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: chf, arf, mediastinal lymphadenopathy major surgical or invasive procedure: bronchoscopy x 2 mediastinoscopy with lymph node biopsy history of present illness: 76m initially went to hospital with l flank and sent home with narcs. represented with doe, weight gain and l flank pain. he reports that he has had intermittent doe for year but notice a sharp increase in his weight over a period of 10 days. he gained 8-10lbs with associated le swelling, but without medication noncompliance, dietary changes, chest pain, orthopnea, pnd. this happened at the beginning of and his lasix was increased from 40 to 60 daily. he also had a holter revealing afib (rate 40-100), nuclear stress ()without ischemia and normal echo on (mild as, mild mr). upon arrival to the ed he was found to be hypotensive with hyperkalemia and arf (cr ~4 from basline of 1.2) he was sent to the floor, diuresed and then sent to the icu after he was hypotensive requiring dopamine and vasopressin. he had a swan-ganz catheter placed on and had renally dosed dopamine. he was thought to be fluid overloaded and had a transudative thoracentesis (amount removed unknown). he was aggressively diuresed with lasix and renally dosed dopamine. his renal function improved prior to transfer. swan numbers: ra: 25 rv: 55/20/10 pa: 55/25 pcw: 26 his l flank pain was evaluated with a ct abdomen and he was found to have l nephrolithiasis and an exophytic cyst on the lower pole of the l kidney. his pain has been controlled with narcotics. he had also been recieving zyvox for presumed pneumonia and solumedrol 60 mg q6h for presumed copd. he was transferred for evaluation of his mediatinal lad. this has been watched for seveal years and he has two non-fdg avid pet cts, most recently in . he denies any b symptoms. he does have decreased appetite, but has been active with outside hobbies including golf and curling. the thoracics service was contact for this evaluation and it was suggested that the patient be admitted to the micu given his underlying medical problems. past medical history: past medical history: ==================== af, on coumadin at home cri cr:1.6 chronic anemia chf ef bladder cis s/p bcg washout in colonic dysplastic lesions on bx osa- unable to tolerate cpap low grade nhl with diffuse stable lad as r popliteal artery endarterectomy uretral stent gout pvd l cea ugib lll lobectomy in nephrolithiasis social history: etoh: 2 martinis daily tobacco: quit 1ppd 25 yrs ago outside hobbies included golf and curling family history: no history of malignancy physical exam: tmax: 35.9 ??????c (96.6 ??????f) tcurrent: 35.9 ??????c (96.6 ??????f) hr: 74 (67 - 75) bpm bp: 113/46(60) {112/46(60) - 113/57(71)} mmhg rr: 20 (20 - 24) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) physical examination general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic, mmm lymphatic: cervical wnl, no(t) supraclavicular wnl, no(t) cervical adenopathy cardiovascular: (s1: normal), (s2: normal), (murmur: systolic), iii/vi holosystolic murmur @ apex, iii/vi holosystolic murmur at base peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bilateral bases) abdominal: soft, no(t) non-tender, no(t) bowel sounds present, distended, no(t) tender: , no(t) obese, hypoactive bowel sounds extremities: right: trace, left: absent, no(t) cyanosis, no(t) clubbing skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed pertinent results: echo: the left atrium is elongated. the right atrium is markedly dilated. the right atrial pressure is indeterminate. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef>75%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is mild to moderate aortic valve stenosis (area 1.2 cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. physiologic mitral regurgitation is seen (within normal limits). the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. pathology report 1. lymph nodes, 4l, biopsy (a-c): metastatic neuroendocrine neoplasm, most consistent with carcinoid tumor, in two of ten lymph nodes/lymph node fragments. 2. lymph nodes, 7, biopsy (d): metastatic neuroendocrine neoplasm, most consistent with carcinoid tumor, in three of four lymph nodes/lymph node fragments. see note. 3. lymph nodes, level 7, biopsy (e): metastatic neuroendocrine neoplasm, most consistent with carcinoid tumor, in one of two lymph nodes/lymph node fragments. note: immunohistochemical stains show the tumor cells are diffusely positive for synaptophysin and chromogranin and are negative for ck 7 and ttf-1. rare tumor cells are positive for ck20. despite the negative ttf-1, the tumor is compatible with a lung primary. clinical correlation recommended. flow cytometry : flow cytometry immunophenotyping: the following tests (antibodies) were performed: hla-dr, fmc-7, kappa, lambda and cd antigens: 2,3,5,7,19,20,23, and 45. