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: chest pain and shortness of breath major surgical or invasive procedure: 1. pericardiocentesis with pericardial window 2. transesophageal echocardiogram history of present illness: 56y/o m with history of hypertension presented to with chest pain and shortness of breath. pain radiated to back. pt underwent cta, which showed a large pericardial effusion, and pt was transferred to for emergent pericardiocentesis. pt was hypotensive at 89/64 in the ed and was taken for emergent pericardiocentesis. tte demonstrated tamponade physiology with rv collapse; about 1 liter of fluid was removed, with reversal of tamponade physiology seen on tee. pt denied chest pain per se, but did complain of indigestion. noted increasing dyspnea over the day prior to admission. denied pnd or orthopnea. no fevers, chills, night sweats. reports losing about 25 lbs in the last 2 years, but says that he has decreased his beer intake. no known tuberculosis exposures. past medical history: 1. hypertension 2. chronic lower back pain 3. s/p appendectomy at 8 y/o 4. s/p tympanoplasty social history: pt worked construction - developed lower back pain worse with working; did not seek medical attention; is now on disability due to back pain. tobacco: about 1 ppd x 36 yrs. etoh: drank about 18 beers a day, for about 36 years, but has had only 4-5 beers in last month. smokes marijuana occasionally, last joint about 3-4 weeks ago. lives with partner , whom he has had a relationship with for the last 30 years. no children with her, though she has a 37y/o son who lives in ca. family history: noncontributory physical exam: on admission: vs: 97/77 110 18 100% nrb gen: a&o x3 heent: perrl, eomi, supple neck, op clear neck: bilateral jvd (not documented how high) pulm: ctab, no crackles but coarse breath sounds cv: rrr, nl s1/s2, distant abd: soft, nt/nd, +bs ext: dusky feet, s cap refill vs: tm 98.8 tc 98.8 120/70 (110s-130s/60s-80s) 101 (80s-110s) 17 95% 5l nc i/o 1657/1050 (18h) gen: nad, pleasant, no respiratory distress heent: op clear, edentulous, mmm, perrl, eomi; r tympanic membrane - will examine further in am, but no visible draining fluid at this time pulm: ctab, though lungs sounds somewhat decreased, no crackles, mild dullness at bases cv: rrr, nl s1/s2, no murmurs appreciated neck: no jvd abd: soft, nt/nd, +bs, no masses ext: no edema, no calf tenderness pertinent results: outside films reviewed by radiology: - hilar/mediastinal lns, mostly r sided, no lung masses - fibrosis/emphysema - adrenals normal - nodes mostly consistent with sclc versus lymphoma vs mets vs tuberculosis - hiatal hernia pericardial fluid (from chest tube): atypical. highly atypical mesothelial cells present, favor reactive. cytology for malignant cells negative. pathology of pericardial window: pericardium with chronic inflammation, reactive mesothelial cells, and focal atypical cellular aggregates; reactive changes are favored. no vasculitis, granulomas, or atypical lymphoid infiltrate identified. cta: 1. predominantly left lower lobe pulmonary embolus, with thrombus filling the left lower lobe superior segment pulmonary artery and extending into the left lower lobe basilar pulmonary artery. a less significant amount of thrombus is probably also be present within the right upper lobe pulmonary arteries. 2. bulky right hilar lymphadenopathy, with other enlarged mediastinal and left hilar lymph nodes. 3. trace pericardial effusion and a small right-sided pleural effusion. 4. no discrete pulmonary masses are seen. 5. bilateral lower lobe atelectasis. 6. emphysema. bilateral le ultrasound: no evidence of dvt. transthoracic echo: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. left ventricular systolic function appears grossly preserved but was not adequately assessed. right ventricular chamber size appears normal with preserved free wall motion. the aortic root is moderately dilated. the aortic valve is not well seen. the mitral valve is not well seen. there is no pericardial effusion. compared with the prior study (tape reviewed) of , the pericardial effusion is now gone. micro data: ear fluid: respiratory culture (final ): proteus mirabilis. heavy growth. trimethoprim/sulfa sensitivity available on request. alpha streptococci. sparse growth. staphylococcus, coagulase negative. rare growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ <=1 s gentamicin------------ <=1 s levofloxacin----------<=0.25 s meropenem-------------<=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s