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: shortness of major surgical or invasive procedure: right-sided thoracentesis ct-guided biopsy of a lung nodule cardiac catheterization history of present illness: the patient is a 61 year old hatian-creole speaking female who presented on with shortness of . history taken via interpreter. the patient reports intermittent sob over the past year. she was admitted for an extended period of time to hospital in of this year and had an extensive workup which included the diagnosis of severe dilated cardiomyopathy. she reports that she returned from a trip to approximately three weeks ago. immediately following her return she started experiencing worsening of her shortness of . she also was experiencing pain in legs bilaterally as well as lower extremity swelling. on presentation she endorsed paroxysmal nocturnal dyspnea and orthopnea also endorsed a cough productive of white sputum. at baseline she is able to walk blocks without shortness of but on presentation had dyspnea with one or two steps. she also reported an itchy rash on her chest, back and feet which has only been present "while she has been sick." finally in the er she was noted to have "vulvar masses." . in the er she was found to be hypertensive with sbp in the 170s for which she was started on a nitroglycerin drip. she also required bipap for two hours. she received lasix 40 mg iv x1, levofloxacin 750 mg iv x1, aspirin 325 mg x1 and zofran 4 mg iv x 1. cxr showed a r. sided pleural effusion and a ct torso revealed multiple filling defects which were felt to represent chronic pulmonary emboli and not an acute process. she was started on lovenox and transfered to the medicine service. . review of systems: denies fevers/chills, headache, chest pain or pressure, and abdominal pain. has noted a decrease in her appetite for a while, with some weight loss (unable to quantify), but recently this is improved. denies n/v, abdominal pain, diarrhea, constipation, brbpr. past medical history: chf - ef 15-20% global hypokinesis h/o + ppd (15 mm) in at , afb neg x 3, untreated chronic pe and r. dvt pulmonary nodules on ct of unclear etiology valvular disease: 3+ tr, 3+ mr, significant pr ? liver problem diagnosed in (records not available) social history: she currently is living wither her daughter. she came from one year ago and her husband is still there. she does not smoke or drink. she denies illicit drug use. family history: both her mother and her father died suddenly. she does not know how old they were when they died. she ahs one brother and 3 sisters who are all healthy to her knowledge. she has nine children and 18 grandchildren who are also healthy. no known family history of heart disease. physical exam: admission physical exam: vs-t96.8 bp108/90 p85 rr18 100%o2 on 4l gen- older dark-skinned woman lying in bed sleeping, breathing only slightly labored on supplemental o2 by nasal cannula heent- sclerae anicteric, perrl, eoms full neck- supple, without lymphadenopathy. no jvd seen at 30 degrees. lungs- good sounds in upper and mid lung fields. reduced sounds over r base, with dullness to percussion there. some minor crackles in l base. heart- regular rhythm, no m/r/g abd- soft, ?somewhat distended abdomen (unknown baseline), without tenderness. liver edge palpable ~1-1.5in below rib margin, nontender and with no palpable nodularity. +bs ext- no pretibial edema bilat. trace edema at ankles. good dp pulses. guaiac negative per ed (not repeated here) . discharge physical exam: vitals: t: 98.8 bp: 84/63 p: 88 r: 20 o2: 97% on ra . general: thin appearing elderly woman, sitting up in bed in no acute distress heent: perrl, eomi, oropharynx clear neck: supple, no lad, jvp not elevated breast: no masses noted on my exam, no nipple discharge, no adenopathy cv: rrr, s1 + s2, ii/vi hsm heard best at apex radiating to axilla lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: non-tender, non-distended, bowel sounds present ext: wwp, 2+ pulses, no c/c/e skin: rash on her back, chest and the soles of her feet. her palms are not involved. the rash on her feet is hyperpigmented discrete macules. on her back and chest she also has irregular shaped hyperpigmented, slightly raised lesions. gu: 2 cm round, soft mass within left labia minora, non-tender lymph: no cervical, axillary, or inguinal lad pertinent results: admission laboratories: ========================================== hematology: 09:25pm wbc-4.0 rbc-4.13* hgb-12.0 hct-37.4 mcv-90 mch-28.9 mchc-32.0 rdw-17.9* 09:25pm neuts-31* bands-0 lymphs-60* monos-5 eos-2 basos-1 atyps-1* metas-0 myelos-0 09:25pm hypochrom-2+ anisocyt-1+ poikilocy-occasional macrocyt-normal microcyt-normal polychrom-normal 09:25pm plt smr-normal plt count-202 09:25pm pt-15.8* ptt-38.5* inr(pt)-1.4* plts 