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. b cells comprise 34% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. t cells comprise 50% of lymphoid gated events, and express mature lineage antigens. interpretation: non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. correlation with clinical findings and morphology (see s08-) is recommended. flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. bronchial washings: bronchial washing, left upper lobe: negative for malignant cells. reactive bronchial epithelial cells and alveolar macrophages. addendum: hematology slide 0559r of bronchoalveolar lavage (bal) was reviewed and shows alveolar macrophages. no evidence of malignancy. cxr: findings: no pneumothorax. there is complete opacification of the left lung, which is indicating collapse in the left upper lung, likely due to mucus plug. there is overlapping opacification, which was seen on the previous film, in the left lower lung which might be postoperative, inflammatory, or malignant and further evaluation is needed. there is a small right pleural effusion, unchanged. there is no consolidation in the right lung. the right jugular line was removed. cxr post-bronch: findings: as compared to the previous examination, the left lung is slightly better aerated. there is no evidence of left-sided pneumothorax. in the right lung, in the middle lobe, some subtle areas of atelectasis are seen. no evidence of larger pleural effusions. cxr: portable chest radiograph: compared to recent studies of , there is improved aeration of the left upper lung, without evidence of new pneumothorax. there persists opacification of the left perihilar and left lower lung, likely representing combination of pleural effusion and atelectasis, although underlying consolidation cannot be excluded. there is also improved aeration of the right lung although small right pleural effusion persists. cxr: reason for exam: status post mediastinoscopy and bronchoscopy. since yesterday, diffuse opacification of the left lung is overall unchanged, mostly in the perihilar and left lower lung region, likely a combination of left pleural effusion and atelectasis, possibly consolidation. small right pleural effusion is unchanged. the right lung is otherwise normal. there is no other change. ct scan chest: impressions: 1. subcutaneous gas consistent with recent mediastinoscopy. a small left lower paratracheal collection containing fluid and gas could represent post- procedural changes. correlation with recent procedure and clinical symptoms recommended. multiple mediastinal lymph nodes are noted. larger soft tissue density in the subcarinal region could represent lymphadenopathy or in the right clinical context could also represent a hematoma. comparison with prior study if available could help differentiate between the two. 2. status post left lower lobectomy with fibrotic changes and atelectasis noted in the left lung. fluid collection with thick enhancing rind in the left posterior sulcus is chronic and organized. 3. nodule in the anterior left lung could represent rounded atelectasis, though in atypical location. recurrent tumor cannot be excluded. 4. moderate right dependent pleural effusion with associated dependent atelectasis of the left lower lobe. 5. left adrenal mass. dedicated imaging of the adrenal glands recommended for further evaluation. there is also suggestion of lymphadenopathy in the retroperitoneum that is incompletely imaged. small ascites noted along the dome of the liver. ekg : normal sinus rhythm. poor r wave progression, possibly related to lead placement. no other abnormality. no previous tracing available for comparison. intervals axes rate pr qrs qt/qtc p qrs t 72 0 88 1 octreotide scan (somatostatin) study date of reason: nhl and lung ca bx showed malignant neuroendocrine neoplasm prelim findings c/w metastatic carcinoid, full report pending. 07:32pm glucose-130* urea n-119* creat-2.2* sodium-141 potassium-3.8 chloride-100 total co2-29 anion gap-16 07:32pm estgfr-using this 07:32pm calcium-9.0 phosphate-5.3* magnesium-2.4 07:32pm urine hours-random urea n-828 creat-45 sodium-less than 07:32pm urine osmolal-427 07:32pm wbc-11.5* rbc-4.11* hgb-11.7* hct-36.4* mcv-88 mch-28.4 mchc-32.1 rdw-15.1 07:32pm neuts-96* bands-0 lymphs-2.0* monos-2 eos-0 basos-0 07:32pm plt count-389 07:32pm pt-33.9* ptt-43.6* inr(pt)-3.6* 07:32pm urine color-yellow appear-clear sp -1.013 07:32pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-sm urobilngn-neg ph-5.0 leuk-tr other labs: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:45am 5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6 288 08:05am 5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7 277 06:45am 5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1 280 07:00am 6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4 242 07:25am 9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5 247 renal & glucose glucose urean creat na k cl hco3 angap 05:45am 96 18 1.0 147* 4.0 105 37* 9 08:05am 81 20 0.9 145 4.0 108 34* 7* 06:45am 77 22* 0.9 1441 4.0 106 36* 6* 07:00am 79 27* 1.0 144 4.1 105 32 11 07:25am 95 30* 1.0 143 4.0 106 33* 8 07:00am 103 37* 0.9 143 4.2 107 33* 7* 03:37pm 104 43* 1.0 147* 4.4 110* 33* 8 02:07am 168* 60* 1.0 146* 4.3 110* 31 9 04:25am 92 87* 1.2 150* 4.2 113* 31 10 07:05am 97 115* 1.7* 147* 4.5 108 31 13 02:52pm 126* 2.0* 05:34am 122* 125* 2.1* 143 4.5 104 28 16 dig added 9:08am 07:32pm 130* 119* 2.2* 141 3.8 100 29 16 07:25am bnp 7554*1 chemistry totprot albumin globuln calcium phos mg uricacd iron 05:45am 8.9 3.2 2.2 08:05am 9.0 3.4 2.3 06:45am 9.0 2.8 2.3 07:00am 8.6 2.7 2.2 hematologic caltibc ferritn trf 05:34am 153* 270 118* dig added 9:08am protein and immunoelectrophoresis pep igg iga igm ife 05:34am no specifi1 1 no monoclo2 dipstick urinalysis blood nitrite protein glucose ketone bilirub urobiln ph leuks 01:50pm neg neg neg neg neg neg neg 5.0 neg source: catheter microscopic urine examination rbc wbc bacteri yeast epi transe renalep 01:50pm 3* 2 few none <1 <1 source: catheter urine casts casthy 01:50pm 9* source: catheter other body fluid analysis wbc rbc polys lymphs monos macro other 08:13am 01 01 71* 8* 6* 15* 02 bronchial lavage 3:37 pm sputum source: expectorated. **final report ** gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. 