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: vancomycin / compazine attending: chief complaint: mec chemotherapy followed by syngeneic transplant major surgical or invasive procedure: hickman placed intubation intra-aortic balloon pump history of present illness: patient is a 39 year old woman diagnosed with aml in after presenting for a routine physical exam, cbc revealed white count of 5300 with 40% blasts. pt noted generalized fatigue at that time. patient found to have normal cytogenetics, immunophenotyping revealed positive cd34; positive cd13, and positive cd17. patient underwent induction 7+3; 5+2 in of , followed by three cycles of consolidation after which she had a bone marrow biopsy with remission in early . patient remained in remission until at which time she was found to have relapsed by bone marrow biopsy and underwent reinduction 7+3/5+2(idarubicin and cytarabine). patient was planned to have synergeneic transplant (she has a twin sister-however this is in the process of being confirmed), with bu/cy containing regimen. she was admitted for a week in for neutropenic fevers, hickman was pulled, and patient was treated with daptomycin. last bone marrow biopsy on shows relapsed aml, cd34/cd13 with 26% blast cells. cmv viral load on was + at 36. . although her english is limited, patient states that she has been feeling relatively well since her discharge. uses ativan to help control her nausea, has had occasional diarrhea with the most recent episode this am, denies any blood in stool. she reports feeling tired most of the time, but her appetite and weight have been stable (she initially lost 5-10lbs after chemo). she denies any fever/chills or night sweats. she notes trouble sleeping, which often results in a headache the following morning. she also reports some chest/substernal "discomfort"-particularly in the am, but denies pain or sob. patient notes increased anxiety with this hospitalization. past medical history: 1) aml, diagnosed in . (a) normal cytogenetics. (b) positive cd34; positive cd13, and positive cd17. (c) status post 7+3; status post 5+2 in . (d) bone marrow biopsy with remission in early . (e) she is status post hidac consolidation in , complicated by fever and neutropenia with no clear source with an admission in . (f) status post hidac two on with mild transaminitis (last dose held). (g) she received her third and last cycle of hidac consolidation in . 2) has noted heavy periods and was recently diagnosed with fibroids. social history: patient is from and has lived in the us for 13 years. formerly worked for an electric company. she is married with two children. she denies use of alcohol or illicit drugs. she has a sister with a human leukocyte antigen match in . she speaks cantonese and some english. family history: non-contributory physical exam: vitals: 103lbs/ 98.1/ 100/18/120/70 100% on ra gen:awake, alert, pleasant, speaks some english, thin but not cachetic heent:atraumatic, sclerae anicteric, no pharyngeal exudate but some whitish coating on tongue. no ulcerations or lesions. neck:no lad, no jvd, no carotid bruits skin:warm/dry/ no rashes, +ttp around old hickman site- no edema/erythema cv:tachy, nml s1/s2, + dp pulses strong bilaterally lungs:cta b/l abdomen:soft, nontender, no organomegaly, decreased bs ext:no c/c/e, normal muscle tone, 5/5 strength in all 4 extremities, symmetric neuro: cn ii-xii relatively intact, a/o x3, no focal deficits (transfer to icu) vitals: t 96.0, bp 89/56, hr 130, rr 31, o2 sat 91% ra gen: lying in bed, intubated, awake heent: allocepecia, anicteric, eomi, perrl, op clear w/ mmm neck: + jvd to angle of jaw cv: tachycardic, reg s1/s2, could not appreciate m/r/g pulm: ventilated bs b/l abd: +bs, soft, nt, nd ext: warm, 2+ pitting edema extending to thighs and sacram b/l, 1+ pitting edema to mid-arm b/l, + dp pulses b/l pertinent results: labs on admission: glucose-98 urea n-10 creat-0.4 sodium-140 potassium-4.0 chloride-104 total co2-28 anion gap-12 calcium-9.6 phosphate-3.7 magnesium-1.8 . alt(sgpt)-18 ast(sgot)-18 ld(ldh)-158 alk phos-44 tot bili-0.3 albumin-4.5 . wbc-2.5* rbc-3.71* hgb-12.1 hct-35.2* mcv-95 mch-32.7* mchc-34.5 rdw-14.9 neuts-22* bands-0 lymphs-63* monos-1* eos-4 basos-0 atyps-5* metas-0 myelos-0 blasts-5* hypochrom-normal anisocyt-occasional poikilocy-occasional macrocyt-occasional microcyt-normal polychrom-occasional teardrop-occasional . labs on expiration: wbc-8.6 rbc-3.14* hgb-10.6* hct-31.7* mcv-101* mch-33.8* mchc-33.4 rdw-25.5* plt ct-20* . pt-15.9* ptt-74.5* inr(pt)-1.7 . glucose-108* urean-67* creat-1.0 na-131* k-4.5 cl-91* hco3-27 angap-18 calcium-8.7 phos-5.5* mg-2.0 . . imaging: pcxr: an endotracheal tube