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 / demerol / heparin agents attending: chief complaint: sharp neck pain with "electric" radiation into arms, right arm weakness major surgical or invasive procedure: none history of present illness: 71 yo female with a history of breast cancer, osteoarthritis and osteoporosis who presents with 2 weeks of neck and arm pain. she says that the pain began suddently two and a half weeks prior to admission. the pain was , located in her cervical spine and had an electric quality. several days later, the pain began to spread to both arms (right worse than left) and she occasionally felt a burning sensation in her arms. she went to her pmd and had and an x-ray, ct and mri (w/o t1, t2 enhancement) of her cervical spine demonstrating degenerative changes at c5-6 with mild narrowing of the left neural foramen. 1 week prior to presentation she noted decreased strength in her right arm. she says that it is too weak to lift. according to the patient, her limited strength is due to actual weakness rather than pain. her pain has continued and seems to be worse in the early morning and night-time. overall, her symptoms seem to be increasing. she has tried multiple pain medications including vioxx, neurontin, valium and roxicet without significant relief. she went to see a neurologist, dr on . he performed an mri (t1, t2, stir) of the brachial plexus demonstrating "right apical soft tissue extending into the chest wall and adjacent to the brachial plexus at several locations with indistinctness of the right brachial plexus approximately 5 cm from the midline" thought to be secondary to radiation fibrosis. her symptoms were attriubted to c5 radiculopathy secondary to brachial neuritis. an emg/ncv study on demonstrated "a moderately severe, subacute, right cervical radiculopathy or polyradiculopathy, most clearly involving the c5 root." she was directly admitted to the neurology service for lp and further work up. ros: she notes removing a tick (uncertain size) from her right shoulder without subsequent rash several weeks prior to her symptom onset for which she "prophylactically" took 1 dose of 2 different antibiotics (name unknown). she denies having fever/vision changes/hearing changes/facial droop. she does report having chills when her pain is severe. she has generalized arthralgias and myalgias which are chronic. she has noted an occasional, mild headache with her symptoms. no photophobia/phonophobia. she denies cough, of breath, chest pain, or nausea/vomiting. she complains of constipation from the pain medication and was recently seen in the er for severe constipation and manual disimpaction. she denies dysuria or urinary retention/incontinence/weight loss. past medical history: 1. breast cancer - first diagnosed 25yrs ago (right breast) treated with lumpectomy and radiation therapy. she had a recurrence (bilaterally) 15 yrs ago which was treated with right mastectomy and left lumpectomy with adjuvant radiation. 2. osteoarthritis with cervical sponylosis at c5-c6. 3. osteoporosis 4. raynaud's phenomenon 6. mitral valve prolapse 7. second degree, type i av block noted on ett stress test in . of hearts monitor also demonstrated ~15 seconds of wenkebach a-v block. beta-blocker was discontinued but patient is still considering a repeat of hearts study off beta-blockers. followed by dr. . 8. chronic, inactive mac infection with hx of bronchiectasis followed by dr. 9. fibromyalgia social history: the patient lives in and spends a significant amount of time on . she works as a clinical psychologist (doctorate in psychology) in . no alcohol or drug use. she smoked irregularly for 10yrs (stopped many yrs ago). divorced, lives with partner . family history: mother died at 98 of "old age" father died at 77 of pancreatic cancer. brother at 75 with asthma and prostate cancer. two daughters in good health. physical exam: per neuro eval: physical exam vitals:t 97.1 bp120/80 hr60 rr18 general: very thin female lying in bed no acute distress heent: normocephalic, atraumatic. no conjunctival injection or pallor. no sinus tenderness. no pharyngeal erythema or exudate. neck: supple, mildly tender. no lymphadenopathy. decreased rom lungs: clear to auscultation bilaterally cv: regular rate and rhythm, no murmur abdomen: normal bowel sounds present, soft, non tender ext: no edema, clubbing or cyanosis neurologic examination: mental status: awake and alert, cooperative with exam, normal affect oriented to person, place, and date. attention: able to recite months backwards language: fluent speech, no dysarthria, repetition intact, follows commands. registers , recalls at 3 minutes. no apraxia, no neglect cranial nerves: visual fields full. pupils equally round and