could be found. while you were in the hospital, you developed muscular side effects from your anti-psychotic medications. these were stopped temporarily and your symptoms improved. we restarted you at low doses of your anti-psychotic medications now that your symptoms have been improving. your blood pressure and heart rate were elevated during your admission. you were started on two new medications to manage this. the following changes were made to your medications: started: hydralazine 10mg by mouth three times a day changed: metoprolol tartrate 200mg by mouth twice a day seroquel 50 mg by mouth twice a day stopped: lorazepam simvastatin: please discuss with your primary care doctor when you can restart simvastatin followup instructions: your doctor, dr. , see you at house. below is his contact information. name: , location: address: 545a centre st, , phone: department: center when: tuesday at 10:15 am with: / md building: sc clinical ctr campus: east best parking: garage procedure: central venous catheter placement with guidance diagnoses: pure hypercholesterolemia urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension acute kidney failure, unspecified other specified cardiac dysrhythmias old myocardial infarction retention of urine, unspecified other diseases of lung, not elsewhere classified diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled encephalopathy, unspecified hyperosmolality and/or hypernatremia chronic diastolic heart failure other nonspecific abnormal serum enzyme levels vascular dementia, uncomplicated cerebral atherosclerosis schizoaffective disorder, unspecified edema pain in limb lupus erythematosus other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use schizoaffective disorder, chronic unspecified extrapyramidal disease and abnormal movement disorder 

Answer: The patient is high likely exposed to