ends in satisfactory position 4 cm above the carina. an ng tube curls in the stomach. a swan-ganz catheter from the inferior approach ends in the proximal left pulmonary artery. mild cardiomegaly is unchanged. a small left effusion is stable. opacity within the left lower lobe and the peripheral right lung base is unchanged. no failure or pneumothorax is seen. impression: lines and tubes in satisfactory position. opacity in the left lower lobe and the right lateral lung base representing possible pneumonia vs. atelectasis are unchanged compared to . . cath: final diagnosis: 1. cardiogenic with vasodilatory 2. iabp insertion. . ruq us: there is a large right-sided pleural effusion. gallbladder is not distended. there is gallbladder wall thickening. no gallstones are seen. there is possible sludge within the gallbladder. there is no intra- or extra- hepatic biliary ductal dilatation. common duct measures 3-4 mm. portal vein appears patent on limited imaging. impression: 1. large right-sided pleural effusion. 2. gallbladder wall thickening without gallstones identified. the appearance of the gallbladder is not significantly changed compared to the exam of seven days prior. causes of gallbladder wall thickening include hypoalbuminemia, chf, liver disease, and other causes of third spacing. if there is continued clinical concern for acalculous cholecystitis, hida scan may be performed for further evaluation. brief hospital course: 39 year old female with relapsed aml, admitted for re-induction followed by syngeneic/identical twin allogenic transplant. patient had been on bmt service for >2 months and was then transferred to the micu for chf, including diuresis and afterload reduction therapy initially with hydralazine changed to ace i (captopril). with these interventions, patient's weight decreased from 130 -> 114 lbs. course was c/b intermittent episodes of hypotension (below baseline hypotension of sbp 80's - 100's) and lightheadedness. following stablization after weight loss and transfer to the floor, patient had orthostasis, continued total body edema and continued to complain of dry mouth. her cardiac managment is otherwise complicated by continuous sinus tachycardia to 120-140's. patient was then transferred from the floor to for management of heart failure and diuresis. she diuresed well over 2 weeks however was still fluid overloaded. patient underwent a trial of nesiritide for diuresis while off captopril and then lasix was added the regimen. on , patient diuresed well on lasix with a slight elevation in creatinine to 1.6, but a new anion gap was noted with a lactate of 7. also, lft's increased without clear cause. on , patient become hypotensive to 60's overnight with worsening respiratory distress. unclear whether this was due to sepsis versus cardiogenic . patient was subsequently transferred to the ccu and intubated due to respiratory distress. a venous blood gas showed a ph of 7.14 and venous lactate of 13. at the time, patient's inr was 4 and her respiratory and hemodynamic status very tenous. also, with tricuspid vegetation and known endocarditis, it was thought placing a swan would be high risk. as mentioned above, hospital course also complicated by strep viridans endocarditis with visible vegetations seen on most recent echo . diagnosed in treated with 10 days gentamicin and 4 weeks ceftriaxone, generalized anasarca, persistent sinus tachycardia with occasional , bilateral pleural effusions, acalculous cholecystitis, portal vein thrombosis, dic and hemorrhoids. . . * aml - pt was started on syngeneic transplant protocol upon admission on . hickman was placed on . pt was preconditioned with mec. of note patient had ppd/ placed. she had positive ppd 12 years ago and was treated for six months - pt can't remember which drug. patient's chest x-ray was negative, no active symptoms now or during previous chemotherapy. no intervention/treatment necessary at this time after consulting with id. on pt was started on allo bisulfan/cytoxan protocol. she was continued on levofloxacin/flagyl coverage. pt also received a picc line in addition to her r double lumen hickman. attemtp to l sided hickman previously failed secondary to inability to advance the catheter during ir. pt tolerated transplant well and her anc gradually increased with resolution of neutropenia. pt was initially started on acyclovir. she was also treated with empiric flucanazole. acyclovir and fluconazole were to be continued for 6 months after trasplant. at that time peripheral blood did not reveal any blasts, and there was normal trilineage maturation. pt was believed to be in complete remission from the aml, and did not required chronic blood