8:13 am bronchoalveolar lavage bronchial lavage. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. 7:10 pm tissue site: lymph node gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (final ): no growth. anaerobic culture (final ): no growth. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): fungal culture (preliminary): no fungus isolated. potassium hydroxide preparation (final ): no fungal elements seen. legionella culture (final ): no legionella isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. brief hospital course: 76m initially admitted to hospital for chf exacerbation, and then transferred icu-to-icu for workup of chronic mediastinal lad. thoracic surgery had been contact and was interested in seeing the patient and deemed that he would be most appropriate for micu given his ongoing arf. while in the icu his renal function improved with gentle intravascular hydration. echo was performed which revealed severe diastolic dysfunction with ejection fraction of >70%. his digoxin was therefore discontinued. he was discharged to the floor after ~24 hours of observation. while on the medical service, the patient was brought to the or on for flexible bronchoscopy with bronchoalveolar lavage of the left upper lobe, cervical mediastinoscopy and bronchoscopy. on post-op cxr there was noticeable whiteout of the left lung field and the patient was kept in the pacu for observation. he was treated with chest pt, is and suctioning for the thought of possible mucus plugging. as per documentation, the patient was doing well until the morning when he had increasing oxygen requirements and more labored breathing. at 8am on the patient underwent unremarkable bronchoscopy by ip. patient continued to have a significant oxygen requirement, satting 93% on 40% facemask, thus was transferred to the icu for monitoring. in icu on , patient underwent upper airway suctioning, along with albuterol, ipratropium, and mucinex treatment. he utilized incentive spirometry as well. serial chest x-rays showed eventual clearing of his left lung. his oxygen saturation improved to 100% on 4l. he underwent a chest ct which showed a large right pleural effusion and left airspace disease possibly consistent with pneumonia. he continued to produce increasing amounts of airway mucous. though he did not spike a fever or develop a leukocytosis, he was started on empiric coverage for hospital acquired pneumonia with vancomycin and zosyn. this was continued for a total of 4 days, and then discontinued. his respiratory status continued to improve, and he was weaned down to 2l nc o2, and often maintained o2 sats > 94% on room air at rest. he was transferred from the icu to the medicine floor on , where the below issues were addressed: hypoxia: thought to be due to mucus plugging in setting of procedure. given the acuity of both the change and the reversal it is likely that he experienced lung collapse and then reaeration of expectorating mucus. received 4 days of vanc/zosyn for presumed hap coverage in setting of hypoxia and increased sputum production, this was d/c'd with no additional fevers and decreasing sputum. he was continued on ipratropium nebs, mucomyst nebs, guaifenesin, incentive spirometry. during his stay, his oxygen requirement was weaned, now requiring 2l nc only intermittently. will continue albuterol and ipratropium nebs on a prn basis. . hypernatremia: na as high as 150, did decrease with ivf but still mildly elevated on transfer to floor. improved to 147 with d5w. iv hydration stopped at this time and pos encouraged given risk of chf. free water deficit estimated at 2.3l on transfer to floor. na remained stable in range of 143-147 when taking more po fluid. recommend continued intermittent monitoring. lad: s/p mediastinoscopy. his mediastinal lymph node biopsy results were consistent with carcinoid. the hematology/oncology service was consulted, and they recommended getting an octreotide scan, the preliminary read showed metastatic carcinoid. these results were discussed with the patient and his outpatient oncologist. the patient requested to be followed by his oncologist in . . diastolic congestive heart failure: echo with ef of 75%, has severe dchf. cards consulted while in icu. digoxin was discontinued in setting of diastolic chf. cardiology recommended using either bb or verapamil to control hr, goal to have <80. hr was well controlled without meds on transfer from icu. added metoprolol 12.5 mg on , though this was d/c'd for episodes of bradycardia to 30s. added 12.5 metoprolol sr , which