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: dyspnea, hypoxia major surgical or invasive procedure: thoracentesis history of present illness: ms. is a 63 y/o woman with pmh of stage iv breast cancer with cutaneous & liver mets who presents to the ed with worsening dyspnea. the patient states that she began therapy with megace on . following initiation of therapy she noticed lower extremity edema which progressed over several weeks; she discontinued therapy on but the edema persisted. over the past several weeks, she has noticed increasing dyspnea on exertion. she has 14 stairs in her home and has noted increased difficulty in climbing them. at times, she must stop to rest halfway up the flight. she denies orthopnea, pnd, chest pain, palpitations, and dizziness/lightheadedness. she was given hctz to "help with fluid" per her report; she has been taking 25 mg daily without much improvement in her edema. . in addition, the patient had two separate bleeds from her external tumor which were substantial per her report. on and , the patient bled from her tumor, requiring multiple washcloths and prolonged application of pressure to stop the bleeding. she denies any hematuria or blood in her stools. . in the ed, the patient was afebrile and 91% on ra; sats increased to 97-98% on 3l nc. she had borderline low blood pressures in the 80s/40s but maintained her mentation and urine output; baseline bps in the 100s per her report. she has continued hctz as above at home. cta of the chest demonstrated no pulmonary embolism but a large r sided pleural effusion. blood cultures were sent, and she received levofloxacin 500 mg iv x 1 for treatment of pneumonia. she also received 1 l ns and was transferred to the for further management. on arrival to the , the patient states that her breathing is "much better." she appears comfortable and is only complaining of chest wall pain and back pain due to "all the moving around." . ros: feels thirsty. appetite and po intake good per her report. no headache, sore throat, trouble swallowing, nausea/vomiting, abdominal pain, diarrhea, constipation, bloody stools, dysuria, or hematuria per her report. . past medical history: * stage iv breast cancer with mets to skin, bone, and liver diagnosed in . prior chemotherapy regimens included: lipodox, navelbine (mitotic inhibitor), gemcitabine, taxotere, oral cmf (cyclophosphamide/mtx/5fu), adriamycin given weekly until , and oral etoposide (). she has also previously been on hormonal therapy with femara, faslodex, exemestane (start ), and xeloda without success. * anemia: previously aranesp dependent. social history: lives with sister. in the trust industry with multiple nonprofit organizations; she worked up until saturday when she felt too poorly to work. never smoker. no alcohol use. . family history: father passed away with pancreatic cancer. mother lived into her 90s with alzheimer's. grandmother had breast cancer but also lived into her 90s. physical exam: afebrile, blood pressure ranging between 80-95 systolic, tach to 110 intermittently sats above 90% on 2 lpm. gen: pleasant, cachetic, pale female in nad. heent: op clear neck: supple. cv: rrr. nl s1, s2. no murmurs, rubs or . lungs: decreased to auscultation but comfortable respiration abd: benign, +sister nodule ext: 2+ pitting edema to the thigh bilaterally, feet warm & well perfused. 2+ dp pulses bilaterally. r arm lymphedema. skin: extensive chest wall erythema, ulceration and tumor. neuro: grossly intact. pertinent results: 12:21 pm pleural fluid pleural fluid. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (pending): 1:53 pm stool consistency: soft source: stool. **final report ** clostridium difficile toxin assay (final ): feces negative for c. difficile toxin by eia. (reference range-negative). 4:35 pm pleural fluid pleural fluid forph. **final report ** gram stain (final ): 4+ (>10 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. anaerobic culture (final ): no growth. pleural fluid cytology: positve for malignant cells consistent with metastatic breast cancer pleural fluid found to be exudative ( lights criteria were positive)> ct chest : conclusion: 1. no pulmonary embolism or aortic dissection. 2. large bibasal effusions with passive atelectasis at the lung bases, more on the right. small lung nodules in right middle lobe worrisome for metastases. 3. extensive metastatic disease involving the breasts and the subcutaneous tissues of the chest and abdomen. 