product transfusion. no further chemotherapy was planned in the near future. if her aml relapsed, her prognosis will be poor. during her micu stay, there was no evidence of aml recurrence. . * abdominal pain - the patient complained of right sided abdominal pain of mild severity, worse with palpation, often absent at rest, during her micu stay. this was attributed to her portal vein thrombosis initially, however patient described early satiety. egd was unremarkable (some linear gastritis only), and not able to account for the patient's symptoms. the patient was placed on a ppi. a ct w/ contrast on revealed contracted portal vein thrombosis, cecal wall thickening, possibly secondary to ascites and a question of free air, which was further discussed with radiology and determined to be most likely in the appendix. however, no clear source for her polymicrobial blood cultures was found. per id, she was continued on her metronidazole for a 10 day course. she has remained afebrile since. . * cp - patient intermittently complained of cp on several occasions. repeated ekgs showed no st changes. later in the course they were significant for sinus tachycardia. cardiac enzymes were significant for troponin of 0.05 x 3, which was stable and not trending up, ck-mb was negative. this was thought to represent mild troponin leak secondary to demand ischemia sometimes as could be expected in high catecholamine states that accompanies severe sinus tachycardia. repeat echo also showed worsening ef with global hypokinesis. pt also had an increasing pulmonary artery pressure. v/q scan was normal and there was only mild pulmonary edema on diagnostic studies. patient had periodic echocardiograms done showing progressively worse systolic right and left sided function. an echo on , done to evaluate interval changes prior to surgery for suspected cholecystitis, showed worsened ef<20% and new vegetations on the tricuspid valve and the chordae to the tricuspid valve. subsequent echos supported the data from the earlier echos (ef<20% w/ marked tr). the patient did not complain of cp during her micu stay. however, on transfer to the bmt floor, she did have several instances of chest pain without ekg changes. her cardiac enzymes were cycled once with negative ck, and ckmb, and stable troponins. her chest pain was thought to be secondary to anxiety, often resolving with ativan, and sinus tachycardia, and was treated with morphine and attempts at better rate control. . * chf - her cardiomyopathy was new since her transplant as a echo prior to transplant revealed normal systolic function. the worsened heart function was believed to be secondary to cytoxan as well as prior anthracycline. she had diffuse anasarca, due to ef <20%, severe tricuspid regurgitation, as well as malnutrition and low albumin with low oncotic pressure. she was managed with lasix, metoprolol 12.5 po tid, spironolactone 25mg po tid, and digoxin 0.125 mg po every other day. it was unclear if her cardiac function would improve. patient's blood pressure with diuresis was marginal and cardiology consult initially did not believe there was room to add ace-inhibitor, neither did they believe that she would benefit from afterload reduction. patient's maximum weight was 130 lbs and she was diuresed to 123 lbs with lasix 20mg po tid and more recently a lasix drip at 2mg/hr in the micu. in addition, she had a thoracentesis of her right sided pleural effusion with removal of 1l, and some improvement of her dyspnea. of note, she has not required supplemental oxygen. echos demonstrated ef<20% on multiple occasions. she was overall fluid overloaded and responded somewhat to diuresis in the micu. she was transferred to the floor for chf optimization when she no longer required micu level care (). on the floor, a cxr showed continued failure, which was confirmed by a ct with contrast on . she was actively diuresed with lasix 40 mg po qd to 114 lbs, with a consequent increase in her serum cr from 0.8 to 1.4. a repeat cxr on showed marked improvement of her asymetric pulmonary edema, though on exam, she continued to have + le edema l>r and ascites. she was also tried on carvedilol per cardiology for rate control with a drop her sbp to the 70s. cardiology then recommended acebutalol for greater beta 1 selectivity, but she also did not tolerate this with a drop in sbp to 69, which returned to 85 after 150 cc iv bolus of ns. her digoxin was titrated to try to improve her rate control and was set at alternating doses of 0.1875 and 0.25 with a resting hr in the 120-130s. she was also started on captopril 6.25 mg po tid for afterload reduction and for her ef<20%. she was subsequently transferred to cardiology () for further cardiac management on . . on cardiology service diuresis was attempted by placing patient on nesiritide drip and supplementing with lasix. patient initially tolerated this well, was able to lose approximately 5 pounds of water weight. however, lasix was discontinued after 2 days due to elevated creatinine. after 1 week on nesiritide, this also had to be discontinued due to hypotension and development of other medical issues including elevated lactate. patient was then transferred to the intensive care unit for further monitoring and treatment. . due to severe hypotension which was thought to be secondary to cardiogenic , intra-aortic balloon pump was placed and milronone drip was initiated. upon presentation to the ccu, the patient was afebrile without white blood cell count or clear souce of infection. however, repeat echo showed persistent vegetations and tr. patient also required vasopressin and levophed to maintain her blood pressure. attempts at weaning either the balloon pump and vasopressin were unsuccessful. patient was continued on the balloon pump for 1 week without ability to wean and so was it was subsequently discontinued. patient expired shortly after balloon pump removal. . *sinus tachycardia - patient was also noted following her chemotherapy to have sinus tachycardia, onset at same time as her above chf. her heart rate stayed in the 120's-160's and was also addressed on her transfer to the cardiology service. it was believed that her sinus tachycardia was likely compensatory for her poor ejection fraction with her chf. a trial of carvedilol and acebutelol was attempted prior to transfer to cardiology, but was not tolerated due to hypotension. on cardiology service a trial of 1mg iv lopressor was attempted with the thought that if her blood pressure tolerated this and her heart rate decreased an oral trial of lopressor could be attempted. however, with the 1 mg iv lopressore, patient's heart rate dropped into 80-90's and her systolic blood pressure dropped to 50's-60's. therefore no nodal was started for her tachycardia. . * - pt has been on telemetry during her stay. she had two episodes of lasting apptoximately 12 beats with a background of sinus tachycardia ranging up to 150s. she has been continued on metoprolol 12.5 mg po tid. she may need evaluation for icd placement, as this may be related to her cardiomyopathy. this did not come up again during her micu stay or stay on the bmt floor. while in the ccu, patient had persistant atrial tachycardia. on , heart rate was in the 140's and was hypotensive with systolic in the 60's and map in 50's. patient was shocked 100j to hemodynamically stable atrial tachycardia. digoxin was discontinued secondary to toxicity. . * endocarditis - multiple cultures including fungal and m.fufur cultures were drawn but remained negative. in addition patient completed an empiric 2 week course of daptomycin (given hx of allergy to vancomycin), meropenem, and ambisome. however, a repeat echo showed unchanged size of the vegetatations, and a diagnosis of marantic endocarditis was suspected. if patient develops a fever, infectious endocarditis once again has to be considered and she needs to be broadly cultured including fungal cultures. a subsequent echo showed worsening tr without note of the vegetation on the echo dated . the patient was tx'd w/ ceftriaxone 2g daily, beginning on and will need 4 weeks of treatment to be completed on . follow up blood cultures and echo should be done at that time to ensure bacteremia and tricuspid vegetations have resolved. - h/o strep viridans endocarditis, s/p 10 days gentamicin and currently on ctx (started ) to complete a 4 week course, repeat echo show persistent vegetations on tr. - discontinued ctx change to daptomycin/meropenum day 9 - dc'd caspofungin day 6 - pt grew 100k enterococcus in urine should be covered for vre with daptomycin - pan-cultured, incl fungal, pulled picc sent tip for culture - apprec pulm recs, will send sputum cx - us of abdomen consistent with volume overload -> hida given persistently incr tuberculosis concerning for cholecystitis - worsening skin breakdown at site of balloon cath sutures, being covered with daptomycin - f/u id recs - appreciate input . # elevated lactate and ag: pt noted to have elevated lactate to 6.57 on , ag = 18/19. infectious work up did not yield any results. repeat lactates continued to rise, and on , patient was noted to have a lactate of 13.9 and an anion gap of 25. during this time, patient was persistently hypotensive with sbp in 60's. therefore likely secondary to hypoperfusion. patient was transferred to icu for further managment. . * acute cholecystitis/elevated