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: shortness of breath major surgical or invasive procedure: hemodialysis intubation history of present illness: 68-year-old woman with lymphoplasmacytic lymphoma diagnosed in . pt initially refused all therapies. in pt admitted with esrd found to be glomerular sclerosis attributed to her lymphoma. during that admission pt was started on hemodialysis along with chemotherapy (cytoxan, vinctristine and prednisone) and discharged to . pt's daughter noticed the pt became increasingly short of breath while in the rehab home and transferred her back to the hospital for evalution. in pt found to be confused and lethargic and was emergently intubated for airway protection and increasing respiratory distress. inititial cxr showed lll collapse, b effusions and evidence of chf. repeat cxr post intubation showed re-expansion of l lung but persistence of bilateral effusions. cta in the emergency room ruled out acute pulmonary emboli. pt started on broad spectrum antibiotics (vancomycin, azithromycin, ceftriaxone and flagyl) and admitted to the icu under the sepsis protocol. ed due to temp spike to 101 and elevated lactate of 6.8 (now nl). pt received one ivf bolus in ed. l ij was placed and cvp was . no episodes of hypotension. nl stim. past medical history: 1. lymphoplasmacytic lymphoma, dx'd 1.5 yrs ago. started on chemotherapy in (vincristine, cytoxan and prednisone). 2. esrd- glomerular sclerosis consistent with end stage disease, likely from the lymphoma-- started on hd 3. atrial fibrillation on verapamil and atenolol 4. hypertension 5. anemia from chronic disease 6. congestive heart failure (ef 20%) 7. mitral regurg / tricuspid regurg social history: she does not smoke or drink currently, previously smoked tobacco for 2 years 48yrs ago. she is married with 2 sons and 2 daughters. daughters are scientists; husband and sons are not, but are supportive of her religious beliefs and of her decisions in the past and presently about treatment. she is a retired science nurse. family history: there is no family history of cancer, renal disease, or mi. she has 1 brother who is alive and well. her mother is 86 years old and alive. her father died at the age of 38 at an accident. her son has atrial fibrillation physical exam: tc 96.1 p92 af bp 130/82 rr 20 97% ra gen: ill appearing female; appears tired; alert and oriented to person, place and time heent: perrl, mmm, opc neck: bulky right cervical lad, soft, mobile, non fluctuant chest: clear bilaterally, sc hd line cv: irregularly irregular, nl s1/s2, no murmurs abd: soft, nd/nt, decreased bs ext: no c/c/e, ambulatory pertinent results: medicine admission labs: wbc-4.9 rbc-2.85* hgb-9.4* hct-30.2* mcv-106* mch-32.9* mchc-31.1 rdw-20.9* plt ct-152 glucose-92 urean-32* creat-3.7* na-137 k-4.2 cl-106 hco3-23 angap-12 calcium-8.0* phos-3.5 mg-2.0 alt-106* ast-54* ld(ldh)-400* alkphos-73 totbili-0.8 vanco-21.1* sputum cx: oropharyngeal flora blood cultures: negative catheter tip culture: negative urine culture: negative cxr: persistent left pleural effusion and opacity : ef of 20% with severe global hypokinesis with relative sparing of the inferior and posterior walls; +3 mr; +3 tr; dilated la and ra; compared to an in pt has decreased ejection fraction from 30% and increased mitral regrugitation. brief hospital course: 68 year old female with history of lymphoblastic lymphoma started on cvp (cytotoxan, vincristine and prednisone) last month. admitted to hospital with increasing respiratory distress requiring intubation for airway support. cxr demonstrated bilateral pleural effusion with concern for pneumonia and echo obtained on confirmed a markedly decreased ejection fraction of 20%. . respiratory failure - the patient was intubated in the ed for airway protection and increasing respiratory distress. chest ct angiogram ruled out acute pulmonary emboli. initial chest x ray showed bilateral pleural effusions and along with a retrocardiac opacity and bibasilar collapse. etiology of her respiratory failure thought to be multifactoral including volume overload in the context of her chf and pneumonia. cultures obtained and patient started on broad spectrum antibiotics including vancomycin, levofloxacin, and flagyl for her community acquired pneumonia. pt was also started on both albuterol and atrovent for maximal bronchodilation. pt's sputum cultures grew out oropharyngeal flora and her blood cultures remained negative throughout her admission. pt was successfully extubated 2 days after she admission and maintained good oxygen saturations on 2l nc. she continued her dialysis sessions with a goal of .5kg fluid removed daily. a. oxygen saturation >94% on room air; however, patient may prefer to have oxygen supplementation for comfort. b. encourage incentive spirometry to lower risk of recurrence of pneumonia. c. continue ipratropium bromide. hold albuterol given history of rapid atrial fibrillation. 