fungal culture (final ): no fungus isolated. pericardial fluid: no growth pericardial tissue: no growth blood cultures negative 12/1704, , urine culture no growth admission labs: 10:43am glucose-134* na+-128* k+-3.2* cl--96* tco2-25 10:37am urea n-32* creat-1.3* 10:37am alt(sgpt)-16 ast(sgot)-12 ck(cpk)-23* alk phos-55 amylase-21 tot bili-0.4 10:37am lipase-18 10:37am ck-mb-notdone ctropnt-<0.01 10:37am albumin-3.2* calcium-7.4* phosphate-3.1 magnesium-1.7 uric acid-8.2* 10:37am tsh-0.71 10:37am cortisol-34.3* 10:37am wbc-17.3* rbc-3.74* hgb-11.6* hct-31.9* mcv-85 mch-31.0 mchc-36.3* rdw-12.3 10:37am neuts-88.8* lymphs-6.4* monos-3.9 eos-0.8 basos-0.1 10:37am pt-14.0* ptt-28.0 inr(pt)-1.2 10:37am plt count-383 01:45pm -positive titer-1:320 01:45pm rheu fact-14 01:45pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 01:40pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg 01:40pm urine color-straw appear-clear sp -1.005 discharge labs: hct 37.2 sodium 133 bun 10 cr 0.5 mg 1.8 brief hospital course: 1. pericardial effusion - pt was initially taken emergently for pericardiocentesis as he was hypotensive with pericardial tamponade physiology with right ventricular collapse. he was placed transiently on a dopamine drip to maintain blood pressure. he was intubated and brought to the or, where pericardiocentesis and creation of a pericardial window were undertaken. close to 1 l of bloody pericardial fluid was removed, and l pleural and pericardial drainage tubes were placed. repeat echo showed resolution of tamponade physiology, and pt was transferred to the ccu. dopamine drip was weaned, pt was extubated, and pt recovered well with no further reaccumulation of fluid. the last drain was removed on . pt was transferred to the floor. his blood pressure remained stable and he showed no clinical evidence or symptomatology indicative of reaccumulation of pericardial fluid. a repeat echocardiogram on showed no interval reaccumulation of pericardial fluid. attention was turned to diagnosing the underlying condition causing pt's pericardial effusion. malignancy was high on the differential diagnosis, as well as rheumatologic conditions and infection such as tuberculosis. pulmonary consult was called. pathology of the pericardial window showed no granulomas and no evidence of malignancy; simply reactive mesothelial cells. given the concomitant presence of a pulmonary embolus (see below) and lymphadenopathy on ct, a tissue diagnosis is necessary. surgery was consulted to evaluate whether a peripheral lymph node could be biopsied at the bedside, but it seemed that these lymph nodes were likely not to be pathologic based on exam. further review of the films with pulmonary team suggested that a mediastinoscopy would be the best procedure to obtain a tissue diagnosis. pt desired strongly to go home for the holidays, and followup was arranged carefully for pt to go to the cardiothoracic surgery clinic to see dr. 2 days after discharge, for a likely elective mediastinoscopy later in the week, with pulmonary followup afterwards. 2. pulmonary embolism - pt was transiently hypoxic in the first 2 days of admission, and he complained of back pain. he also had sinus tachycardia. a pulmonary embolus was found on ct angiogram, predominantly in the left lower lobe but possibly also in the right upper lobe. pt was placed on a heparin drip and had no further complication, with good oxygen saturation. he was discharged on lovenox, which will be stopped prior to his mediastinoscopy. the initiation of coumadin was deferred until after pt's definitive procedure for tissue diagnosis, and he will follow up as an outpatient for management of his coumadin. the presence of both pe and pericardial effusion placed malignancy higher on the differential. 3. proteus mirabilis otitis externa - pt had noted progressive hearing loss over the last few months and has a history of a perforated tympanic membrane. his ears were draining fluid, particularly the right ear. this fluid was sent for culture and grew out proteus mirabilis, which was pansensitive. ent was curbsided, and ciprofloxacin drops were recommended, as well as po augmentin, both for 10 day course. pt will follow up with ent as an outpatient to monitor clinical progress. 