lfts - pt consistently had tachycardia which was thought to possibly be related to an occult infection. she began developing ruq pain and us was done suggestive of acute cholecysitis. her transaminases were elevated to the 200s, but the bilirubin was normal. while being transported to w campus for surgery, her echo report came back with worsening lv function and a vegetation on the tv. she was admitted to the micu after a cholecystostomy tube was placed by ir. general a repeat us showed a decompressed gallbladder. her transaminases continued to rise above 1000, and a repeat abdominal u/s and ct scan were done, showing a new partial portal vein thrombus. her transaminases then trended downward and the patient left the micu w/ unremarkable transaminases. on the bmt floor, her transaminases remained unremarkable. on transfer to cardiology, lfts were noted to elevate again. hepatology was reconsulted and believed this rise was secondary to hepatic congestion from right heart failure. throughtout remainder of time of cardiology service, lfts began to normalize except for her t. bili and d. bili which continued to rise. . * portal vein thrombosis - patient was started on a heparin drip and continued with a goal ptt 60-80. her liver abdnormalities resolved on the heparin drip. the patient accidentally partially removed the cholecystostomy drain, her labs remained stable as did the abdominal pain for the next few days and the drain tube was discontinued. repeat u/s showed consistently decompressed gall bladder. the patient was continued on heparin drip with plans to switch to lovenow injections for continued anticoagulation. a repeat u/s showed persistent thrombus. the heparin drip was d/c at the recommendation of the heme/onc service for concern of hit. multiple hit ab tests were negative and a serotoninin assay that was reported to be more sensitive for hit was negative. a ct on showed a contracted portal vein thrombosis. a ruq ultrasound on demonstrated resolution of her portal vein thrombosis. . * rue swelling, labial swelling - the pt was noted to have a swollen r arm. an us obtained while the pt was in the micu revealed no clot and was believed to be related to anasarca. in addition, she had labial swelling r>l, concerning for abscess. fluid was aspirated and negative for infection. nothing further. . * dic - on transfer to the micu the pt was felt to be in early dic, with increasing lfts, decreased fibrinogen, increased ldh, and decreasing platelets. she received 6 units of ffp and 1 bag of cryo and serial dic labs were followed, with improvement over the time she was in the micu. it was felt that the endocarditis or sepsis were the most likely etiologies, although initial blood cultures did not grow any organisms. the pt was maintained on broad-spectrum antibiotics and antifungals with input from id. her dic resolved, but this was postulated as a possible unifying diagnosis to explain the portal vein thrombosis. on , her fibrinogen was noted to drop, and she was transfused 1 bag of cryoprecipitate. . * hemorrhoids - on she started complaining of hemorrhoidal pain c/w large external hemorrhoids. pt was intially put on stool softeners and eventually made npo with tpn in order to minimized potential infectious exposure in the rectal area. she was empirically covered for colon flora with levoquin and flagyl. morphine was used for pain control. pt stool was c. diff negative x 3. although she did have intermittent diarrhea that was controlled with immodium. . dispo - pt transferred from to cardiology for optimization of her cardiac regimen. pt then transferred to the unit due to persistent hypotension, elevated anion gap, elevated lactate for further management. . patient then transferred from cardiology floor to cardiac intensive care unit for persistent sinus tachycardia and hypotension. due to persistent hypotension refractory to fluid boluses and pressors, an intra-aortic balloon pump was placed in the setting of cardiogenic +/- septic . . ##cardiac #ischemia: no known history of prior cath's. . #pump: nonischemic cardiomyopathy/chf: ef ~10%, likely secondary to chemo toxicity vs persistant tachycardia. given improvement with iabp, on milrinone, no wbc, afebrile, no clear source of infection likely in cardiogenic , also have an element of septic . repeat echo show persistent vegetations on tr. - attempted to wean iabp however ci 1.7 on 1:2 - cont max doses of vasopressin, milronine and levophed - keep at goal cvp 16-18 - need to consider insensible losses - total body anasarca, likely related to her low ef. also likely contributed to by her low alb (last value = 2.9). . #rhythm: persistant atrial tachycardia. 