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: cc: increasing lethargy, malaise and chest secretions major surgical or invasive procedure: replacement of g-tube on after it fell out. history of present illness: 25 year old female with h/o cell anemia, 2 strokes, wheelchair bound, recently had aspiration pneunomia which was treated with ceftriaxone and unasyn. patient was sent to rehab after a brief hospitalization and then from rehab to home. patient had increased secretions from 5 days pta. from the morning of , patient had increased lethargy and had fevers to 102. seen at hospital where there was concern for stroke; she was noted also to have guaic positive drainage from j-tube site. ct raised the concern of possible stroke with new bleed in the r external capsule. inr measured there was 3.9, as patient had been on coumadin since stroke in . patient was transferred here because of concern for intracranial hemorrhage. there is also a history of a bloody stool; it is unclear when that bloody stool happened. mother reports dark discharge from the j-tube. er course: patient had leukocytosis to 51.7 with 81% neutrophils, 1% bands. repeat head ct shows r basal ganglia calcification, however bleed could not be excluded; size has not increased from ct at osh taken 8 hours earlier; multiple old bilateral hemispheric infarcts and likely pontine infarct. micu admission for: initial concern for new intracranial hemorrhage. past medical history: pmh: s/p cva x 2; 1st at age 7 years which left her mildly mentally retarted, 2nd in gave her l foot and r arm plegia, wheelchair bound, aphasic, s/p peg, s/p j-tube, chronic leukocytosis, urinary tract infections, seizure disorder, chronic aspiration pneumonia, vertigo. social history: lives at home; mother is primary caregiver) . does not smoke, drink alcohol or use illicit drugs. patient has a 5 year old child. she receives vna services. patient at baseline is unable to take care of herself; dependent on assistance for adls. family history: son has trait vs disease, as does a cousin. physical exam: examination: t:102, hr:110, bp: 112/69, r:13, 93% on ra. gen: young aaf, eyes open, responsive through gestures, lying in bed looking fatigued. heent: perrl, eomi, anicteric neck: supple, nt. skin: wwp; no rashes. chest: crackles at both bases; patient unable to respond to request to cough. cvs: tachycardia, normal s1/s2. abd: j-tube and g-tube in place; purulent, greenish drainage surrounding j-tube. ext: tender l foot; no obvious swelling or sign of trauma; no warmth. neuro: mental status as described above. cnii-xii: appears to be grossly intact. motor: r arm 0/5, l arm ; able to grasp with l hand. dtrs: , elbow 2+/2 bilat. sensory: hard to examine. pertinent results: cxr : low lung volumes, no radiographic evidence of pneumonia. ct head w/o contrast : 1) amorphous area of increased attenuation in the right basal ganglia/subinsular white matter/periventricular white matter near the atrium of the right lateral ventricle. this has the appearance of calcification, but blood products cannot be excluded. the area has not increased in size since the head ct scan from eight hours earlier. 2) multiple bilateral hemispheric infarcts and likely pontine infarct as well. 3) decreased size of brain, with expansion of maxillary sinuses and inner table, consistent with the patient's chronic mental retardation. mr head w/o contrast : 1) no evidence of acute infarction, although diffusion-weighted imagining would be more sensitive for acute infarction. 2) evidence of multiple past infarcts, including evidence of past hemorrhage in the right putamen and in a small region of the right parietal lobe. ct head w/o contrast : 1) stable appearance of the brain with no interval change noted since the previous exam. multiple old hemispheric infarcts noted. diffusion-weighted images are more sensitive to detect acute infarct. 2) a small area of increased attenuation in the right basal ganglia is suggestive of amorphous calcificatinos rather than blood by-products. a followup scan might be helpful based on clinical findings. cxr : interval development of bibasilar patchy opacities, which may represent aspiration. mra brain w/o contrast : 1) no significant interval change in the brain mr. on this study, however, diffusion weighted images were performed, and these showed no evidence of acute infarction. there is evidence of a chronic resolved slit hemorrhage in the right putamen, likely related to previous ischemic infarction. there are widespread areas of chronic infarction in the subcortical white matter. 2) the mra shows absent flow signals in multiple major arteries of the circle of with evidence of extensive formation of collaterals. this appearance is consistent with moyamoya syndrome related to chronic occlusions among the major cerebral arteries. cxr : 1) since the previous study there has been some improvement in the degree of right lower lobe partial atelectasis. 