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: iodine; iodine containing attending: chief complaint: hypoxemia major surgical or invasive procedure: bronchoscopy ultrasound guided thoracentesis history of present illness: this pt is a 65 yr old female with pmhx significant for stage iiib non-small cell lung ca s/p one cycle of taxol/carboplatin and xrt admitted for with shortness of breath and hypoxemia. the patient states that she has had a persistent cough since her lung biopsy performed three weeks ago. she was initially diagnosed w/ nsclc due to 3 weeks of an intractable dry cough. in she also had mri of brain which showed small right cerebellar metastasis. she states that she has had a chronic dry cough for months but in the last three weeks it has turned productive with clear sputum. she also complains of doe for the last two weeks. she also c/o recent decrease in po intake and per her husband she has lost ~ 10 lbs over the last three months. on , day for her xrt she was note to have a temp of 100.4 w/ a persistent productive cough. at that time a cxr showed lul density and she was started emprically on levofloxacin. despite taking levo x 4 days pt saw little improvement in her condition. she persisted to have fevers with chills while taking tylenol and had a temp of 102 and came to ed. she denies any nausea, vomiting, chest pain, le edema (though present in ), calf pain, palpitations, or change in sputum culture. in ed she was found to have temp 100.4, hr 115-125, bp 123/61, rr 32, 92% ra. she was found to have a wbc of 14k, hct 32, d-dimer > 8000, lactate of 2.5, abg 7.49/33/66 on 4l nc. cxr also showed new lll retrocardiac density. ecg showed sinus tachycardia, low voltage (previously present), and new q waves in v2-v4 compared to ekg from . cta angio not performed b/c pt has a hx of hives from contrast allergy in past. she was started in heparin drip, given cefepime 2 gm iv x1, and 1l ns then transferred to the for monitoring of her hypoxia. past medical history: poorly differentiated adenocarcinoma of the lung s/p chemo/xrt metastasis to the r cerebellum in anxiety depression type 2 dm x 2 months uterine ca in ' s/p xrt social history: she is married and retired. she worked in a medical records department. she has 6 children, 11 grandchildren. she smoked for 25 years a pack a day. she quit about 16 years ago. family history: pertinent in that her mother died at age 62 with complications of diabetes, and someone in her family either her mother or sister evidently had renal cell carcinoma. her one sister was recently diagnosed with breast cancer. her father died of an mi. no other history if lung cancer. physical exam: admission: vs temp 100.7 bp 138/57 p 120 rr 32 sao2 94% 2l today: tm 100.7 tc 98.9 bp 122/53 (110-141/52-62) p 107 (92-120) sa o2 95% 4l nc 17 hours (/0) gen: lying in bed sweating, persistently coughing, breathing quickly. heent: no scleral icterus, perrl, eomi, mmm, no jvd. chest: + erythema over area of biopsy site, warm to palpation, nontender, no drainage. lungs: tachypneic, decreased bs in lll & lul, egophany rul cardiac: tachycardic nl s1 s2 no m/r/g abdomen: soft nt nd + bs no hsm. extremities: no c/c/e. neuro: a&o x3. report some decreased hearing on r ear. cn ii-vii & -xii intact. dysmetria on right finger to nose. reflexes wnl. pertinent results: echo: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. left ventricular systolic function is hyperdynamic (ef 80%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated. there are complex (>4mm and/or mobile) atheroma in the aortic root. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but not stenotic. there is no valvular aortic stenosis. the increased transaortic gradient is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. ---- cta: 1. multiple right lung pulmonary emboli. 2. large left hilar mass and marked mediastinal adenopathy with left upper lobe atelectasis. 3. bilateral pleural effusions, left greater than right ---- mri head: 1. no abnormal areas of enhancement. 2. nonspecific small t2 and flair signal abnormality in the left cerebellum. recommend correlation with outside studies 3. chronic lacunar infarct in left centrum semiovale. ---- cxr: interval increase in left upper lobe opacity around the apical mass and worsening of left lower lobe retrocardiac consolidation. these findings are concerning for a pneumonic process vs obstructive pulmonary collapse. ---- cxr: diffuse density in the left upper lobe area with concave delineation is compatible with atelectasis in left upper lobe area. the density obliterates partially also the aorta and the mediastinal structures. in the left hila area, an additional convex contour is noted indicative of a centrally located mass most likely the cause of the atelectasis in the left upper lobe as it results in central, subtotal airway obstruction. the diaphragmatic contour on the left side is obliterated. the same holds for its invisibility on the lateral view indicative of both pleural effusion and atelectasis in the posterior segment of the left lower