2. neuro / psych - mental status improved to baseline with difficulty word finding, mild anxiety, and occasional mild confusion. avoid benzodiazepines because they are oversedating even at low doses. a. continue to avoid sedating medications b. frequent reorientation c. psych consult thought pt not competent to make major decisions . esrd - secondary to focal glomerulosclerosis likely from involvement of lymphoma. pt was dialyzed daily, with removal of about 3kg fluid. a. discontinued phosphate binder for low phosphate as per renal consultation. b. dialysis three times weekly. c. renally dose all medications . cardiac. pt presented with bilateral pleural effusions and was diuresed. found to be in atrial fibrillation and started on an esmolol drip in the unit. obtained on showed a marked decrease ejection fraction of 20% with global lv hypokinesis aside from the inferior and posterior walls. echo also revealed a severly dilated ra and rv. compared to in the ef down from 30% and the mitral regurg has increased. a. fluid removed by daily dialysis and ultrafiltration until three times weekly schedule resumed . b. gentle use of beta blockers to control rate because the patient may need the tachycardia to offset her markedly depressed ef of 20%. continue to hold her calcium channel blockers given her low ejection fraction and propensity for extensive lower extremeity edema. c. cardiac diet; control fluid status via dialysis three times weekly. d. not currently anticoagulated for her afib. the patient had refused anticoag in past even after extensive discussions involving the risk of stroke. now, she is likely not a good candidate for aggresive anticoagulation given the extensive tumor burden. e. started on digoxin. testing of digoxin levels is recommended for goal of 0.7. f. started on lisinopril. . anemia - thought to be due to anemia of chronic disease, likely from lymphoma, chemotherapy, and esrd. hct stable from last admission. a. continue epogen with dialysis b. continue multivitamin and iron. c. follow hematocrit over time 6. lymphoma - started cvp (cytoxan, vincristine and prednisone)protocol in . pt's lymphadenopathy appears dramatically improved on most recent ct scan. she will follow up with oncology in 1 month to determine future need for chemotherapy. a. continue renally dosed allopurinol for prevention of tumor lysis syndrome. b. oncology is holding further cvp (cytoxan, vincristine and prednisone) for now and will reevaluate need for further palliative chemotherapy at follow up outpatient appointment in one month. . prophylaxis - protonix, subcutaneous heparin nutrition - encourage oral intake. if unable to provide proper oral nutrition, resumption of tube feeding via nasogastric tube may be required. . access - picc line; piv; hd catheter . code - full . - husband, sister and son. medications on admission: mvi qd calcium acetate 1337 tid w/meals verapamil 80mg q8hrs colace 100mg metoprolol 60mg sc heparin 5000units tid compazine 10mg q6hrs prn allopurinol 100mg qd lansoprazole 30mg qd senna nystatin 5ml qid bisacodyl 10 qd acetamenaphen 1000mg q6hrs mag hydroxide 30mls q6hrs prn anzemet 12.5mg q8hrs epogen 3000units tiwk morphine prn ativan prn discharge medications: 1. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection q8h (every 8 hours). 2. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. phytonadione 5 mg tablet sig: one (1) tablet po daily (daily). 7. digoxin 125 mcg tablet sig: 0.5 tablet po daily (daily). 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 10. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 11. heparin flush cvl (100 units/ml) 1 ml iv daily:prn 10ml ns followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen qd and prn. inspect site every shift 12. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 13. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily): hold for sbp<90. 14. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po twice a day: hold for sbp<90 or hr<60. discharge disposition: extended care facility: - discharge diagnosis: pneumonia volume overload due to renal disease end stage renal disease on hemodialysis lymphoma anemia from chronic disease atrial fibrillation congestive heart failure (ef 20%) other: hypertension discharge condition: hemodynamically stable, breathing comfortably on room air, and tolerating oral diet discharge instructions: please take all medications as prescribed. call your doctor or go to the ed for shortness of breath, chest pain, bleeding, excessive bruising, abdominal pain, nasea/vomiting, diarrhea, fever, chills, or other concerning symptoms. new medications: to improve your heart function, you have been started on lisinopril and digoxin in addition to your usual metoprolol. continual the inhaled ipratroprium to improve breathing. otherwise, continue your usual medical regimen including vitamin supplementation. you are encouraged to eat a healthy low salt diet and drink plenty of fluid. if you are unable to provide adequate oral nutrition, resumption of nasogastric tube feeding may be required. to prevent future pneumonias, do not eat lying down or while excessively sleepy. monitor your weight and call your doctor if it increases more than 3 pounds in a short period of time to be evaluated for worsening heart function. you will continue dialysis three times weekly. you also have an appointment for one month at the oncology clinic where your need for additional chemotherapy medications will be evaluated. followup instructions: call dr. ( to make a future appointment for after leaving the rehab facility. provider: , md where: cardiac services phone: date/time: 10:00 provider: , md where: hematology/bmt phone: date/time: 10:00 provider: where: hematology/oncology phone: date/time: 10:00 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis diagnoses: pneumonia, organism unspecified other primary cardiomyopathies anemia of other chronic disease unspecified pleural effusion congestive heart failure, unspecified unspecified septicemia severe sepsis atrial fibrillation pulmonary collapse hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease acute respiratory failure other and unspecified coagulation defects acute leukemia of unspecified cell type, without mention of having achieved remission 

Answer: The patient is high likely exposed to