2) areas of patchy infiltration in the right upper lobe and left upper lobe and left lower lobe are unchanged. 3) the tip of the svp line remains in the right atrium. ct head w/o contrast : 1) no new intracranial hemorrhage. appearance of brain unchanged since . ct abd/pelvis w contrast : 1) bilateral lower lobe patchy consolidations consistent with patient's known chronic aspiration. 2) no evidence of acute intraabdominal abnormality. multiple small mesenteric lymph nodes are present which do not meet ct criteria for pathological enlargement. spleen small and dense, likely reflecting calcification. video oropharyngeal swallow study : penetration and aspiration with nectar thick and thin liquids secondary to poor bolus control and premature spillover. aspiration was silent, and cued coughs were inefective for clearing the airway of barium. she showed evidence of phonatory apraxia in her delayed and discoordinated cued coughs. pureed and honey think liquids (by tsp) were not penetrated or aspirated during this study today. 1) maintain peg for primary source of nutrition, hydration, meds. 2) pureed foods and honey thick liquids by teaspoon for pleasure may be allowed. 08:50pm pt-19.3* ptt-44.8* inr(pt)-2.5 08:50pm plt count-453* 08:50pm hypochrom-2+ anisocyt-2+ poikilocy-3+ macrocyt-1+ microcyt-1+ polychrom-2+ spherocyt-occasional -2+ stippled-2+ pappenhei-2+ 08:50pm neuts-81* bands-1 lymphs-9* monos-9 eos-0 basos-0 atyps-0 metas-0 myelos-0 nuc rbcs-1* 08:50pm wbc-51.7* rbc-2.84* hgb-9.1* hct-26.1* mcv-92 mch-31.9 mchc-34.7 rdw-21.7* 08:50pm calcium-9.3 phosphate-4.4 magnesium-2.1 08:50pm glucose-114* urea n-15 creat-0.4 sodium-144 potassium-4.8 chloride-106 total co2-26 anion gap-17 10:45pm urine rbc->50 wbc- bacteria-occ yeast-none epi-0-2 10:45pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-sm urobilngn-8* ph-7.0 leuk-sm 10:45pm urine color-amber appear-hazy sp -1.014 04:15am wbc-34.9* rbc-2.59* hgb-8.0* hct-24.2* mcv-93 mch-30.8 mchc-33.0 rdw-21.2* 06:30am haptoglob-<20* 01:33pm hct-23.1* 06:30am tsh-1.2 brief hospital course: micu course: while in the micu, the patient was seen by neurology and neurosurgery to further evaluate the possibility of a new intracranial hemorrhage. in light of this, coumadin was discontinued, pending the results of the workup. the patient had multiple head cts, described in pertinent results section. the conclusion from the scans was that ms. did not have any new cva, ischemic or hemorrhagic. of note, the findings raised a suggestion of moyamoya disease. also while in the micu, the patient was found to have one blood culture bottle positive for enterococcus that was ampicillin sensitive. the change in mental status and elevated wbc count and temperature on admission were thought to be secondary to chronic aspiration, as a cxr on revealed bilateral opacities consistent with aspiration pneumonia. also while in the micu the patient was seen by gastroenterology to investigate the guaiac positive drainage noted from the j-tube site while the patient was at hospital, and the report of one episode of bloody stool, as per the mother. they did not feel that the patient was having a gi bleed, as the patient's hematocrit remained stable, and there was noted to be no melanotic drainage from j-tube since arrival in our hospital, nor hematochezia. stool was found to be negative for salmonella, shigella, campylobacter, c.difficile. we followed with serial hematocrits, which have been stable between 19 and 22 (unclear baseline), with no further melena/hematochezia noted. the patient was transferred from the micu to the general floors on . while on the floors, we addressed the patient's numerous problems, with the common difficulty being uncertainty regarding the rational for medical decisions made for her in the past. 1) infectious disease: we continued to treat the patient for her presumed aspiration pneumonia with ceftriaxone and flagyl. a tte was performed to rule out endocarditis in light of the enterococcus cultured from her blood, which was negative. at this time, on , flagyl was discontinued and a two week course of iv ampicillin for treatment of the positive enterococcal blood culture was begun. at the time of this discharge summary (), the patient is on day of ampicillin, and has completed a 10 day course of ceftriaxone. 