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 attending: chief complaint: hyperglycemia major surgical or invasive procedure: none history of present illness: ms. is a 57 yof with a history of type i diabetes, complicated by polyneuropathy and gastroparesis, as well as a history of cva, disease, and untreated hep c from blood transfusion who has had multiple admissions for dka (last admitted to for dka, previously in , and two other times before that this year) who presented to the ed with hyperglycemia. her vna came to her house today and noted the bg >600 so she gave her 19 units of humalog at 11:30 am. she reports that her bg usually run in the 300s when she checks them. however yesterday and today (since her discharge) her sugars were elevated to over 500. she states she has been taking her glargine 24 units at bedtime. in the past her dka had been precipitated by utis, but currently she denies any infectious symptoms. she states that she did not start "feeling bad" until today and this was due to her urinating a lot and feeling fatigued. she otherwise denies dysuria, cp, sob, rhinorrea, sinus pain, ha, cough, nausea, , diarrhea, or rash. of note, the patient's recent hospitalization was complicaetd by an episode of unresponsiveness. a full work up was negative other than the presence of benzodiazepines on tox screen when the pt was reportedly not prescribed any. her room was serached and no medications were found. it was recommended after her hospitalization that she discontinue her diazepam and percocet. she was also evaluated by psychiatry who thought she should establish care as an outpatient and undergo neuropsychological testing. sw was also called to investigate options for placement. her only medication change was a decrease in losartan for her outonomic neuropathy causing hypotension. in the ed, initial vitals were: 98.9 110 113/58 14 100%. the patient was well appearing. labs were notable for na 125, bicarb 10, and anion gap 29, glucose 665. she had >1000 glucose and 40 ketones on ua, but neg le, nitrites, or bld. wbc was 11.4, hct 29.5. lactate was 3.6 and ph 7.38. cxr: no focal infiltrate, no effusion, no acute intrathoracic process. she was given 3 l ivf in ed, given 10 units regular insulin, and started on an insulin gtt at 7u/hr. repeat fs was in the 400s. she was then given ns with 40 meq k. access: 22g l hand, 20g piv. on the floor, pt appeared comfortable. ros as per hpi, + for diffuse abd pain, that she says is there chronically and is from her gastroparesis. otherwise, denies fever, chills, headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, , diarrhea, constipation, or changes in bowel habits. denies dysuria, frequency, or urgency. denies rashes or skin changes. past medical history: ---type i dm: diagnosed at age 5, multiple hospitalizations for dka and hyperglycemia. complicated by retinopathy, severe peripheral neuropathy, and gastroparesis with marked constipation. -- dka has been complicated by cva, 3 episodes suspected (including episode) --diabetic polyneuropathy --hypertension --grave's disease, on mmi --reactive airway disease --seronegative arthritis, followed in rheumatology --hepatitis c, genotype 1a, biopsy with grade 1 inflammation, not on antiviral therapy; acquired from a blood transfusion in . had previous liver biopsy without significant fibrosis. never been treated with antivirals. --gerd --status post bilateral knee arthroscopies --migraine headaches -asthma -s/p tah -depression -mouth surgery for removal of tumors --bilateral foot drop requiring wheelchair use social history: patient lives in an apt building. she has a son, daughter and another brother who live on another floor. she is a never smoker and does not use alcohol or drugs. she has not worked for many years. she uses a wheelchair at baseline. family history: mother died of colon cancer. there are multiple family members with dm. physical exam: admission physical exam: vitals: t: 100 bp: 143/60 p: 103 r: 11 o2: 99% general: somnolent, closes eyes and drifts off to sleep during conversation, oriented, no acute distress : sclera anicteric, hyperpigmentation around right eye, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally cv: regular rate and rhythm, no murmurs abdomen: + bs, soft, mildly tender to palpation, non-distended, no rebound tenderness or guarding gu: foley ext: warm, well perfused, 2+ pulses, no edema. neuro: cn 2-12 intact, 4/5 strength in all extremities, but poor effort with rest of neuro exam discharge physical exam: vitals: 98.3, 