4. metastatic disease in the liver and evidence of prior chemoembolization. abdominal lymph nodes are incompletely covered/ assessed on this chest cta and may be further evaluated with a dedicated ct abdomen. cxr (two days following thoracentesis). impression: bilateral pleural effusions, slightly increasing. 07:15am blood wbc-14.6* rbc-3.61* hgb-10.6* hct-31.9* mcv-88 mch-29.5 mchc-33.4 rdw-17.0* plt ct-440 05:01am blood wbc-17.8* rbc-3.48* hgb-10.5* hct-30.6* mcv-88 mch-30.1 mchc-34.2 rdw-16.9* plt ct-370 12:09pm blood wbc-35.5*# rbc-3.26*# hgb-9.5*# hct-28.4*# mcv-87 mch-29.0 mchc-33.2 rdw-15.9* plt ct-418 09:30pm blood wbc-28.8*# rbc-2.49*# hgb-6.6*# hct-21.9*# mcv-88 mch-26.7*# mchc-30.3* rdw-16.5* plt ct-663* 03:11am blood neuts-93* bands-0 lymphs-3* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 03:11am blood pt-13.0 ptt-20.3* inr(pt)-1.1 03:11am blood ret man-2.8* 07:15am blood glucose-91 urean-49* creat-1.1 na-133 k-4.8 cl-98 hco3-23 angap-17 09:30pm blood glucose-113* urean-63* creat-1.3* na-133 k-5.0 cl-93* hco3-20* angap-25* 03:11am blood alt-36 ast-47* ld(ldh)-281* ck(cpk)-32 alkphos-402* amylase-42 totbili-0.1 09:30pm blood ck(cpk)-35 09:30pm blood ck-mb-notdone probnp-* 07:15am blood calcium-8.1* phos-2.9 mg-2.7* 03:11am blood albumin-2.7* calcium-8.2* phos-5.3* mg-3.1* iron-12* 03:11am blood caltibc-289 ferritn-144 trf-222 06:02am blood lactate-5.9* 01:15am urine color-yellow appear-clear sp -1.029 01:15am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 12:21pm pleural wbc-165* rbc-215* polys-24* lymphs-55* monos-15* macro-2* other-4* 04:35pm pleural wbc-181* rbc-49* polys-48* lymphs-35* monos-6* atyps-2* other-9* 12:21pm pleural totprot-2.0 ld(ldh)-106 04:35pm pleural totprot-2.6 glucose-137 ld(ldh)-137 cxr - impression: no evidence of pneumothorax. interval increase in size in the moderate-to-large left pleural effusion with decrease on the right side. single ap portable view of the chest: comparison is made with prior studies from and 17. left subclavian vein catheter remains in place. moderate-to-large bilateral pleural effusions and bibasilar atelectasis are grossly unchanged, accurate comparison is difficult to be made due to difference in position of the patient. cardio-mediastinal contours are unchanged. brief hospital course: ms. is a 63 yo female with unresectable invasive breast cancer s/p multiple chemotherapeutic agents, who was admitted with dyspnea due to pleural effusions and anemia. breast cancer/palliative care. ms. desire is to concentrate on comfort and palliative care. she has reached a stage where she in non-treatable with regards to her breast cancer. her chest wall lesions were infected on arrival, and have a great liklihood of recurrent infection and bleeding. she should continue on oral and topical antibiotics indefinitely. she will require pain management and antianxiety medications for supportive care. hospice will be involved in her ecf care. she initially desired to return home with hospice, but she is full assist, and her elderly sister is not capable of 24 hour care (hospice can only be present approx 2 hours daily). hence she was transferred to rehab with hospice. shortness of breath. this is secondary to malignant pleural effusions. she is arranged for follow up with interventional pulmonary for pleurodesis, and to call prior to appointment if symptoms worsen. this is if the patient desires a thoracentesis. initial workup included the following: pe was ruled out by cta chest. cardiac enzymes were negative. the pleural effusion was tapped by ip and was found to be exudative. cytology from thoracentesis was positive for malignant cells. repeat thoracentesis was done on for relief of symptoms. patient was maintained on lit nc while in hospital with o2 sats greater than 92%. hypotension. multifactorial, but stable. patient was hypotensive to sbp of 80s on admission. she was bolused ivfs and given blood transfusions with improvement of her blood pressure. her bp is usually between 75-85 systolic, asymptomatic and mentating well. she was treated initally with vanco/zosyn and then started on levofloxacin. anemia: patient had a hct of 21.9 on admission with mcv of 88 with a baseline crit of 30 - 35. anemia studes revealed an anemia of chronic disease. patient also reported several episodes of bleeding from cutanous breast metastases requiring pressure to be applied to stop the bleeding. was guiaic negative in ed. patient was transfused 2 units to keep hct greater than 25. hct remained stable. le edema. patient has had increasing le edema and doe over past month, likely related to a combination of chronic disease with decreased oncotic pressure as well as possible ivc compression from