2) neuro: an extensive effort was made at obtaining ct scan reports from the patient's stroke, which the mother says was managed at (medical college of ), phone number (, however they claim that the patient was not there in . after a review of all ct/mri reports from our hospital, and a thorough investigation of the issue, we have decided to stop this patient's coumadin treatment. the rationale behind this is many-fold. first, we have to assume that the coumadin was initially begun due to concern for strokes that were embolic in nature. however, patients with cell disease are known to develop ischemic strokes, and coumadin has no demonstrated efficacy in these patients (see review in the american journal of medicine, ). additionally, there is still some uncertaintly as to whether or not the patient has had a hemorrhagic stroke in the past, as the mri of revealed evidence of past hemorrhage, in which case coumadin would most definitely be contraindicated. additionally, the finding of changes characteristic of moyamoya syndrome on mri also preclude the use of coumadin, as these patients are prone to ischemic strokes as children, followed by hemorrhagic strokes as adults due to the fragility of the collateral vessles that develop in response to the stenotic vessels of the circle of . for all of these reasons, we believe that holding coumadin is the most rational approach to the management of this patient's unfortunate neurologic status. the patient also has a history of seizures, and was maintained on oxcarbazepine 300 mg po bid without any seizure activity. 3) heme: the patient continued to have a chronically low hematocrit, which fluctuated between 19 and 22 without receiving any transfusions. we obtained iron studies, which demonstrated iron overload, which was expected in this patient who has been transfusion dependent, as per mother, and was on deferoxamine therapy 12 ml iv before admission to our hospital. we restarted her deferoxamin at 1g im per day, however the patient should be switched to iv so that she doesn't have to get painful im shots everyday in the future. her reticulocyte count was 10.4, which indicates appropriate marrow response to her severe anemia. a b12 level was within normal limits. we started the patient on folic acid 3 mg per day, which should be continued in this patient with chronic hemolysis from cell disease. additionally, her peripheral smear persistently demonstrates not only sickled cells but also target cells, which is not typical of ssd, therefore a hemoglobin electrophoresis was ordered, and the patient was seen by hematology. she will follow up with dr. with whom she has an appointment on (). should be on iron chelators chronically however it would be safe for her not to be on chelators for a few weeks while at rehab. this would only be acceptable for 2-3 weeks at most. ms. also appears to have a chronic leukocytosis, usually in the 20,000 range. she is currently at her baseline after being as high as 50,000 on admission. 4) gi: the patient has had a g and a j tube for unknown duration, with multiple adjustments and replacements. there was noted to be scant purulent drainage around both tubes, which surgery evaluated. as per the mother, there is always some drainage around the tubes, however it was noted to have increased. surgery felt that the drainage was simply the tube feeds, as the areas were not noted to be erythematous, indurated, or tender. a would culture from revealed sparse growth of mrsa, which was presumed to be colonization rather than infection in this chronically ill and hospitalized patient, without obvious signs of infection around the tube site. the question of the rationale behind the coexistance of a g-tube and a j-tube was discussed. we do not have any records, however it was assumed that the g-tube may have been placed in order to decompress the stomach and prevent aspiration if gastroparesis was present. the patient was also on reglan, assumedly for the same rationale. the g-tube has not been used while in our hospital, as the j-tube is used for the tube feeds, therefore it is unclear whether or not the patient really needs this additional tube. we are keeping it capped for now, not on continuous suction, and flushing it periodically to maintain patency. this tube should be kept in and flushed periodically for now, but if there continues to be no use for the tube, dr. (her new pcp) will consider having the tube removed. additionally, the patient has not received reglan for the 3 days prior to discharge, without any problems, therefore we will leave this medication on a prn basis, and it may be safe to completely discontinue if there continues to be no need. there continued to be no evidence of gi bleed for the remainder of the hospital course. gi recommended that if there is ever again any suspicion, the patient can at that time have an egd. 5) fen - the patient had a video swallow study in light of the suspicion of chronic aspiration, which is detailed in the pertinent results section. the outcome of this was that the patient may try pureed and honey thick foods for pleasure, still maintaining tube feeds as her primary source of nutrition - probalance full strength at 55 ml/hour. the patient aspirated with non-thickened fluids. for now, the patient has been taking pureed and honey-thick foods, however if the patient continues to develop aspiration pneumonias, these may have to be discontinued. the patient's aspiration, however, is most likely gastric contents rather than food. 6) chronic pain: the patient has a history of chronic pain and came in on a fentanyl patch, which was continued while in house. in the future it would be useful to clarify the necessity of maintaining this. in light of the chronic opiate use and immobility, ms. was given a bowel regimen while here, which should be continued. 