lobe. the right lung remains aerated with somewhat irregular vascular distribution, possibly related to the previously demonstrated pulmonary embolism. the right-sided mediastinal contour is also prominent suggestive of upper mediastinal widening related to adenopathy and/or venous congestion. there is only mild blunting of the right lateral and posterior pleural sinus. comparison with the next previous ap single chest view obtained on , both the atelectasis in the left upper lobe and the hilar density appear to have increased. there is no evidence of any pneumothorax as it existed on more remote examinations. ---- 12:30pm blood wbc-14.4* rbc-3.87* hgb-10.1* hct-32.0* mcv-83 mch-26.0* mchc-31.5 rdw-14.5 plt ct-210 12:30pm blood neuts-89.8* bands-0 lymphs-7.7* monos-2.2 eos-0.2 baso-0.1 12:30pm blood plt smr-normal plt ct-210 12:50pm blood wbc-5.0 rbc-3.93* hgb-10.7* hct-32.1* mcv-82 mch-27.2 mchc-33.3 rdw-16.4* plt ct-483* 12:50pm blood plt ct-483* 12:30pm blood pt-13.7* ptt-22.6 inr(pt)-1.3 12:30pm blood d-dimer-8789* 01:10pm blood ret aut-3.6* 12:30pm blood glucose-148* urean-13 creat-0.6 na-136 k-3.8 cl-97 hco3-22 angap-21* 12:30pm blood ck(cpk)-50 04:25am blood ck(cpk)-32 12:30pm blood ck-mb-3 ctropnt-0.62* 04:25am blood ctropnt-0.43* 06:50am blood ld(ldh)-607* totbili-0.5 dirbili-0.3 indbili-0.2 04:25am blood calcium-8.3* phos-3.0 mg-2.0 07:25am blood albumin-2.5* calcium-7.8* phos-3.2 mg-1.9 12:30pm blood iron-15* 12:30pm blood caltibc-216* ferritn-993* trf-166* 12:30pm blood caltibc-216* ferritn-993* trf-166* 12:30pm blood tsh-1.1 12:38pm blood lactate-2.5* 08:45am urine color-straw appear-clear sp -1.012 08:45am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-tr 08:45am urine rbc-0 wbc-0 bacteri-none yeast-none epi-0-2 11:59am pleural wbc-250* rbc-9625* polys-84* lymphs-3* monos-5* meso-8* 11:59am pleural totprot-1.8 glucose-74 ld(ldh)-309 03:00pm bal fluid: wbc-111* rbc-2267* polys-34* lymphs-5* monos-60* mesothe-1* blood cultures (>10) negative for growth over month. urine cultures (5) negative, except for 1 which had yeast. bal fluid grew no bacteria, but did grow albicans. pleural fluid culture negative. brief hospital course: mrs is a 65 yo female w/ pmhx significant for a recent diagnosis of nsclc s/p chemo/xrt admitted for persistent fever, sob, cough x 5 days and found to have leulocytosis, elevated d-dimer, and new lll findings on cxr. the following issues were addressed during her extended hospitalization: 1.pulmonary/pe: she did not have a cta initially due to dye allergy. an echo was done which showed no evidence of right heart strain. she continued to be hypoxic though, and pe was suspected. she was put on heparin empirically and d-dimer was drawn and very high. this could be the result in someone with cancer as well though. she was premedicated and had a cta. it revealed multiple right sided pes. she was continued on the heparin after this finding. she was also continued on oxygen and was maintaining good o2 sats. she remained tachypneic and tachycardic though. due to a recent study in the nejm, which showed a benefit of lmwh over coumadin in cancer patients at preventing recurrent venous thromboembolism, she was started on lovenox instead of coumadin. she continued to be tachypneic and tachycardic for the remainder of the admission. she also continued to require oxygen to keep her sats up. she was switched back to a heparin drip for several days in order to have invasive procedures undertaken without problem. after this, she was put back on lovenox and had no issues with her pes. she was sent out on lovenox 1 mg/kg to prevent recurrence of dvt or pe. 2.fevers/id/pneumonia: she initially presented after having a lul density on cxr while at xrt. this was treated as an outpatient for 4 days with levaquin with no improvement. she had fevers/chills/night sweats for 4 days before admission. when she was admitted, she was started on unasyn in the . she defervesed initially on this and remained so for several days. she continued to have a persistent cough though, and her o2 requirement did not decrease. cxrs continued to show a lul infiltrate and she again began having daily fevers. she was changed to zosyn, but continued to have daily fevers on this. no other source of infection was identified, as she had negative blood cultures, negative urine cultures, and no obvious source of cellulitis/skin involvement. she did continue to have a persistent productive cough, with nothing growing from her sputum. pulmonary was consulted and performed a bronchoscopy. they found that she had no complete airway obstruction, but did have some partial compression of her airways by her tumor. this added to the suspicion that she may have a post-obstructive pneumonia. a bal was performed and grew no bacteria, but did grow albicans. she had some known oral , there was a question of whether this was a contaminant. id was consulted, and she was started on iv fluconazole and azithromycin. the zosyn was also continued. she continued to spike daily fevers through her antibiotics though. repeat cxrs showed a growing