4. hyponatremia - pt's sodium remained stable, on the low side of 131-133 for the majority of his hospitalization. concern was for siadh in the setting of probable malignancy in his clinical context. pt was placed on fluid restriction and was advised to continue this at home. 5. back pain - this was a chronic issue, musculoskeletal in nature. pt was placed on oxycodone and tylenol for control of back pain. 6. hypertension - pt was continued on his ace inhibitor. his hydrochlorothiazide was held in the hospital and then was restarted at discharge. pt also started on toprol xl with good bp control. 7. fen/gi - pt was placed on a cardiac/heart healthy diet on transfer to the floor, with fluid restriction due to hyponatremia. his other electrolytes remained stable. 8. hematuria - pt was noted to have lg blood on his ua on the day of discharge from the hospital; this should be followed up as an outpatient. no further workup was done during his hospital stay as he was hemodynamically stable with a normal hematocrit. 9. code - full medications on admission: hydrochlorothiazide 25mg po daily lisinopril 20mg po daily ibuprofen 600mg discharge medications: 1. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. amoxicillin-pot clavulanate 875-125 mg tablet sig: one (1) tablet po bid (2 times a day) for 7 days. disp:*14 tablet(s)* refills:*0* 5. toprol xl 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* 6. enoxaparin sodium 100 mg/ml syringe sig: one (1) injection subcutaneous q12h (every 12 hours) for 25 days. disp:*50 injection* refills:*0* 7. ciprofloxacin 0.3 % drops sig: four (4) drop ophthalmic tid (3 times a day) for 8 days. disp:*1 bottle* refills:*0* 8. nicotine 21 mg/24 hr patch 24hr sig: one (1) patch transdermal once a day for 4 weeks. disp:*28 patches* refills:*0* 9. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch transdermal once a day for 2 weeks: use these patches after you are finished with the 21 mg patches. disp:*14 patches* refills:*0* 10. nicotine 7 mg/24 hr patch 24hr sig: one (1) patch transdermal once a day for 2 weeks: use these after you have completed the 14mg patches. disp:*14 patches* refills:*0* 11. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: 1. pericardial effusion, with tamponade, status post pericardial window 2. pulmonary embolus 3. otitis externa with pansensitive proteus mirabilis 4. lymphadenopathy secondary: 1. hypertension 2. tobacco dependence 3. hematuria discharge condition: stable, no pericardial effusion on repeat echo, no chest pain or sob, ambulating, tolerating po discharge instructions: if you notice shortness of breath or chest pain, come to the emergency room. please take all of your medications as prescribed. if you notice any blood in your stool, maroon-colored stool, or if you have bloody vomiting, please come to the emergency room. you will need to come back next week for a mediastinoscopy to get a biopsy of your lymph nodes. at 9am on monday, please call dr. office at (. you will see dr. on monday, and then you will return a few days later for your mediastinoscopy. tell them that dr. said that you need to see him on monday. you will need to give yourself lovenox shots twice a day to keep your blood thin. on the morning that you come in for the mediastinoscopy, do not give yourself a shot. dr. will tell you when you should restart the lovenox. after the mediastinoscopy, you will need to have coumadin begun to treat your pulmonary embolus (clot in the lung). you will need to be followed in coumadin clinic to have your blood drawn to make sure that you are on the correct dose. more specific instructions will follow. you have an ear infection, for which you are being treated with amoxicillin/clavulanate (a pill) and ear drops. you should follow up with an ent doctor for this, as below. please call to make an appointment. followup instructions: 1. on monday, at 9am, call dr. office at ( to make an appointment to see him on the same day. he is the cardiothoracic surgeon who will be doing your mediastinoscopy. 2. please call ( to make an appointment to see dr. in 2 weeks (first week of ), who will be your primary care doctor at least until this is all sorted out. 3. please call the pulmonary clinic, at (617) 667-lung (() to make an appointment to see any of the pulmonary doctors sometime in the second week of . they will tell you the results of the biopsy. 4. you should call to make an appointment to see an ent doctor for your ear infection: (. you have a perforated tympanic membrane and the fluid draining from your ear is infected. procedure: diagnostic ultrasound of heart pericardiocentesis pericardiotomy diagnoses: tobacco use disorder hyposmolality and/or hyponatremia unspecified disease of pericardium infective otitis externa, unspecified 

Answer: The patient is high likely exposed to