172-225 . chemistries: 09:25pm glucose-100 urea n-14 creat-1.0 sodium-145 potassium-3.7 chloride-110* total co2-24 anion gap-15 09:25pm alt(sgpt)-19 ast(sgot)-33 ld(ldh)-298* alk phos-202* amylase-117* tot bili-1.8* 09:25pm lipase-32 09:25pm albumin-3.1* calcium-9.0 phosphate-3.7 magnesium-1.8 d-dimer-4878* . other admission labs: probnp-7535* toxicology asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 03:26am lactate-4.2* 09:31pm lactate-2.0 02:00am d-dimer-4878* 05:00am urinalysis - negative . cardiac enzymes: 02:00am ck(cpk)-101 ck-mb-3 ctropnt-0.02* 08:30am ck(cpk)-56 ck-mb-notdone ctropnt-0.01 03:45pm ck(cpk)-47 ck-mb-notdone ctropnt-0.01 05:00pm ck(cpk)-62 ck-mb-notdone ctropnt-<0.01 . other laboratories: ================================================ iron studies: iron-28* caltibc-350 ferritn-78 trf-269 . lipid panel: triglyc-123 hdl-30 chol/hd-4.5 ldlcalc-79 cholest-134 . hepatitis panel: hbsag-negative hbsab-negative hcv ab-negative hiv ab-negative anca-negative b . thyroid: tsh-2.2 . rpr: non-reactive . induced sputum samples: : negative afb : negative afb : negative afb . pleural fluid cytology- negative for malignant cells. reactive mesothelial cells, histiocytes and lymphocytes . flow cytometry, peripheral blood- interpretation: non-specific t-cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by non-hodgkin's b-cell lymphoma are not seen in specimen. correlation with clinical findings is recommended. flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. . discharge laboratories: ================================================== hematology: cbc: wbc: 3.4 hgb: 10.8 hct: 34.3 plts 213 coags: pt: 23.4 ptt: 64.0 inr: 2.3 . chemistries: na: 140 k: 5.1 cl: 105 hco3: 26 bun: 25 cre: 1.0 glu: 88 ca: 10.1 mg: 2.1 p: 5.3 alt: 13 ast: 24 ldh: 269* ap: 114 total bili: 1.0 ggt: 222 . studies: ==================================================== ecg, - nsst changes laterally . cxr, portable, - right pleural effusion with associated consolidation, likely atelectasis. however, pneumonic consolidation cannot be excluded and clinical correlation is recommended . cta & ct abd/pelvis, - 1. multiple eccentrically located filling defects and linear webs in the branches of the pulmonary arteries as described above, concerning for chronic pulmonary emboli. no defintite acute pe is identified. 2. multiple nodular opacities measuring up to 9 mm in diameter. followup ct exam within three months is recommended. 3. gallbladder wall thickening and edema with calcified gallstones suggestive of acute cholecystitis. correlate clinically. . bilat le us, - 1. extensive occlusive dvt of the right distal femoral, popliteal and posterior tibial veins with more acute clot distally and a more chronic appearance proximally. 2. chronic dvt with recanalization of the right superficial femoral vein. 3. no definitive evidence of left-sided acute or chronic thrombus, however, some wall irregularity is noted. . echo (tte), - conclusions: the left atrium is markedly dilated. the right atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. the left ventricular cavity is moderately dilated. there is an inferobasal left ventricular aneurysm. there is severe global left ventricular hypokinesis (lvef = 15-20%). the distal anterior, distal lateral and apical segments have relatively preserved function. the right ventricular cavity is markedly dilated. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. an eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is mild pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. impression: severe biventricular hypokinesis/akinesis. moderate to severe mr . right ventricular pressure/volume overload. the estimated pulmonary artery systolic pressure is likely underestimated due to elevated right atrial pressures. . cxr, portable, - reason: evaluate for ptx s/p r thoracentesis in comparison with the study of , there has been removal of a substantial amount of fluid from the right pleural space. no convincing evidence of pneumothorax. . rest thallium, viability scan, - 1. normal myocardial perfusion, viable myocardium. 