pleural effusion on the left. ip was called to do an ultrasound guided thoracentesis. they were able to get very little fluid, despite seeing a large amount on ultrasound. it appeared to be possibly loculated? it appeared to be a transudate, and did not grow anything in culture. she did have a complication of a pneumothorax on that side. she had pain, but kept good o2 sats with this. it was treated with 100% nrb oxygen and followed by serial cxrs. it resolved on its own by the next day and the 100% oxygen mask was stopped. it did not recur. she continued to spike fevers despite the above antibiotics. again, no good source was found. she also continued coughing. multiple blood cultures and urine cultures continued to be sent with no growth. another though physical was performed, with no evidence of skin infection/abscess, oral infection, otitis, sinusitis, or perirectal abscess. she was having no dysuria or abdominal pain, and a lactate was sent and normal. at this point, the main hypothesis was post-obstructive pneumonia, but tumor fever was also a possible cause of these fevers in the face of countless negative cultures, as was drug fever. she had had the fevers as an outpatient though, and none of her drugs were suspicious for causing fevers. also, the candidal lung infection was considered, but her symptoms showed no improvement despite high dose iv fluconazole. ip was consulted about stenting her bronchus to help alleviate a possible post-obstructive pneumonia, but due to her anatomy, she was not a candidate for this intervention. as she had finished a full course of fluconazole with really no change, this medication was stopped. she was also switched to po cipro and augmentin which continued to cover her for all possible gram positive and negative pathogens that we were covering with with her iv antibiotics. she did not have a change in her clinical picture with this switch. the hypothesis on post-obstrucive pneumonia was the most likely, and as she was not a candidate for a pulmonary stent, the plan became to continue radiation therapy and also to restart low dose chemo, with the hope of shrinking the tumor and relieving the obstruction. this was tried, but had not occured after several chemo administrations. her oxygen requirement had been improving slowly though, and she had gradually worked down to needing 2-3 l to maintain good oxygenation. with this, she was eventually sent home with the po ciprofloxacin and augmentin. she continued to have daily fevers, but no positive cultures. her fevers were controlled with tylenol throughout the hospitalization and this worked well. she was also on atrovent nebs here fairly regularly, which helped to keep her breathing easier and her oxygen requirements down. she was sent home with mdis to use. albuterol wasn't used often due to her already persistent tachycardia. 3.tachycardia:she had persistent tachycardia for the entire admission. it was attributed to the pes, fever, anxiety, or some combination of these three. she had an echo which showed no wall motion abnormalities and her cardiac enzymes checked. her troponins were mildly elevated, and this was felt to be a leak from the strain she was under from the pes as opposed to an actual mi. ecgs showed an old mi, but no new ischemic changes. a tsh was normal. she never had any chest pain. her tachycardia continued for the entire hospitalization, but more mildly. her fevers continued as well, so it is difficult to separate the two. the tachycardia was monitored but not treated in this setting. she was also anemic as below, and this may have contributed. 4.anemia: as an inpatient, her hct started gradually drifting downward. she had negative stool guaiacs throughout. no hematuria, no melena, no hematemesis or hemoptysis. iron studies were sent and showed a combination of anemia of chronic disease and possible iron deficiency anemias. she had a normal b12 and folate. hemolysis labs were sent and did not indicate hemolysis. she was transfused on two separate occasions to keep her hct up. she was anticoagulated, so bleeding was considered thoroughly. she never had a source of bleeding identified. the chemo may have been partially responsible for her dropping hct. 5.lung cancer: she continued to receive xrt for most of her hospitalization. she also received several cycles of /taxol while an inpatient, but at low doses due to her acute illness. she tolerated all of this very well. she had an initial mri at an outpatient center that suggested the presence of a brain met. the mri was repeated here on superior equipment, and there was no evidence of any metastases to the brain. near the end of her stay, a planning ct done by rad onc suggested progression of disease rather than regression. her chemo was changed as was her radiation portal. she will continue with this new protocol as an outpatient. a follow-up ct will also be done as an outpatient, as she wasn't able to get one as an inpatient. she will continue with daily outpatient xrt and weekly chemo with dr . 