12/19 hr 140's hypotensive syst 60's map 50's required 100j to stable atrial tach. - dc digoxin given toxicity - monitor on telemetry . #. id: - h/o strep viridans endocarditis, s/p 10 days gentamicin and currently on ctx (started ) to complete a 4 week course, repeat echo show persistent vegetations on tr. - discontinued ctx change to daptomycin/meropenum day 9 - dc'd caspofungin day 6 - pt grew 100k enterococcus in urine should be covered for vre with daptomycin - pan-cultured, incl fungal, pulled picc sent tip for culture - apprec pulm recs, will send sputum cx - us of abdomen consistent with volume overload -> hida given persistently incr tuberculosis concerning for cholecystitis - worsening skin breakdown at site of balloon cath sutures, being covered with daptomycin - f/u id recs - appreciate input . # elevated lfts/inr: h/o possible acalculous cholecystitis treated successfully with transcutaneous drain, now s/p drain removal. lfts trending up again. ? hepatic congestion from r heart failure vs repeat acalculous cholecystitis vs gvhd vs vod vs hepatic candidiasis. pt clinically asymptomatic. ruq u/s () - no liver or gb abnormalities, patent portal vein (previously thrombosed). hepatology consulted, believe elevated lfts hepatic congestion from r heart failure. - gradually elevated from originally event , per liver likely lag in , bili unmeasurable - would like to hida scan to assess for recurrence of acalculous cholecystitis however need to remove balloon pump and no portable available - cont heparin for balloon pump - trend lfts daily - daily fibrinogen if <100 give cryo - heparin . #. thrombocytopenia/dic: noted earlier in hospital admission of unknown etiology - all hit ab's negative x multiple times inlcuding more sensitive hit test (serotonin assay). pt was stabilized with stable plts 50's-60's now stable in 20's. - apprec heme/onc recs, started heparin drip for iabp. - follow plat count, tranfuse if spontaneously bleeds or plat<10k. - consider bm bx . # skin breakdown/blister: likely to anasarca and severe fluid overload - wound care - apprec plastics recs - apprec derm . #. respiratory distress: intubated unresponsiveness and hypoxia. - plan for extubation today allow pt to speak with family . #. aml: currently without evidence of recurrence of disease however in setting of new thrombocytopenia may benefit from bm bx - concerning nucleated rbcs, ?recurrence - monitor cbc with diff daily to eval for blasts, atyps, etc - cont acyclovir, renally dosed - apprec heme/onc recs . fen: holding additional fluids and concentrating fluids given anasarca - cont tf as tolerated - electrolyte repletion - cont anti-emetics . #. access: left groin triple lumen, iabp placed right femoral vein. . #. ppx: anzemet/compazine for nausea, on iv heparin . #. communication: (husband) or ; (bmt sw, knows pt well) pager ; needs translator for any medical discussions . #. dispo: on family and patient decided that patient was to be extubated to allow her an opportunity to communicate with her family prior to withdrawal of the intra-aortic balloon pump. patient expired shortly after discontinuation of the intra-aortic balloon pump from cardiac and respiratory failure. medications on admission: ativan prn for nausea, pt denies any meds otc or herbal supplements discharge disposition: home discharge diagnosis: cardiomyopathy. congestive heart failure. endocarditis (culture positive). abdominal pain. acute renal failure. portal vein thrombosis. thrombocytopenia. acalculous cholecystitis. acute myelogenous leukemia. anxiety. discharge condition: expired procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances other electric countershock of heart thoracentesis implant of pulsation balloon right heart cardiac catheterization percutaneous aspiration of gallbladder injection or infusion of cancer chemotherapeutic substance allogeneic hematopoietic stem cell transpant without purging injection or infusion of nesiritide injection or infusion of biological response modifier [brm] as an antineoplastic agent transplant from live related donor other puncture of vein diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified unspecified septicemia severe sepsis acute respiratory failure defibrination syndrome cardiogenic shock septic shock acute cholecystitis paroxysmal supraventricular tachycardia other specified disorders of skin unspecified hemorrhoids with other complication portal vein thrombosis acute myeloid leukemia, without mention of having achieved remission chronic passive congestion of liver acute rheumatic endocarditis other specified symptoms associated with female genital organs 

Answer: The patient is high likely exposed to