2. increased left ventricular cavity size. . cxr, pa & lat, 12:03pm- reason: questionable reaccumulation of right pleural effusion. there is interval increase in right pleural effusion ], which appears to be partially loculated with predominantly increased anterolateral rather than posterior component of pleural fluid. the cardiomegaly is moderate-to-severe and unchanged. the lungs are clear except for unchanged opacity in the right mid lung consistent with area of atelectasis demonstrated on a torso ct from . . cxr, portable, 4:19pm- reason: evaluate acute pulmonary edema, patient with acute shortness of , 15%. comparison is made with prior study performed four hours earlier. there have been no acute interval changes. marked cardiomegaly, right pleural effusion are unchanged. there is no pneumothorax and overt chf. . ekg, - sinus rhythm with premature ventricular beat. left atrial abnormality. probable left ventricular hypertrophy. compared to prior tracing of . q-t interval is slightly shorter. otherwise, no major change is evident. . ct chest w/o contrast, - reason: please assess pulmonary "nodules" noted in cta for round atelectasis chf vs. masses, suspicious for malignancy. impression: one-week stability of multiple roughly nodular subpleural lesions in the lower lungs argues against bacterial infection, such as septic emboli, and could be due instead to more indolent pathogens such as nocardia or even fungus. involution of the thymus also argues for an infection, but more likely is vasculitis, including wegener or churg-, and lymphoma, including lymphomatoid granulomatosis. . ekg, - sinus rhythm. left atrial abnormality. left ventricular hypertrophy. diffuse st-t wave changes - could be due in part to left ventricular hypertrophy. clinical correlation is suggested. since previous tracing of , further st-t wave changes seen. . ct-guided needle biopsy, - successful right lower lobe lung nodule biopsy. the patient tolerated the procedure well without any immediate post-procedure complications. pathology results on tissue sample pending. . cxr, portable, - reason: post lung biopsy comparison: chest radiographs of , ct of the chest from , as well as screen capture images from ct-guided lung biopsy performed earlier on the same day. impression: no increase in small right pleural effusion, no pneumothorax and no new parenchymal opacity are present after ct-guided lung biopsy. multiple lung lesions are better evaluated on the ct scan of three days prior. moderate-to-severe cardiac enlargement with prominence of the left ventricle is unchanged. no new pulmonary lesions are identified. . cardiac catheterization : 1. coronary angiography in this right dominant system demonstrated an lmca, lad, lcx and rca all without angiographically significant disease. 2. limited resting hemodynamics revealed severely depressed cardiac index of 1.3 l/min/sq meter. pulmonary artery pressures were markedly elevated, as were biventricular filling pressures. 3. iv lasix was given in the lab and milrinone was initiated. the patient tolerated milrinone load well and was transferred to the ccu with stable blood pressure for further care of her heart failure. brief hospital course: 61 yo haitian-creole-speaking female who presented with shortness of and unclear past medical history, revealed to have r pleural effusion, ef 15-20% on echo, chronic pes and r dvt, and pulmonary nodules on ct of unclear etiology . systolic congestive heart failure: on admission the patient was complaining of shortness of and was found to have a bnp in the 7535. she was found on echocardiogram to have severe global hypokinesis, with etiology unclear and no focal abnormality. prior to this admission she was not taking any medications for her congestive heart failure despite being diagnosed with heart failure at hospital in of this year and was found to have an ejection fraction of 24%. during this admission, the patient was informed of her problem and the importance of outpatient follow up and chronic medication adherence was emphasized. diuresis was performed with iv lasix, with good response and she was ultimately transitioned to an oral regimen. she lost a total of 6kg during this diuresis. additional cardiac medications were gradually added during the admission, and her sbp held in the 80s-100s. this medication regimen included lasix 10 mg po daily, lisinopril 5 mg po daily, and toprol xl 25 mg po daily. she was followed by the congestive heart failure service throughout this admission who adjusted this regimen to optimize her function and symptoms. she was observed on telemetry throughout her stay with baseline normal sinus rhythm with frequent premature ventricular contractions. a cardiac catheterization on was significant for no angiographically apparent disease in all vessels, a ci of 1.3, svr 3015, and elevated biventricular filling pressures as well as pa pressures. she briefly was transferred to the cci to allow for her to receive milrinone and iv lasix for more aggressive diuresis. on the floor, she tolerated the above medication regimen well. her baseline sbp was 80s-90s, but she was asymptomatic without lightheadedness, dizziness, chest pain or shortness of . she was oxygenating well on room air. she will be following up with dr. in the clinic. . pulmonary nodules: patient was noted to have multiple nodular opacities on admission ct scan. of note she also had a ct scan during her admission to hospital in of this year at which time she was also noted to have "ground