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: no known allergies / adverse drug reactions attending: chief complaint: shortness of breath major surgical or invasive procedure: central line placement and removal history of present illness: the patient is a 68 year-old female with history of bilateral breast cancer and metastatic kidney cancer, with extensive osseous and pulmonary metastases, who was discharged to nh from on after an admission during which she was diagnosed with extensive bony metastasis, and was treated with t9-l1 posterior fusion for unstable t11 metastasis. reportedly, she developed fever and was found to have decreased oxygen saturation to 80s at room air at the nh and some confusion and was transferred to the ed at . she had denied chest pain, and reported mild sob. denied abdominal pain, diarrhea, or dysuria. denied calf pain. she had been minimally mobile at nh and was taking heparin sq tid for dvt prophylaxis. her vs in the ed were: 99.6 (tm:101),124/91, 20, 96% 4l nasal cannula. a ua was abnormal. and she had an elevated wbc to 15. she had a head ct that did not show evidence of acute cva. unfortunately due to iv access issues (it could not be determined whether she had a power port), she could not obtain a ct chest with contrast to evaluate for pe. but was empirically treated with therapeutic dose of lovenox after a d-dimer was found to be mildly elevated. a chest cxr showed worsening pul edema, but given extensive lung mets, a consolidative process could not be ruled out. she was empirically started on vancomycin and cefepime for uti as well as possible pneumonia, and admitted to the floor. review of systems: (+) per hpi (-) denies chills, night sweats, recent weight loss or gain. denies blurry vision, diplopia, loss of vision, photophobia. denies sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations, lower extremity edema. denies cough, or wheezes. denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. denies rashes or skin breakdown. no numbness/tingling in extremities. all other systems negative. past medical history: oncologic history: : left nephrectomy for 11 cm clear cell renal cell carcinoma : diagnosted with bilateral breast cancer (node-positive on left, er/pr positive, her-2 negative). treated with neoadjuvant dose-dense ac and weekly taxol ending , bilateral mastectomy (after lumpectomy with positive margins), radiation ending . on arimidex since completion of chemotherapy. : ct torso (done because of elevated alk phos) showed 1.5 and 0.6 cm left upper lobe nodules. : left upper lobectomy showed two foci of clear cell renal cell carcinoma. : mri of t/l spine with disease at t10, t11 vertebral bodies, soft tissues t10-t12, and l3 body. ct-guided biopsy consistent with renal cell carcinoma. bone scan also showed involvement of several left ribs. subsequently received xrt to thoracic spine. : began sunitinib; dose reduced over time to 25 mg because of toxicities. sutent ended in because of disease progression. : mri l-spine with t11 disease with persistent mass effect on thecal sac but no significant cord compression, and t9 and t10 disease, all likely unchanged. new t12 compression fracture. significant progression of l3 vertebral body lesion with pathologic fracture and retropulsion of posterior cortex. : ct torso with interval marked progression of innumerable pulmonary mets since . destructive lytic lesion within left femoral head. : xrt to lumbar spine : signed consent for 08-184 trial of avastin and temsirolimus. ct torso showed osseous mets in spine and left ibs, with interva lincrease in size in soft tissue component at t11 encasing thecal sac, invading cord, and invading more than 50% of the spinal canal. at l3, compression fracture with soft tissue component extending into spinal canal. increase in number and size of numerous pulmonary mets bilaterally. destructive lytic lesion within left femoral head. : c1d1 08-184 (avastin/temsirolimus) : ct torso with significant decrease in size of bilateral pulmonary lesions and stable osseous disease with decrease in soft tissue mass at t11 - : admitted for pna, mental status changes, found to have frontal cva, taken off study - ct torso: stable disease other past med hx: - hypertension - breast cancer s/p resection - gout social history: she lives with her 3 sons who assist with her medical care. she used to work at in the gi division. she is a non-smoker, no alcohol or other drugs. family history: father had esophageal cancer. her maternal grandmother had breast cancer in her 70s. physical exam: admission physical exam: vitals: t: 100.4 bp: 132/81 p: 111 r: 28 o2: 100% on 4l nc general: drowsy, confused but orientable, mild respiratory distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad, exam limited by body habitus lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi, mildly decreased air entry. