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: gatifloxacin / penicillins / ciprofloxacin attending: chief complaint: ams major surgical or invasive procedure: mechanical ventilation history of present illness: 60f insulin-dependent diabetes mellitus complicated by ophthalmopathy, polyneuropathy, and nephropathy, hypertension hyperlipidemia, peripheral arterial disease p/w ams. . family called ems because she was not acting like herself; returned from work, slurring speech and ramming wheelchair into wall. they deny overdose, no obvious symptoms, save for open sores on feet. no sick contacts. presented via ems yelling/mumbling, tachy to 103, dry skin, flushed. unable to follow commands. thrashing about in bed. per family report was dry heaving today and not acting like herself, otherwise no changes in medical history or meds they believe. . ed course : - initial vitals/trigger: 99 79 179/67 20 99% - has rx for nortriptyline, urine tox + for tca - physostigmine 2 mg dose for concern of tca overdose. equivocal whether any effect on mental status. - 5 mg haldol, 6 mg ativan to control behaviour serial ekg: - ekg: sr@83 qrs 98 qtc 452 no terminal r - ekg: sr@83 qrs 100 qtc 444, ? terminal r avr now - ekg: sr@73 qrs 96 no terminal r - cxr (my read) - ? atelectasis on left, vascular prominence bilaterally - head ct - normal - torso ct - incidental findings and atelectasis - foley placed - fluids (unknown amount) - io in left tibia - suc, etomidate via tibia - 7.5 et tube - ua pending - propofol swicthed to fentanyl and versed - ij central line - lp - attempted x3 - carboxy hgb - 1 - abg - ph 7.28 pco2 50 po2 231 hco3 24 basexs -3 - abx vanc 1g, cefepime 2g - patient pcn allergic admission vitals: 188/72, p88 bp 188/72, rr 24, sat 100 with fio2 50, vt450 past medical history: 1. dm2: insulin-dependent may be type 1 -followed by clinic -c/b recurrent ulcers, urosepsis -charcot deformity 2. s/p amputation of l 2nd & 3rd toe 3. chronic ulcer of r pretibia 4. hx of mrsa foot 5. htn 6. pvd 7. hypercholesterolemia 8. anemia, ? acd, baseline low 30s 9. hematemesis in thought to be small , egd ulcer in ge junction social history: the patient lives with her husband and has a 10 year old child. she works at the causeway va as a secretary. she smokes 10 cigs per day x 40 years. no etoh and drugs. family history: mother had dm2, died of diabetes related coma father has dm2, still alive several family members on paternal side with dm2 no fh of cad, mi, or cancer. physical exam: admission exam: 188/72, p88 bp 188/72, rr 24, sat 100 with fio2 50, vt450 general: intubated, sedated heent: sclera anicteric, mmm, oropharynx clear, ett in place. neck: obese,jvp inestimatable, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused; diffuse ulcerations on lower extremities discharge exam: 97.7 156/82 72 18 98%ra general - alert, interactive, well-appearing, nad heent - perrl, eomi, mmm heart - distant heart sounds, rrr, nl s1-s2, no mrg lungs - ctab, no r/rh/wh, fair air movement, resp unlabored, no accessory muscle use abdomen - nabs, morbidly obese, soft/nt/nd, no masses or hsm extremities - wwp, charcot deformities of feet, several ulcers, discolorations in digits of feet lymph - no cervical lad neuro - awake, a&ox3, cns ii-xii grossly intact pertinent results: admission labs: 09:15pm blood wbc-9.0 rbc-4.47 hgb-13.9 hct-40.8 mcv-91 mch-31.2 mchc-34.2 rdw-13.0 plt ct-208 04:30am blood pt-11.3 ptt-25.4 inr(pt)-1.0 09:15pm blood glucose-349* urean-24* creat-1.3* na-134 k-5.5* cl-97 hco3-22 angap-21* 09:15pm blood alt-16 ast-34 alkphos-119* totbili-0.6 04:25pm blood ck-mb-4 ctropnt-0.04* 03:15am blood ck-mb-4 ctropnt-0.03* 03:47pm blood ck-mb-3 ctropnt-0.03* 09:15pm blood albumin-4.2 calcium-9.8 phos-3.2 mg-1.6 04:30am blood free t4-1.3 04:30am blood tsh-2.3 04:30am blood vitb12-323 09:15pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-pos 12:07am blood type-art rates-20/ tidal v-450 peep-5 fio2-100 po2-231* pco2-50* ph-7.28* caltco2-24 base xs--3 aado2-436 req o2-75 -assist/con intubat-intubated 09:25pm blood lactate-2.1* 08:00pm blood freeca-1.12 pertinent interval labs: 04:11am blood wbc-8.1 rbc-3.70* hgb-11.3* hct-34.6* mcv-94 mch-30.5 mchc-32.6 rdw-13.3 plt ct-163 07:50am blood wbc-6.7 rbc-3.86* hgb-11.8* hct-34.8* mcv-90 