glass opacities, peribronchial thickening and mediastinal and hilar lymphadenopathy as well as a small right pleural effusion." she underwent bronchoscopy and biopsy at hospital which was negative in but was not directed. she underwent ct guided biopsy of a nodule during this hospitalization which was negative for malignancy but showed reactive cells. she underwent three induced sputum samples which were afb stain negative for tuberculosis. she will follow up in the pulmonary clinic here at for further management. she will likely need a vats biopsy as an outpatient for further investigation of these nodules. . pulmonary embolism: patient diagnosed with subacute pulmonary embolisms on admission. she had an elevated d-dimer at 4878. she was also diagnosed with chronic right sided dvt. it is unclear why the patient is so coagulopathic. given the patient's prolonged illness and weight loss there was concern for malignancy. the patient was also experiencing hemoptysis and vaginal bleeding. per her records from hospital it appears that the vaginal bleeding is chronic and was worked up with a transvaginal ultrasound in which revealed a 5 mm endometrial stripe. the hemoptysis was new on this admission. it began upon initiation of anticoagulation. she had three negative induced sputum samples for tuberculosis. she had a ct guided biopsy of her pulmonary nodules which was negative for malignancy. she was seen by the pulmonary service who recommended that there was no contraindication to her anticoagulation given that her degree of hemoptysis was slight. for the majority of her hospitalization she was anticoagulated with a heparin drip and ultimately transitioned to warfarin for chronic anticoagulation. on discharge her inr was 2.3. she will follow up in coumadin clinic at . . abnormal cbc: on admission the patient was noted to have a lymphocytosis on differential with a normal wbc. of note this was also present on differential from her hospital admission. differential diagnosis for a lymphocytosis is extremely broad and includes infectious, autoimmune, hypersensitivity, malignant and pre-malignant states. flow cytometry revealed non-specific t-cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by non-hodgkin's b-cell lymphoma were not seen in specimen. no etiology was found for her abnormal differential. outpatient hematology follow up may be warranted. . abnormal liver enzymes: on admission the patient was noted to have a midly elevated ldh and alkaline phosphatase. she also was found to have an elevated ggt. on admission she had a ct scan which was consistent with acute cholecystitis. at no time during this hospitalization did she complain of right upper quadrant pain. her enzyme abnormalities were attributed to congestive heart failure leading to hepatic congestion. they improved over the course of her hospitalization. given her lack of symptoms this was deferred to outpatient management. . vulvar swelling: on admission er physical exam the patient was noted to have "multiple vulvar lesions." on my initial physical exam she pointed out a 1x1 cm firm nodule in labia minora which she says has been present since she gave birth to her children. it is non-painful. the location is consistent with a bartholin's gland cyst. it does not appear infectious. she had a negative rpr during this admission. she may consider gynecology follow up as an outpatient. . breast lumps: on admission physical exam the patient was noted to have a "soft, mobile, non-tender 1.5-2cm lump at the 2:00 position on the right breast and a small, firm, non-tender lump in the 10:00 position on her right breast (exam on )." i was not able to appreciate any abnormalities on my exam. the patient reports that she has never had a mammogram. this may be considered as an outpatient. . vaginal bleeding: patient with noted vaginal bleeding since initiation of anticoagulation for her pulmonary embolism. she describes having blood on the toilet paper when she urinates. in records from her previous hospitalization at hospital she was also noted to have vaginal bleeding and underwent transvaginal ultrasound which revealed a 5 mm endometrial strip no specific abnormalities. she did have a pelvic exam during this hospitalization which revealed scant blood in the vaginal canal. on discharge she reported that the bleeding persisted. need to consider repeat ultrasound and endometrial biopsy as an outpatient. . hemoptysis: the patient began to experience hemoptysis after initiation of anticoagulation. on presentation she had a chronic, non-productive cough. patient did have a positive ppd during this hospitalization and currently has three negative induced sputums on acid fast stain. patient does have a number of pulmonary nodules and underwent ct guided biopsy which was negative for