150/94, 94, 20, 97% ra general: awake, alert, nad : sclera anicteric, hyperpigmentation around right eye, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally cv: regular rate and rhythm, no murmurs abdomen: + bs, soft, moderately tender on left, non-distended, no rebound tenderness or guarding gu: foley ext: warm, well perfused, 2+ pulses, no edema. neuro: cn 2-12 intact, 4/5 strength in all extremities pertinent results: # admission labs: 01:50pm blood wbc-11.4*# rbc-3.11* hgb-9.8* hct-29.5* mcv-95 mch-31.4 mchc-33.2 rdw-15.2 plt ct-485* 01:50pm blood neuts-86.3* lymphs-11.4* monos-1.9* eos-0.2 baso-0.2 01:50pm blood pt-11.9 ptt-24.8 inr(pt)-1.0 01:50pm blood glucose-665* urean-35* creat-1.8* na-125* k-4.4 cl-86* hco3-10* angap-33* 01:50pm blood alt-48* ast-28 alkphos-87 totbili-0.3 01:50pm blood lipase-38 01:50pm blood albumin-3.5 calcium-9.1 phos-4.5# mg-2.0 02:05pm blood type-art temp-37.1 rates-/16 fio2-20 po2-133* pco2-19* ph-7.38 caltco2-12* base xs--10 intubat-not intuba vent-spontaneou comment-green top 02:05pm blood glucose-greater th lactate-3.6* na-126* k-4.3 cl-93* # cbc: 01:50pm blood wbc-11.4*# rbc-3.11* hgb-9.8* hct-29.5* mcv-95 mch-31.4 mchc-33.2 rdw-15.2 plt ct-485* 07:36am blood wbc-14.9* rbc-3.17* hgb-9.7* hct-29.4* mcv-93 mch-30.7 mchc-33.1 rdw-15.7* plt ct-526* 12:48pm blood wbc-14.8* rbc-3.22* hgb-10.0* hct-29.6* mcv-92 mch-31.0 mchc-33.8 rdw-15.6* plt ct-555* 01:51am blood wbc-10.4 rbc-3.05* hgb-9.3* hct-28.3* mcv-93 mch-30.6 mchc-33.0 rdw-15.9* plt ct-474* 06:05am blood wbc-7.7 rbc-2.70* hgb-8.3* hct-25.2* mcv-93 mch-30.7 mchc-32.9 rdw-16.2* plt ct-384 05:55am blood wbc-5.9 rbc-2.76* hgb-8.7* hct-25.5* mcv-93 mch-31.7 mchc-34.3 rdw-16.5* plt ct-315 06:31am blood wbc-5.7 rbc-2.82* hgb-8.9* hct-26.9* mcv-96 mch-31.6 mchc-33.0 rdw-16.8* plt ct-334 01:50pm blood neuts-86.3* lymphs-11.4* monos-1.9* eos-0.2 baso-0.2 # coags: 01:50pm blood pt-11.9 ptt-24.8 inr(pt)-1.0 01:50pm blood plt ct-485* 07:36am blood plt ct-526* 12:48pm blood plt ct-555* 01:51am blood plt ct-474* 06:05am blood plt ct-384 05:55am blood plt ct-315 06:31am blood plt ct-334 # lytes: 01:50pm blood glucose-665* urean-35* creat-1.8* na-125* k-4.4 cl-86* hco3-10* angap-33* 03:55am blood glucose-112* urean-22* creat-1.2* na-135 k-4.2 cl-104 hco3-23 angap-12 12:48pm blood glucose-105* urean-15 creat-1.0 na-134 k-4.4 cl-102 hco3-20* angap-16 11:50pm blood glucose-123* urean-11 creat-0.9 na-134 k-4.1 cl-103 hco3-20* angap-15 03:30pm blood glucose-268* urean-10 creat-1.0 na-133 k-4.0 cl-101 hco3-25 angap-11 06:05am blood glucose-29* urean-10 creat-0.9 na-136 k-3.5 cl-104 hco3-29 angap-7* 05:55am blood glucose-75 urean-11 creat-0.9 na-139 k-4.1 cl-104 hco3-30 angap-9 06:31am blood glucose-279* urean-16 creat-0.9 na-132* k-4.5 cl-96 hco3-30 angap-11 # lfts: 01:50pm blood alt-48* ast-28 alkphos-87 totbili-0.3 # lipase: 01:50pm blood lipase-38 # alb, ca, mg, phos: 01:50pm blood albumin-3.5 calcium-9.1 phos-4.5# mg-2.0 03:55am blood calcium-8.3* phos-2.1*# mg-1.7 12:48pm blood calcium-8.3* phos-2.3* mg-1.7 01:51am blood calcium-8.2* phos-2.3* mg-1.7 06:05am blood calcium-8.7 phos-2.7 mg-1.7 05:55am blood calcium-8.7 phos-3.8 mg-1.7 06:31am blood calcium-9.4 phos-4.0 mg-1.7 # tox screen: 12:48pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 10:38pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg # blood gases: 02:05pm blood type-art temp-37.1 rates-/16 fio2-20 po2-133* pco2-19* ph-7.38 caltco2-12* base xs--10 intubat-not intuba vent-spontaneou comment-green top 08:46pm blood type-art po2-154* pco2-37 ph-7.40 caltco2-24 base xs-0 11:46pm blood type-art ph-7.35 04:18am blood type-central ve ph-7.39 # u/a 02:00pm urine blood-neg nitrite-neg protein-neg glucose-1000 ketone-40 bilirub-neg urobiln-neg ph-5.0 leuks-neg # blood cultures: bcx: pending # urine culture: ucx: negative # mrsa: mrsa screen: negative # ekg: sinus tachycardia. compared to the previous tracing of there is no change. # cxr: impression: no acute intrathoracic process. brief hospital course: assessment: ms. is a 57 yof with dmi with multiple admissions for dka who presented in dka. active diagnoses: # diabetic keto acidosis: bg > 600 with anion gap 29 and ketonuria. pt was given 4 l ns in the ed (the 4th with k+) and started on insulin gtt. upon arrival to the floor, she was continued on the insulin gtt and on repeat fs her bg was 100. insulin gtt was stopped and she was given amp d50. she recieved 25 units of lantus. however, patient was not able to take po nausea, so insulin and d10 were continued and she was given reglan