mch-30.6 mchc-33.9 rdw-13.8 plt ct-191 04:56pm blood glucose-124* urean-31* creat-2.0* na-139 k-3.6 cl-104 hco3-25 angap-14 04:11am blood glucose-286* urean-53* creat-2.4* na-141 k-4.7 cl-105 hco3-24 angap-17 09:00am blood glucose-234* urean-42* creat-1.5* na-139 k-4.3 cl-103 hco3-24 angap-16 07:50am blood glucose-105* urean-34* creat-1.3* na-144 k-4.2 cl-108 hco3-26 angap-14 04:25pm blood ck-mb-4 ctropnt-0.04* 03:15am blood ck-mb-4 ctropnt-0.03* 03:47pm blood ck-mb-3 ctropnt-0.03* methylmalonic acid 767 h 87-318 nmol/l beta-hydroxybutyrate h 0.4 mmol/l <0.4 urine: 03:12am urine color-straw appear-hazy sp -1.020 03:12am urine blood-mod nitrite-neg protein-100 glucose-1000 ketone-10 bilirub-neg urobiln-neg ph-6.0 leuks-lg 03:12am urine rbc-12* wbc-95* bacteri-few yeast-occ epi-2 11:41pm urine color-yellow appear-hazy sp -1.013 11:41pm urine blood-sm nitrite-neg protein-100 glucose-300 ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 11:41pm urine rbc-3* wbc-5 bacteri-few yeast-none epi-2 csf: herpes simplex virus pcr specimen source csf result negative not applicable 04:43pm cerebrospinal fluid (csf) wbc-9 rbc-0 polys-63 lymphs-21 monos-14 macroph-2 04:43pm cerebrospinal fluid (csf) totprot-88* glucose-128 micro: blood cultures (, ): no growth urine (, ): no growth rpr: non-reactive csf: gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. fungal culture (preliminary): no fungus isolated. viral culture (preliminary): no virus isolated. sputum: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): no growth. ct head (): there is no hemorrhage, mass, mass effect, or acute large territorial infarction. the ventricles and sulci are normal in size and configuration. there is no shift of the usually midline structures. suprasellar and basal cisterns are widely patent. areas of periventricular and deep white matter hyperattenuation are suggestive of chronic small vessel ischemic changes. a punctate hypodensity within the posterior limb of the right internal capsule suggests prior lacunar infarct. there is no scalp hematoma or acute skull fracture. there is mild mucosal thickening within the right sphenoid and left maxillary sinuses. the remainder of the visualized paranasal sinuses and mastoid air cells are well aerated. . ct c/a/p (): 1. bibasilar atelectasis. no confluent consolidation to suggest pneumonia. no pleural effusion. 2. malpositioned endotracheal tube terminating in the right main stem bronchus. findings were reported to dr. at 11:48 p.m. on who stated that she was aware, given recent chest x-ray. 3. extreme laxity of the anterior abdominal wall. 4. normal appendix. 5. multiple thyroid nodules. dedicated thyroid ultrasound is recommended for further characterization, if it has not been completed previously. 6. bilateral indeterminate adrenal nodules. further characterization with adrenal protocol (contrast washout) ct can be completed if clinically indicated. 7. fibroid uterus . eeg (): abnormality #1: the background is slow and disorganized with 5-6 hz theta activity posteriorly. abnormality #2: there are frequent bursts of 2 hz generalized delta slowing. hyperventilation: could not be performed. intermittent photic stimulation: could not be performed. sleep: no sleep morphology was recorded. cardiac monitor: showed a generally regular rhythm. impression: abnormal eeg due to the slow and disorganized background rhythm and bursts of generalized slowing indicative of a widespread encephalopathy affecting cortical and subcortical structures. possible causes include infectious, metabolic or toxic etiologies. there were no areas of prominent focal slowing although widespread encephalopathies can obscure focal findings. there were no epileptiform features. . mri brain (): 1. old lacunar infarcts and small vessel ischemic disease without without evidence of acute ischemic infarct, intracranial hemorrhage, or mass. 2. bilateral opacification of the mastoid air cells as well as sphenoid sinus disease. . mri c/t/l spine (): 1. no evidence of epidural abscess intracanal mass on this non-enhanced scan. 2. multilevel, relatively mild degenerative changes of the spinal axis as detailed above, most notably with bilateral pars defects and anterolisthesis of l5 on s1. cxr (): tip of the endotracheal