malignant cells and showed reactive cells. at no time was the hemoptysis hemodynamically significant. she will follow up in pulmonary clinic as an outpatient. . positive ppd: the patient was noted to have a 15 mm ppd at hospital in . while on a heparin gtt for her pe/dvts as above, she was noted to have several episodes of hemoptysis. this was discussed with infection control, who recommended placing the patient on tuberculosis precautions and ruling her out for tuberculosis with three induced sputum samples for acid fast stain. this was done successfully. the patient will need 9 months of inh therapy as an outpatient. this can be coordinated by her primary care physician or her new outpatient pulmonologist. . rash: patient reported a pruritic rash on presentation. on exam she has a rash on her back, chest and the soles of her feet. her palms were not involved. the rash on her feet is hyperpigmented discrete macules. on her back and chest she also has irregular shaped hyperpigmented, slightly raised lesions. differential for rashes that involve the soles of the feet is not particularly long. includes secondary syphilis, rickettsial infections, rmsf, guttate psoriasis, hand-foot-mouth disease. she had a negative rpr during this admission. the other above etiologies did not appear consistent with her presentation. she received symptomatic treatment with sarna lotion. . prophylaxis: given her known history of blood clots she was anticoagulated with heparin with a bridge to coumadin. . code: full code . disposition: to home with follow up with her new primary care physician . at . medications on admission: none x1yr. says at one time she was took 2 medications in prescribed by two different doctors. unable to give more details (?for a liver problem). discharge medications: 1. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*2* 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. furosemide 20 mg tablet sig: 0.5 tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. coumadin 2.5 mg tablet sig: two (2) tablet po at bedtime. disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. idiopathic dilated cardiomyopathy 2. congestive heart failure 3. bilateral pulmonary embolism 4. right deep venous thrombosis 5. hemoptysis 6. positive ppd 7. vaginal bleeding 8. pulmonary nodules 9. mitral regurgitation 10. tricuspid regurgitation 11. abnormal liver function tests 12. vulvar lesions 13. breast masses 14. rash discharge condition: stable. on room air. discharge instructions: you were admitted with shortness of on . during this hospitalization you were found to have an enlarged and poorly functioning heart. you were also found to have blood clots in your lungs and in your right leg. you underwent ct-guided biopsy of a pulmonary nodule, which was negative for malignancy. it will be important for you to follow up with cardiology, pulmonary, the coumadin clinic and your new pcp in order to continue to manage these conditions. these appointments with an interpreter have been set up. . please call 911 or your doctor if you develop lightheadness, dizziness, chest pain, worse shortness of , bleeding that will not stop or any other concerning symptom. . you are being discharged on several new medications. it is important to take these medications as prescribed. if you develop lightheadedness or dizziness, please call your doctor. followup instructions: 1. pcp: . , at 2:30 pm at health clinic through the . you will need to come in 15 minutes early (2:15) to fill out paperwork. the clinic is located at , , ma. the phone number is . . 2. coumadin management: your coumadin will also be managed by health clinic. dr. will help you to coordinate this. . 3. cardiology: dr. , phone:, 9:00. 7. . 4. pulmonology: pulmonary breathing test phone: date/time: 10:30, dr. phone: date/time: 11:00. . 5. you should also see an ob/gyn doctor as an outpatient regarding your episode of vaginal bleeding and the mass you have noticed at your vulva. this can be coordinated with dr. . procedure: combined right and left heart cardiac catheterization coronary arteriography using two catheters thoracentesis non-invasive mechanical ventilation closed [percutaneous] [needle] biopsy of lung diagnoses: other primary cardiomyopathies anemia, unspecified mitral valve disorders unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension cardiogenic shock other diseases of lung, not elsewhere classified rash and other nonspecific skin eruption lump or mass in breast dehydration acute on chronic systolic heart failure other pulmonary embolism and infarction other nonspecific abnormal serum enzyme levels tricuspid valve disorders, specified as nonrheumatic lymphocytosis (symptomatic) unspecified noninflammatory disorder of vulva and perineum 

Answer: The patient is high likely exposed to