7) psych: ms. was on lexapro 20 mg po qd on admission, and was maintained on this. however, the mother reports that the patient has continued to have depressed mood and lack of motivation, with behavior indicating hopelessness since her stroke in , and therefore psychiatry was consulted regarding the appropriate medication choice. in patients with multiple medical problems and a clear organic basis for depression, ritalin can be helpful, and this should be considered in the future. 8) lines: ms. has had a portacath for 4 years, as per admission note. for now this should be left in as she is on iv abx and with chronic aspiration is likely to need iv abx in the future, in addition to multiple other iv medications. also see discussion of g and j tubes above. 9) prophylaxis: ms. was given lansoprazole oral suspension 30 mg ng qd while here, which does not need to be continued as there is no clear indication (no high dose steroids, respirator, sepsis, etc.) for a ppi. however, if the g-tube were ever to resume function this might be a good addition, as it could help prevent the development of alkalosis (would be removing a less acidic fluid from the stomach). she was started on prophylactic lovenox 40 mg sq per day on the day of discharge, as she is largely immobile with multiple medical problems. 10) pt/ot - was seen by pt and ot on , who both felt that the patient could benefit from continued therapy. pt felt the patient has good potential to improve her functioning, and felt she would benefit from a rehab facility to include hours of combined therapy per day. ot also felt that has good potential for progress given cognitive status, willingness to work with therapy, and arom of all 4 extremities, and recommended d/c to acute rehab facility with goal of eventually returning home with family once functional status is maximized. medications on admission: coumadin 10 mg po once daily, deferoxamine, escitalopram 20 mg qpm, miralax, colace 100, reglan 10 mg q6, xanax 0.125 mg prn, morphine 20 mg q6, baclofen, fentanyl patch 150 q72h, trileptal 300 mg q6h, percocet. discharge medications: 1. oxcarbazepine 300 mg tablet sig: one (1) tablet po bid (2 times a day). 2. fentanyl 75 mcg/hr patch 72hr sig: one (1) patch 72hr transdermal q72h (every 72 hours). 3. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 4. escitalopram oxalate 10 mg tablet sig: two (2) tablet po qd (once a day). 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po qd (once a day) as needed. 7. lorazepam 0.5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 8. folic acid 1 mg tablet sig: three (3) tablet po qd (once a day). 9. deferoxamine mesylate 500 mg recon soln sig: two (2) recon soln injection q24h (every 24 hours). 10. metoclopramide hcl 10 mg tablet sig: one (1) tablet po qid (4 times a day) as needed. 11. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) subcutaneous q24h (every 24 hours). 12. ampicillin sodium 2 g recon soln sig: one (1) recon soln injection q6h (every 6 hours). discharge disposition: extended care facility: hospital - discharge diagnosis: cell disease, previously transfusion dependent cerebrovascular accident x 2 with residual aphasia, mild mental retardation, plegia l>r. chronic pain syndrome chronic aspiration aspiration pneumonia absence seizure disorder recurrent uti chronic leukocytosis discharge condition: stable, at baseline. discharge instructions: please continue medications as directed. please keep g-tube capped for now, with tid flushes to maintain patency (will consider removal at a later date). continue iv ampicillin for 9 more days (pt. on day 5 out of 14 on ). acute pt/ot. can wean off o2, keeping sats above 90-93% (currently on nc 1l). followup instructions: provider: , md where: hematology/oncology phone: date/time: 11:00 -call to confirm appointment primary care provider: , md. call for appointment (. procedure: enteral infusion of concentrated nutritional substances diagnoses: other convulsions pneumonitis due to inhalation of food or vomitus bacteremia long-term (current) use of anticoagulants late effects of cerebrovascular disease, hemiplegia affecting unspecified side infection and inflammatory reaction due to other vascular device, implant, and graft gastrostomy status status of other artificial opening of gastrointestinal tract sickle-cell disease, unspecified 

Answer: The patient is high likely exposed to