and zofran for nausea. her gap remained closed. was consulted who felt it was ok to stop the gtts and check fs q4 hours. she was placed on 20 of lantus , and iss when she started to eat. she remained stable taking po and was transferred to the general medical floor. on the floor she had two episodes of hypoglycemia, one to the 30's and one to the 40's. these were treated with glucose and resolved. recs her evening dose of lantus was stopped completely and she had no further episodes of hypoglycemia. she was sent on 20 units of lantus in the am with humalog ssi. given her multiple admissions for dka and her poor glycemic control it is questionable that the patient has been compliant with her insulin, which may have been the cause for this current presentation. pt discharged from hospital 2 days prior to admission with bg reportedly 180-280 the day of discharge. she has many admission for dka and is followed closely by . she has no other obvious signs of infection on history to precipitate dka and ua and cxr do not support uti or pna. we had a long meeting with the pt, her daughter, nursing, social work, case management to discuss her multiple admissions for dka. the patient explained that her social situation has been so stressful lately that she "may miss" insulin doses because she is so distracted with other aspects of her life. she is wheel chair bound and her biggest request is to get a letter (which was written and given to the daughter) saying that she needs a wheel chair accessible apartment. we stressed to her that close follow up with vna and her endocrinologist were integral to controlling her diabetes and not bouncing back to the hospital in dka. she explained that she does not want to burden her family but will accept daily vna if this will help her to control her diabetes. a plan was set in place to have daily home vna and close endocrine follow up to make sure that she does not bounce back to the hospital. # abdominal pain: left sided abdominal pain. pt reports this pain is baseline. been worked up extensively per past notes in omr without clear etiology. no periotneal signs on exam. possibly just due to dka. pain treated with home oxycodone. # hypoglycemia: exact etiology unknown. pt was on less insulin than she is supposedly on at home. pt had bg in the 30's on . in the 40's on . insulin scale adjusted recs. docs believe the best way to titrate her insulin dose would be as an outpatient where she is home and eating what she would normally eat. pt has an appointment with . # somnolence: pt was drowsy and fell asleep easily early during admission. she remained oriented when aroused. on previous admission concern for benzodiazepine use causing somnolence. she is also on many anticholinergic medications which could be contributing. her urine tox screen was negative. her sedative medications were held during this admission but she was sent on them at discharge. # arf: likely from volume depletion in the setting of dka. she was given ivf with resolution of her . cr 0.9 on discharge. chronic issues: # diabetic polyneuropathy and gastroparesis. pt continued on reglan, amitriptyline. # hypertension. pt hypertensive througout most of admission. losartan initially held in the setting of . restarted later. she was not aggressively diuresed given dehydration on admission. will leave definitive management up to the pcp. # grave's disease; s/p rai . pt continued on methimazole througout admission. # reactive airway disease, allergies. pt continued on albuterol prn, advair and montelukast. # seronegative arthritis. pt continued on sulfasalazine. # depression. pt continued on amitriptyline. # ecchymotic right eye. was noted on prior admission, pt states this is from itching her eye. inr normal on . not further worked up. transitional issues: 1. further titration of insulin regimen to ensure that she has adequate glucose control in her home environment. 2. possible titration of bp medications. 