reactive to light, 3 to 2 mm bilaterally. extraocular movements intact, no nystagmus. facial sensation intact. face is symmetric. tongue is midline, no fasciculations. palate elevation is symmetric. sternocleidomastoid and trapezius strength normal. motor: muscle tone was normal generalized muscle atrophy, especially of intrinsic hand muscles no fasciculations, tremorl /is tri wfl wext fifl fiext ip gl q h af ae tf te right 3-/3 5 5 5 5 5- 5- 5- 5 5 5 5 5 5 5 left 5 5 5 5 5- 5- 5 5 5 5 5 5 5 5 lumbricals , 5th digit abduction sensation were intact to light touch, slightly decreased pinprick and vibration sensation in bilateral le to ankles. proprioception is intact reflexes: tri br pat ach plantar right 2 2 2 2 (brisk) 2 flexor left 2 2 2 2 (brisk) 2 flexor coordination: normal finger-nose-finger, and heel to shin. gait: narrow based, tentative. negative romberg pertinent results: 04:09pm cerebrospinal fluid (csf) protein-76* glucose-54 04:09pm cerebrospinal fluid (csf) csf-pep-oligoclona 04:09pm cerebrospinal fluid (csf) wbc-58 rbc-3* polys-0 lymphs-93 monos-4 other-3 04:09pm cerebrospinal fluid (csf) wbc-36 rbc-0 polys-0 lymphs-97 monos-1 atyps-2 12:17pm blood lyme by western blot: postive igg and igm 11:30am blood heparin dependent antibodies: positive 05:25am blood wbc-6.8 rbc-3.76* hgb-11.9* hct-34.7* mcv-93 mch-31.7 mchc-34.3 rdw-12.8 plt ct-337 05:25am blood neuts-75.6* lymphs-18.2 monos-5.0 eos-0.9 baso-0.3 05:25am blood pt-12.4 ptt-32.4 inr(pt)-1.0 05:25am blood albumin-3.6 calcium-9.0 phos-3.7 mg-2.0 brief hospital course: the patient was initially admitted to the neuromed service, transferred to the micu, then to the surgery service, back to the micu and then to the apg medicine floor team. 1. lyme meningitis- based on the patient's radiculopathy, headache and lp in the ed with 58 wbc (93% lymphs), 3 rbc, mildly elevated protein at 76 and glucose 54. repeat serum serology demonstrated positive lyme igg and igm serology (confirmed by western blot) in the blood (after just the igm positive results 2 days prior). infectious disease consult service was consulted and recommended a 21 day course of ceftriaxone 2 gm qd, begun on . her symptoms improved somewhat, but she continued to experience aches and pains associated with the meningitis. the neurology service suggested that her symptoms might not resolve for weeks, even after treatment. cessation of iv ceftriaxone is . 2. hypotension and bradycardia- after 1 day in the hospital the patient developed multiple parasympathetic-mediated symptoms (diarrhea, nausea, diaphoresis) and was noted to be bradycardic and hypotensive (without response to fluids). she was ruled out for mi. the hypotension was thought to be due to heightened vagal tone vs. lyme sepsis vs volume depletion. cardiology was consulted to consider heart block as a causative for her hypotension given that an ekg demonstrated 3:2 secondary degree type i a-v block; they doubted that heart block was the causative . a tte on demonstrated hyperdynamic, ef 75-80%, 1+ mr, 1+ ar, without pericardial effusion. she was admitted to the micu and placed on a dopamine drip, with resulting normotension. stim test showed mild adrenal insufficiency with random cortisol level of 14. she was placed on stress dose steroids and weaned off of dopamine after 24 hours with return to normal sinus rhythm. blood cultures to date are negative. stool cultures were positive for c. diff. she was treated with iv ceftriaxone, po vancomycin, iv flagyl, and aggressive ivf. she was intermittently on the surgery service after developing abd pain with question of acute cholecystitis, but u/s of gallbladder demonstrated only distension, without wall thickening, stones, or bile duct dilatation. ct abd had evidence of toxic megacolon and gallbladder distension but no other cause for abd pain. during micu stay, patient was placed on tpn in setting of c. diff colitis and abdominal pain. 3. infectious disease issues: we are treating c. diff with metronidazole, and will continue this treatment 3 days past the cessation of the ceftriaxone (last dose on ). blood cultures negative to date. see above. 