6.diabetes: she was kept on her home glipizide dose and riss to cover for any high blood glucoses. she had fairly good control throughout, with occassional high numbers on days after she received steroids for chemo premedication. otherwise, this was stable. 7.anxiety: she was fairly anxious for much of the hospitalization, as there was a lot going on around her and not many definite answers. she was given ativan prn for this and it worked well. she also used codeine cough syrup at nights, which helped her cough and her insomnia. 8.external yeast infection: she developed a candidal infection in her groin folds. this was treated with miconazole powder effectively. it had begun to return upon discharge, and she was sent home with this treatment to use for herself. she had also had oral candidiasis at one point. this was treated with nystatin s&s along with the iv fluconazole. it resolved with these therapies. 9.pt:she was encouraged to get out of bed frequently, both to prevent atelectasis and deconditioning. she worked with pt often and regained some of her energy and strength. she was eventually able to climb stairs and walk the halls well. she also spent most of her days in a chair instead of in bed. she did require oxygen while ambulating and at rest though. she was discharged home with services for home o2, vna, home pt, and plans to come for daily xrt and weekly chemo. she was continued on her cipro and augmentin, as well as lovenox. she continued to have daily fevers, but they were well controlled with tylenol and she sometimes had to use ibuprofen in addition. she also got mdis and codeine to help ease her breathing and to help control her cough at night. medications on admission: glyburide 2.5 mg qd mvi discharge medications: 1. lorazepam 0.5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for anxiety. disp:*50 tablet(s)* refills:*0* 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 3. glyburide 2.5 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 5. atrovent 18 mcg/actuation aerosol sig: two (2) puffs inhalation three times a day. disp:*1 inhaler* refills:*2* 6. codeine sulfate 30 mg tablet sig: 0.5 tablet po at bedtime as needed for cough. disp:*15 tablet(s)* refills:*0* 7. enoxaparin sodium 80 mg/0.8 ml syringe sig: one (1) injection subcutaneous q12h (every 12 hours). disp:*60 injection* refills:*2* 8. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 9. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 10. prochlorperazine 10 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for nausea. disp:*30 tablet(s)* refills:*0* 11. see order please provide patient with a spacer to use with her mdis. 12. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation three times a day as needed for shortness of breath or wheezing: please be aware that this medicine will cause your heart rate to increase. disp:*1 inhaler* refills:*0* discharge disposition: home with service facility: vna of -east & visiting nurse hospice discharge diagnosis: probable post-obstructive pneumonia non-small cell lung cancer anemia right-sided pulmonary embolism diabetes mellitus anxiety possible pulmonary candidiasis oral pneumothorax discharge condition: she is still having daily fever spikes(usually overnight or in the morning). her o2 requirement is 3lnc and stable. she is able to ambulate well and can climb 10 steps at a time. her cough is still present and productive, but also stable. can be controlled with codeine. she is eating and drinking well. she does not have any pain. post-chemo, she had some nausea this morning, but no vomiting. discharge instructions: please call dr or return to the hospital if you get shortness of breath or chest pains. also call for any uncontrolled dizziness or other symptoms which worry you. please call dr office for the exact time of your follow up appointment scheduled for thursday. you will need to continue your antibiotics (ciprofloxacin and augmentin) until the tumor in your lung shrinks and your obstruction is improved. this can be decided by dr as your treatment procedes. i am sending you home with 2 inhalers. the atrovent is for use every day. the albuterol is to use if you have shortness of breath and feel you need an extra medicine to help you breathe easier. the side effect of the albuterol is that it will make your heart beat faster for a short time. followup instructions: provider: , multi-specialty multi-specialty thoracic unit-cc9 where: clinical ctr. - 9th fl. multi date/time: 2:00 provider: ,hem/onc hematology/oncology-cc9 where: hematology/oncology phone: date/time: 2:00 md procedure: diagnostic ultrasound of heart thoracentesis injection or infusion of other therapeutic or prophylactic substance closed [endoscopic] biopsy of bronchus diagnoses: subendocardial infarction, initial episode of care unspecified septicemia sepsis personal history of malignant neoplasm of other parts of uterus iatrogenic pneumothorax secondary malignant neoplasm of brain and spinal cord candidiasis of lung other pulmonary embolism and infarction malignant neoplasm of main bronchus 

Answer: The patient is high likely exposed to