liver metastases. pt requests ace wraps bilaterally for comfort. arf. patient has creatinine of 1.3 on admission with baseline of 0.8. cr did not improve with ivf. etiology of arf remained unclear. chest wall infection at breast cancer site. patient had elevated wbc that improved with initiation of zosyn/ vanco and topical flagyl. this was switched to levofloxacin. she remained afebrile during hospitalization. atrial fibrillation. patient went into afib on . she was rate controlled with digoxin and started on po digoxin. a digoxin level was 1.4 on . however, digoxin was stopped on because of the difficulty with monitoring digoxin levels due to difficulty drawing blood, absence of symptoms while in atrial fibrillation, and patients' desire for hospice care. code status: patient decided to be dnr/dni and will discharge to local ecf with hospice care. palliative care followed her in the hospital and hospice will care for her further needs. ### the patient does not have a primary care doctor, she used to follow up with dr in clinic. medications on admission: hctz 25 mg daily vicodin prn pain (mainly used at night) discharge medications: 1. roxanol concentrate 20 mg/ml solution sig: 5-20 mg po q 2 hour prn as needed for shortness of breath or anxiety. disp:*30 mg* refills:*0* 2. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 6. hexavitamin tablet sig: one (1) cap po daily (daily). 7. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed. 8. metronidazole 1 % gel sig: one (1) appl topical (2 times a day): to chest . 9. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 10. levofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours) 11. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 12. oxygen continuous at 2-4 l by nasal canula to keep sats > 94% 13. adaptic bandage sig: topical twice a day. 14. xeroform petrolatum dressing 5 x 9 bandage sig: topical twice a day. 15. sof- sponge sig: four (4) topical twice a day. 16. lorazepam 0.5 mg tablet sig: 1-2 tablets po q8h (every 8 hours) as needed. 17. morphine 10 mg/5 ml solution sig: 10-20 mg po q2h (every 2 hours) as needed for for pain. 18. codeine sulfate 30 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for cough. 19. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea or vomiting. 20. albuterol 90 mcg/actuation aerosol sig: one (1) inhalation four times a day as needed for shortness of breath or wheezing. discharge disposition: extended care facility: landing discharge diagnosis: 1. metastatic (stage iv) breast cancer, involving chest wall, skin, liver, lungs, pleura. 2. pleural effusion 3. chest wall cellulitis 4. atrial fibrillation 5. anemia discharge condition: comfortable, with chronically low blood pressures in the 80-95 systolic range discharge instructions: you were hospitalized with shortness of breath, related to fluid in your lung space conpressing your lungs. this has improved since thoracentesis. as you know, you have metastatic breast cancer. you will be going to an inpatient extended care facility, for supportive and comfort care during the remainder of your illness. your hospice company will work with you and the extended care facility to assure you remain comfortable and have good pain control. followup instructions: please followup with interventional pulmonology on at 9am to discuss management of the fluid in your lungs, if you wish to. please have a chest xray done before that appointment in the building at (you can walk in at any time). the number for interventional pulmonology is . if you feel short of breath before the and desire fluid removed from the lungs, please call this number and press option 1 to schedule a sooner appointment. provider: ,room two ip rooms date/time: 9:00 provider: , md phone: date/time: 9:00 call dr. at to arrange a follow up appointment with him if you desire. procedure: venous catheterization, not elsewhere classified thoracentesis thoracentesis transfusion of packed cells diagnoses: pneumonia, organism unspecified malignant neoplasm of liver, secondary cellulitis and abscess of trunk acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) atrial fibrillation secondary malignant neoplasm of other specified sites secondary malignant neoplasm of pleura personal history of malignant neoplasm of breast pulmonary collapse hypotension, unspecified secondary malignant neoplasm of skin secondary malignant neoplasm of lung dehydration secondary malignant neoplasm of bone and bone marrow anemia in neoplastic disease neoplasm related pain (acute) (chronic) edema 

Answer: The patient is high likely exposed to