tube is just below the upper margin of the clavicles, no less than 3 cm from the carina. moderate bilateral pleural effusions, left greater than right and moderately severe pulmonary edema have all worsened. cardiomegaly is severe, probably not appreciably changed. no pneumothorax. right jugular line passes at least as far as the low svc and possibly into the upper right atrium. no mediastinal widening or other evidence of complications. ekg (): sinus rhythm. premature atrial complexes. delayed r wave progression is likely a normal variant. left atrial abnormality. low voltage in the precordial leads. compared to the previous tracing of no significant difference. brief hospital course: =============== brief patient summary =============== 60 f with iddm here with ams requiring admission to the micu for mechanical ventilation for airway protection. the patient was weaned off the ventilator and transferred to the medical 2-3 days prior to discharge. =============== active issues =============== # ams: likely due to toxic/metabolic encephalopathy in the setting of cap. was originally thought that uti may have contributed, but no growth in urine. positive serum tca tox screen was initially concerning for tca toxicity, but her toxidrome was not consistent with this given the absence of qrs widening and prominent anticholinergic findings. however, + serum tca screen is usually representative of a toxic dose, and as such, a component of tca toxicity cannot be ruled out. eeg was performed and showed only generalized slowing consistent with encephalopathy but no epileptiform activity. there was some concern for meningitis, and the pt was started on vanc/ceftrixone/acyclovir while in the icu. lp was performed and showed: wbc 7 rbc 1 pmn 52% lymp 23% mono 24% macro 1%. hsv pcr was negative. given her mild pleocytosis and hyperactive patellar reflexes bilaterally, neurology was concerned for an epidural abscess or other spinal infectious process. for this, mri brain and spine was performed, which showed no cause for her symptoms (see report). tsh, ft4, b12 and rpr were all normal. abg showed: 7.28/50/231 on 100% fio2, intubated. hypercarbia was felt to not be contributing to her ams given improvement with intubation and slow recovery of her mental status. she was extubated on without event. at the time call out from the micu, mma and beta-hydroxybutyrate were pending. mma returned elevated, but unlikely to be related to b12 metabolism as b12 well w/in normal limits. beta-hydroxybutyrate borderline. for her uti/cap, she was treated with ceftriaxone and levothyroxine initially, and transitioned to cefpodoxime on floor. the patient was sent home with a total 7 d course of abx for cap, through . she was at baseline mental status and eager to return home. . # troponinemia: pt with very mild tropinemia in micu, likely related to demand in the setting of ckd. there was no e/o acs throughout her course and upon being extubated denied cp/sob/n/v, lightheadedness or palpitations. . # : likely cin c/b atn in the setting of a large contrast load for ct c/a/p with contrast. she has baseline ckd, which is likely related to her dm and htn. renal was consulted and recommended holding acei and continuing supportive care. her urine ouput initially decreased, likely related to atn, and the pt subsequently autodiuresed with improvement in her cr. cr peaked at 2.4 in micu, and recovered to 1.3 x2 measurements on day of discharge (near b/l). the patient was initiated back on hctz and lisinopril on day of discharge and was sent with prescription for outpatient lab work check chem 7 (esp cr considering restarting hctz and lisinopril) on , to be faxed to dr. at . # charcot foot deformities: pt w/ charcot foot deformities and chronic skin changes. podiatry evaluated pt both in micu and on the a day prior to discharge, and they thought extremely low likelihood there is an active infection. pt w/ significant neuropathic pain, and pt restarted on nortryptilene at home dose, and advised pt not to take more than directed on prescription. pt had podiatry f/u arranged. ====================== chronic issues: ====================== # htn: htn controlled w/ labetalol in micu and floor until hctz and lisinopril started on day of discharge (secondary to ) . # dm: pt was maintained on lantus and a humalog insulin sliding scale . # hld: pt was continued on statin ====================== transitional issues: ====================== 1. radiology incidental findings: -multiple thyroid nodules. dedicated thyroid ultrasound is recommended for further characterization, if it has not been completed previously. -bilateral indeterminate adrenal nodules. further characterization with adrenal protocol (contrast washout) ct can be completed if clinically indicated. 