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, +obesity, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place, draining yellow urine. ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical exam: vitals: 96.0 100-140/70-90 90-100 18-22 93-96%ra, requiring some o2 at night general: awake and oriented but anxious appearing heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp difficult to interpret, no lad, exam limited by body habitus lungs: clear to auscultation bilaterally except for mild anterior wheezes (unable to get full posterior lung exam due to pain) and some bibasilar crackles cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, obese, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place, draining yellow urine ext: warm, well perfused with 2+ nonpitting edema on all four extremities, lue>rue pertinent results: admission labs 05:05pm wbc-15.7*# rbc-3.09* hgb-9.2* hct-28.1* mcv-91 mch-29.8 mchc-32.9 rdw-16.6* 05:05pm neuts-96.5* lymphs-1.6* monos-1.5* eos-0.3 basos-0.1 05:05pm plt count-263 05:05pm pt-15.0* ptt-50.1* inr(pt)-1.3* 05:05pm glucose-100 urea n-12 creat-0.9 sodium-136 potassium-3.8 chloride-101 total co2-25 anion gap-14 05:38pm lactate-2.0 08:43pm d-dimer-2523* 06:15pm urine blood-sm nitrite-neg protein-100 glucose-neg ketone-tr bilirubin-sm urobilngn-8* ph-5.5 leuk-lg 06:15pm urine rbc-14* wbc-173* bacteria-mod yeast-none epi-2 trans epi-1 06:15pm urine color-amber appear-hazy sp -1.030 discharge and other pertinent labs: 04:34am blood wbc-8.6 rbc-2.94* hgb-8.7* hct-27.1* mcv-92 mch-29.6 mchc-32.1 rdw-16.5* plt ct-281 04:34am blood pt-14.7* ptt-38.7* inr(pt)-1.3* 12:29pm blood esr-81* 04:09am blood ret aut-2.3 04:34am blood glucose-94 urean-14 creat-0.7 na-136 k-4.0 cl-105 hco3-21* angap-14 04:09am blood ld(ldh)-226 totbili-0.5 04:34am blood totprot-pnd calcium-7.0* phos-2.0* mg-2.0 04:09am blood hapto-348* 04:34am blood tsh-pnd 04:09am blood cortsol-19.5 04:09am blood crp-greater th 08:41am blood lactate-1.4 cxr: upright frontal chest radiograph: a right-sided catheter terminates within the right atrium. spinal fusion hardware in the mid thoracic region is unchanged in position. multiple left upper quadrant surgical clips are present. again seen are innumerable pulmonary nodules, compatible with known history of metastatic disease. since the examination, there has been interval increase in pulmonary vascular congestion and mild underlying pulmonary edema is present. small bilateral pleural effusions are present. there is no pneumothorax. ct head w/o contrast: no acute intracranial process or evidence. no evidence of metastatic disease, though please note mri is more sensitive. cta chest: 1. no pulmonary embolism or acute aortic pathology. 2. ground-glass opacification in the right middle lobe likely reflects infectious process with new right greater than left small-to-moderate pleural effusions. 3. innumerable pulmonary metastases, many of which are increased in size. unchanged left sixth rib, left pectoral and t11 vertebral body metastases with interval vertebral fusion, which is incompletely characterized. lle us: 1. no left lower extremity dvt above the knee. 2. diffuse subcutaneous edema. lue us: 1. no left upper extremity dvt. 2. diffuse subcutaneous edema. tte: the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. an eccentric, laterally directed jet of at least mild to moderate (+) mitral regurgitation is seen (likely moderate 2+). the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. : mri t/l spine: metastatic disease to l3 vertebral body is again identified and unchanged. indentation on the thecal sac and moderate spinal stenosis is also seen at this level. fluid collection is identified in the upper lumbar posterior soft tissues at l1 level measuring 3 x 2.5 cm which likely is postoperative in nature, but mri appearances alone cannot help in excluding infection in this postoperative collection and clinical correlation is recommended. : ct t/l spine: 1. no evidence of retroperitoneal fluid collection, however, a large fluid collection in the subcutaneous fat posterior to the paraspinal region extending from l2-t10, larger than on mr from 2 days prior. in order to visualize if this is a csf leak, a ct myelogram would be a more appropriate study. 