3. her social situation will need further attention. there is real question as to whether the patient is omitting insulin doses in order to go into dka in an attempt to show how disabled she is so that she can get a different apartment. from our perspective, we have given her the letter she requested saying that she needs a wheel chair accessible apartment. we stressed to her that she needs to take her insulin and that the vna will help with this. she does not want help with her insulin from her family because she does not want to burden them but we explained that it is much more of a burden to them if she keeps bouncing back to the hospital in dka. this should be restressed to the patient in the future. this patient is at very high risk to present yet again in dka in the future if her social/psych issues are not further addressed. medications on admission: (from previous d/c summary) 1. amitriptyline 50 mg hs 2. fluticasone-salmeterol 250-50 mcg/dose 3. methimazole 10 mg tid 4. montelukast 10 mg qday 5. pantoprazole 40 mg qday 6. polyethylene glycolqday 7. simvastatin 10 mg qday 8. sulfasalazine 500 mg 9. prochlorperazine maleate 10 mg 10. docusate sodium 100 mg 11. gabapentin 300 mg 12. metoclopramide 10 mg qidachs 13. calcium carbonate 200 mg tid 14. cholecalciferol (vitamin d3) 400 unit qday 15. ferrous sulfate 300 mg (60 mg iron) qday 16. hyoscyamine sulfate 0.375 mg er 17. oxycodone-acetaminophen 5-325 mg prn pain 18. losartan 25 mg qday 19. lantus 100 unit/ml solution sig: twenty four (24) units subcutaneous at bedtime. 20. humalog mix 75-25 13 units q day 21. humalog 100 unit/ml solution sig: per sliding scale discharge medications: 1. amitriptyline 50 mg tablet sig: one (1) tablet po at bedtime. 2. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 3. methimazole 10 mg tablet sig: one (1) tablet po tid (3 times a day). 4. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 7. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 8. sulfasalazine 500 mg tablet sig: one (1) tablet po bid (2 times a day). 9. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po twice a day as needed for nausea: as needed for nausea. 10. docusate sodium 100 mg tablet sig: one (1) tablet po twice a day. 11. gabapentin 300 mg capsule sig: one (1) capsule po bid (2 times a day). 12. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). 13. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 14. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 15. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 16. hyoscyamine sulfate 0.375 mg capsule,extended release 12 hr sig: one (1) capsule,extended release 12 hr po bid (2 times a day). 17. oxycodone 5 mg tablet sig: one (1) tablet po twice a day as needed for pain. 18. losartan 25 mg tablet sig: one (1) tablet po daily (daily). 19. humalog 100 unit/ml solution sig: dose per sliding scale units subcutaneous four times a day: please take insulin dosages based on your home sliding scale. 20. lantus 100 unit/ml solution sig: twenty (20) units subcutaneous once a day: please give patient 300 unit insulin pen. please take 20 units in the morning. disp:*1 pen* refills:*0* discharge disposition: home with service facility: uphams corner home care discharge diagnosis: diabetic ketoacidosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , you were admitted to the hospital with high blood sugars. while you were here we treated you with iv fluids and insulin and you improved. unfortunately, while you were here you also had 2 episodes of low blood sugars which we treated and you improved. as we discussed in our family meeting today, the key to preventing rehospitalization lies in close follow up with (appointment tomorrow), daily home nursing visits, and allowing close supervision by members of your family to help you manage your challenging disease. we also encourage you to visit your gastroenterologist (appointment this fall) to better manage your gastroparesis, which contributes to the difficulties in controlling your blood sugar. the following changes were made to your medications: change lantus insulin from twice per day to one dose per day, 20 units, in the morning. stop the humalog mix we have made you an appointment to follow up with your diabetes doctor tomorrow, . additionally we have made you an appointment with your regular doctor below. thank you for allowing us to participate in your care. we wish you a speedy recovery. followup instructions: name: , location: diabetes center address: one place, , phone: appointment: thursday 11:00am name: location: uphams corner health center address: , , phone: appointment: friday 1:30pm procedure: central venous catheter placement with guidance diagnoses: acute kidney failure, unspecified unspecified viral hepatitis c without hepatic coma polyneuropathy in diabetes depressive disorder, not elsewhere classified toxic diffuse goiter without mention of thyrotoxic crisis or storm diabetes with neurological manifestations, type i [juvenile type], uncontrolled diabetes with ketoacidosis, type i [juvenile type], uncontrolled gastroparesis 

Answer: The patient is high likely exposed to