2. f/u w/ pcp 3. f/u w/ podiatry medications on admission: hydrochlorothiazide - 25 mg tablet - 1 tablet(s) by mouth once a day insulin detemir - 70 units at bedtime insulin lispro - lisinopril - 20 mg tablet - 1tablet(s) by mouth once a day nortriptyline - 75 mg capsule qd pantoprazole - 40 mg tablet qd rosuvastatin - 20 mg tablet qd discharge medications: 1. insulin detemir 100 unit/ml solution sig: seventy (70) units subcutaneous at bedtime: take insulin regimen as you had prior to hospitalization. 2. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous before each meal: dose per sliding scale. 3. lisinopril 20 mg tablet sig: one (1) tablet po once a day. 4. nortriptyline 25 mg capsule sig: three (3) capsule po hs (at bedtime). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day: take thirty minutes prior to meal. 6. rosuvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*60 tablet, chewable(s)* refills:*0* 8. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. disp:*qs * refills:*0* 9. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. 10. outpatient lab work check chem 7 (esp cr considering restarting hctz and lisinopril) on and fax to dr. at 11. cefpodoxime 200 mg tablet sig: one (1) tablet po twice a day for 2 days: take through . disp:*4 tablet(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnoses: acute delirium secondary to toxic/metabolic encephalopathy pneumonia secondary diagnoses: insulin dependent dmii w/ renal complications acute-on-chronic kidney disease htn hld charcot foot abnormalities discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure taking care of you. you were admitted to the for altered mental status. it was thought that this was secondary to you having a potential infection in your lungs or urine. you have been treated with antibiotics for this. you also had some renal (kidney) dysfunction while you were in the hospital, which has recovered. you have an appointment coming up with dr. , who may decide to replace the felted foam offloaded dressings at that time. you should continue to take all of your medications as you previously had prior to your hospitalization, except: - start cefpodoxime 200mg twice per day through - continue insulin as you previously had been taking, call your doctor if you have persistent readings > 250, one > 400 or low readings < 80. - start aspirin 81 mg once per day - start miconazole nitrate 2 % powder to affected areas followup instructions: name: , : internal medicine/cardiology location: healthcare - address: , , phone: **we are working on a follow up appointment with dr. within 1 week. you will be called at home with the appointment. if you have not heard from the office within 2 days or have any questions, please call the number above.** department: podiatry when: tuesday at 4:20 pm with: , dpm building: ba ( 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 central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified acidosis nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere esophageal reflux tobacco use disorder acute kidney failure with lesion of tubular necrosis toxic encephalopathy unspecified essential hypertension diabetes with neurological manifestations, type ii or unspecified type, not stated as uncontrolled polyneuropathy in diabetes other and unspecified hyperlipidemia long-term (current) use of insulin morbid obesity diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled diabetes with ophthalmic manifestations, type ii or unspecified type, not stated as uncontrolled ventral, unspecified, hernia without mention of obstruction or gangrene arthropathy associated with neurological disorders body mass index 50.0-59.9, adult physical restraints status 

Answer: The patient is high likely exposed to