2. l3 compression fracture secondary to metastatic disease. lytic lesion within the posterior rib at the t8 vertebral level. 3. multiple pulmonary metastatic nodules. bilateral pleural fluid, right greater left. 4. cholelithiasis. 5. possible kink in the centralv enous catheter on the scout, unchanged from prior cta chest - d/w rn taking care of pt by dr. on . pending studies: - pleural fluid cytology - tsh - pleural fluid beta2-transferrin and protein electropheresis - blood cultures pending, no growth to date - pleural fluid culture, no growth to date brief hospital course: 68 year-old female with history of bilateral breast cancer and metastatic kidney cancer with extensive osseous and pulmonary metastases who was discharged to nh from on after an admission during which she was diagnosed with extensive bony metastasis, and was treated with t9-l1 posterior fusion for unstable t11 metastasis. on this admission, she presented with fevers, confusion, hypoxia and felt to have sepsis due to uti. #. hypotension: she was admitted with hypotension that was fluid responsive. it was ultimately felt to be sepsis due to uti. she did not require pressors. she was ruled out for pe. am cortisol was 19.5. tte was unremarkable. she was initially treated with vancomycin and cefepime which was narrowed to cipro and then changed to bactrim. #. hypoxia: she has extensive pulmonary disease as evidenced by her cxr and cta. no evidence of pe as above. she had the new development of pleural effusions felt to be either related to her spinal wound drainage or the fluid resuscitation in the icu. she responded well to one dose of lasix but further doses were deferred as she was on room air most of the time and refused further labs draws. she also responded to nebulizers at times. # urinary tract infection: admission ua was consistent with infection. urine culture grew e coli and klebsiella both sensitive to cipro and bactrim. she was initially on broad spectrum antibiotics and then narrowed to cipro. there was some concern for delirium induced by cipro and her antibiotics were changed to bactrim. she is being discharged with a chronic foley. #. wound drainage s/p spinal fusion: she recently had spinal fusion on and her wound drained a large amount of serous fluid during her admission. her orthopedics team followed her wound and consulted neurosurgery. she had multiple imaging studies that showed a fluid collection around the wound. there was concern that her new pleural effusions may be related to leakage of csf. therefore, she underwent thoracentesis to sample the fluid. beta2 transferrin and pep are pending at the time of discharge, which will help determine if the pleural fluid is csf. the neurosurgery team will follow-up these studies as an outpatient and decide if a lumbar drain is needed. she has follow-up scheduled with neurosurgery. #. metastatic renal cancer with mets: patient was recently found to have extensive bony mets and has reportedly had difficulties controlling pain. palliative care follwed during this admission for titration of pain control meds. #. anemia: likely anemia of chronic disease secondary to underlying cancer. received 1 unit prbc on with good response. hemolysis labs were unremarkable. # htn: valsartan was held given episode of hypotension that responded well to fluid boluses. it can be restarted after discharge. #. port-a-cath blockage: she had difficulty with blood return from her port. she refused a chest film to confirm patency of indwelling chest port. there was also some concern that the line was kinked on her ct chest. her line was given tpa in an attempt to clog it. blood return was achieved and line was patent on dc. #. delirium/anxiety: she was mildly delirious during her admission with difficulty with attention. this is likely related to her ongoing medical issues, as well as pain. she responded well to olanzapine 2.5mg po at night, and also was written for ativan as needed. she continued to be anxious, requiring frequent reminders of her medical plan. #. goals of care: the patient was refusing multiple procedures and studies during this admission. she was following by primary care and her primary oncologist. she expressed a desire to focus on comfort, but a full discussion of hospice was deferred until her delirium improves. she refused all labs and xrays over the last 1-2 days of her admission. transitional issues: - pending studies: tsh, blood culture, pleural fluid culture, cytology, beta2 transferrin and pep - needs neurosurgical/ortho-spine followup for her wound in 2 weeks. it has continued to drain serous fluid requiring multiple changes per day. medications on admission: - anastrozole 1 mg tablet 1 tablet(s) by mouth once a day (not taking as prescribed: no prescription now so not taking) - levothyroxine 50 mcg tablet 1 tablet(s) by mouth once a day - lorazepam 0.5 mg tablet tablet(s) by mouth three times a day as needed for anxiety - ondansetron 4 mg tablet, rapid dissolve 1 tablet(s) by mouth every 8 hours as needed for nausea - oxycodone 5 mg tablet 1 tablet(s) by mouth every 4 hours as needed for pain - oxycodone 10 mg tablet extended release 12 hr 2 tablet(s) by mouth twice a day - prochlorperazine maleate 10 mg tablet 1 tablet(s) by mouth every six (6) hours as needed for nausea/vomiting - simvastatin 10 mg tablet 1 tablet(s) by mouth once a day - valsartan 160 mg tablet 1 tablet(s) by mouth once a day hold for bp < 110 - acetaminophen 325 mg tablet 1 tablet(s) by mouth every 6 hours (otc) prn - aspirin 81 mg tablet, chewable 1 tablet(s) by mouth daily - docusate sodium 100 mg capsule 1 capsule(s) by mouth discharge medications: 1. anastrozole 1 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 3. lorazepam 0.5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for anxiety. 4. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 5. oxycodone 60 mg tablet extended release 12 hr sig: one (1) tablet extended release 12 hr po q8h (every 8 hours). 6. hydromorphone 2 mg tablet sig: 3-5 tablets po q3h (every 3 hours) as needed for pain. 7. prochlorperazine maleate 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 8. simvastatin 10 mg tablet sig: one (1) tablet po once a day. 9. docusate sodium 100 mg tablet sig: one (1) tablet po twice a day. 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 13. lactulose 10 gram/15 ml syrup sig: fifteen (15) ml po bid (2 times a day): hold for loose stool. 14. olanzapine 2.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia: patient may refuse. 15. enoxaparin 30 mg/0.3 ml syringe sig: thirty (30) mg subcutaneous q12h (every 12 hours): for prophylaxis. 16. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day) for 5 days. 17. ipratropium bromide 0.02 % solution sig: one (1) nebulization inhalation q6h (every 6 hours) as needed for wheeze. discharge disposition: extended care facility: rehab discharge diagnosis: primary diagnosis: urinary tract infection pleural effusions wound fluid collections metastatic renal cell carcinoma secondary diagnosis: hypertension gout discharge condition: activity status: out of bed with assistance to chair or wheelchair. level of consciousness: alert and interactive. mental status: confused - sometimes. discharge instructions: you were admitted to the hospital due to fevers, confusion and low blood pressures felt to be related to an urinary tract infection (uti). you were admitted to the icu and were given antibiotics for your uti and your symptoms improved. your oxygen level was also low on admission, but improved prior to discharge. it was felt to be due to some fluid around your lungs, as well as the cancer in your lungs. you had a procedure where fluid was removed around your lungs. you were also evaluated by the orthopedic surgeons and neurosurgeons due to concern about leakage from your wound. it is still leaking significantly and you have labs that are pending to determine the source of leakage. your neurosurgery team will follow-up on these studies. changes to your medications: add bactrim 1 ds tab by mouth twice daily for 5 more days increased oxycontin to 60mg by mouth every 8 hours add olazapine 2.5mg by mouth at bedtime as needed add enoxaparin 30 mg sc every 12 hours for prophylaxis followup instructions: you have the following appointments scheduled: department: spine center when: friday at 9:30 am with: , md building: sc clinical ctr campus: east best parking: garage *you should discuss with him if you need a separate appointment with dr. * procedure: thoracentesis diagnoses: unspecified pleural effusion urinary tract infection, site not specified unspecified essential hypertension friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site unspecified septicemia severe sepsis gout, unspecified personal history of malignant neoplasm of breast constipation, unspecified septic shock seroma complicating a procedure do not resuscitate status secondary malignant neoplasm of lung hypovolemia personal history of malignant neoplasm of kidney delirium due to conditions classified elsewhere secondary malignant neoplasm of bone and bone marrow anemia in neoplastic disease arthrodesis status other and unspecified escherichia coli [e. coli] adjustment disorder with anxiety 

Answer: The patient is high likely exposed to