he has tolerated well. also added candesartan at low-dose (4mg, home dose 16 mg) given h/o diastolic chf and goal of reducing afterload. this can be titrated up as his blood pressure allows. he did have some increased edema during his stay on the medical floor, and was given teds stockings and encouraged to ambulate. he also received 40 mg iv lasix x 1 , and an additional dose of 40 mg po on and 40mg iv on . the long-term goal remains to minimize diuretics, but use extreme caution with fluids as pt is exquisitely volume sensitive due to severity of dchf. discharged with instructions to continue home lasix (40 mg) for 3 days with monitoring of daily weights and chemistries, this may need to be reassessed and monitored. . rhythm: he has chronic afib. his heparin was held after surgery. he was restarted on coumadin 1.25 mg daily on . his inr rose to the therapeutic range, and was 2.5 on discharge. recommend intermittent monitoring to tritrate necessary dosing regimen. . arf: improved with hydration. renal signed off prior to transfer to floor. diuresis minimized on the floor, received 40 mg iv lasix and 40mg po lasix on two occasions with good diuresis, pt maintained blood pressures. the goal continues to be to minimize diuresis to prevent excessive preload reduction. . cad: he was continued on his statin, held asa due to h/o gi bleed medications on admission: ppi lipitor 10 atacand 16 (confirmed with spouse) digoxin 0.125 mg qd aldactone 25 qd lasix 40 qd allopurinol 100 mg qd verapamil 180 qd coumadin 2.5 (mwf); 1.25 (ttss) flomax 0.5 discharge medications: 1. metoprolol succinate 25 mg tablet sustained release 24 hr sig: 0.5 tablet sustained release 24 hr po daily (daily). 2. warfarin 1 mg tablet sig: 1.25 tablets po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 5. candesartan 4 mg tablet sig: one (1) tablet po daily (). 6. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed. 10. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 11. lasix 40 mg tablet sig: one (1) tablet po once a day for 3 days. discharge disposition: extended care facility: - discharge diagnosis: primary: mediastinal lymphadenopathy metastatic carcinoid acute renal failure secondary: chronic diastolic congestive heart failure anemia atrial fibrillation chronic renal insufficiency discharge condition: fair, tolerating po, afebrile, vs wnl, o2 95-100% on supplemental o2 2l transfer to chair with assist discharge instructions: you were admitted to the hospital with mediastinal lymphadenopathy. you had a mediastinoscopy and bronchcoscopy. the pathology reports showed this was consistent with carcinoid. you were seen by the oncologists, who recommended an octreotide scan; you indicated you would like to follow up with your outpatient oncologist. you were also noted to have an exacerbation of your heart failure. you were seen by the cardiologists, who recommended you stop your digoxin. you were given diuretics to remove fluid. you also had acute renal failure, which resolved during your stay. . a ct scan showed a mass on your left adrenal gland, this should be worked up as an outpatient, you should talk with your primary care doctor about further evaluation. . the following changes were made to your medications: your digoxin, verapamil and aldactone were stopped your atacand dose was decreased to 4 mg you were started on metoprolol you were started on docusate, senna, and bisacodyl as needed for constipation and albuterol and ipratropium nebs as needed for sob/wheezing your allopurinol and flomax were held, these can be restarted during your rehab stay your coumadin was decreased to 1.25 mg daily, this can be adjusted based on your inr . please call your doctor or return to the ed for: - fevers/chills - shortness or breath or chest pain - increasing sputum production - weight gain > 3 lbs - any other new or concerning symptoms followup instructions: follow up with your primary care provider, . (, within 1 week of leaving rehab. on a ct scan, you were noted to have a mass on your left adrenal gland, and they recommended dedicated ct or mri for better characterization. dr. should help you this setting this up. follow up with your cardiologist dr. , fax within the next 2-3 weeks for reevaluation and adjustment of heart failure meds as needed. oncology dr. . you have an appointment on at 1:20 pm, call if you need to reschedule or be seen sooner. procedure: closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus biopsy of lymphatic structure mediastinoscopy diagnoses: pneumonia, organism unspecified anemia in chronic kidney disease obstructive sleep apnea (adult)(pediatric) congestive heart failure, unspecified acute kidney failure, unspecified gout, unspecified atrial fibrillation personal history of malignant neoplasm of bronchus and lung acute on chronic diastolic heart failure aortic valve disorders peripheral vascular disease, unspecified chronic kidney disease, unspecified pulmonary collapse other malignant lymphomas, unspecified site, extranodal and solid organ sites long-term (current) use of anticoagulants hyperosmolality and/or hypernatremia secondary and unspecified malignant neoplasm of intrathoracic lymph nodes foreign body in main bronchus 

Answer: The patient is high likely exposed to