4. pain: throughout the hospitalization, pain continues and still is a primary issue. multiple pain regimens have been tried. given lyme disease, the nature of the patient's pain changes unpredictably. she was initially on gabapentin 800 mg tida and iv dilaudid. the gabapentin had to be titrated up due to continued nighttime pain. pain service was consulted on two separate occations. the final regimen, based on their recommendations was to increase gabapentin to 1200 mg tid, add oxycodone 10 mg with dilaudid po 4-6 mg every 4-6 hours. a muscle relaxant, flexeril (5 mg tid) was added to patient's pain regimen two days prior to discharge. a benzodiazepine was tried, but was stopped due to excessive sedation in setting of pain regimen. at , it will be necessary to get pain service involved early as her pain will continue for weeks to months according to the neurology team. 5. pulmonary issues: she initially had a 4l o2 requirement in setting of pleural effusions s/p volume resusitation in the micu. with diuresis, she was eventually able to ventilate/oxygenate well without supplemental o2. she was diuresed with iv lasix and effectively diuresed off more than 10 l (over a one week period). her chronic bronchiectasis was not thought to be an issue during this admission. 6. hit positive- her admission plt level was 370 but dropped to a nadir of 129 on . heparin products were discontinued and she was tested by for heparin antibodies (pf4) which returned positive. hematology was consulted. despite the lack of true thrombocytopenia (level was never below 129) she was diagnosed with type ii hit given ab + (which carries a ~50% risk of thrombosis at 30-days) and started on an argatroban drip. after developing transaminitis and given advantage of qd dosing without the need for monitoring levels, she was switched to fondapirinux 2.5 sc qd. this was overlapped with coumadin with a plan to discontinue fondapinanux after therapeutic inr of 2.0-3 was achieved. at , she will need to have the fondaparinux stopped after therapeutic levels (inr 2.0-2.5) are achieved on coumadin. after diagnosis, she had le pain and lenis were (-) for dvt. she will follow-up with dr. in hematology. 6. nutrition: given inability to sustain adequate po in the setting of c. diff colitis, she was started on tpn. patient will need to continue tpn until she has an adequate daily po caloric intake. 7. access: patient currently has a double lumen picc line placed for continued tpn administration. given concern for arm swelling, she had an upper extremity u/s on which was negative for dvt. 8. code: full medications on admission: accupril 5mg po qd neurontin 900mg tid tramadol 50mg po q4-6h prn valium 2.5-5mg po qd discharge medications: 1. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 6 days: until . disp:*30 tablet(s)* refills:*0* 2. gabapentin 400 mg capsule sig: three (3) capsule po q8h (every 8 hours). disp:*qs 1 month* refills:*2* 3. fondaparinux sodium 2.5 mg/0.5 ml syringe sig: one (1) injection subcutaneous qd () as needed for hit: this medication will be discontinued once your inr is at 2.0. disp:*qs 1 week* refills:*0* 4. sucralfate 1 g tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 5. oxycodone hcl 10 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po q12h (every 12 hours). disp:*60 tablet sustained release 12hr(s)* refills:*2* 6. ceftriaxone sodium in d5w 40 mg/ml piggyback sig: two (2) grams intravenous q24h (every 24 hours) for 4 days: last dose on . disp:*qs 4 days* refills:*0* 7. dilaudid 2 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for pain: please do not take if you are feeling sedated. disp:*120 tablet(s)* refills:*0* 8. flexeril 5 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 9. coumadin 5 mg tablet sig: one (1) tablet po once a day: titrate to inr 2.0-2.5. discharge disposition: extended care facility: & rehab center - discharge diagnosis: lyme meningitis c5 radiculopathy clostridium difficile colitis heparin induced thrombocytopenia s/p breast cancer type ii wenkebach a-v block discharge condition: stable discharge instructions: please notify nurses or doctors of breath, weakness, sensory changes, chest pain, headache, fatigue, pain or any other symptoms of concern. please let us know if you have any questions regarding your fondapirinux and coumadin dosing. followup instructions: 1) please call your new primary medical doctor, dr. (), within 2 weeks of leaving the hospital to arrange an appointment. you have three specialty appointments in the future, please take note of them: 2)provider: where: clinical center radiology phone: date/time: 10:00 3) provider: , m.d. where: cardiac services phone: date/time: 10:30 4) provider: , md where: hematology/oncology phone: date/time: 10:00 5) please call dr. (hematology) regarding your heparin-induced thrombocytopenia. procedure: venous catheterization, not elsewhere classified spinal tap incision of lung parenteral infusion of concentrated nutritional substances diagnostic ultrasound of heart arterial catheterization diagnoses: mitral valve disorders unspecified pleural effusion unspecified septicemia severe sepsis septic shock intestinal infection due to clostridium difficile mobitz (type) ii atrioventricular block lyme disease meningitis in other bacterial diseases classified elsewhere 

Answer: The patient is high likely exposed to