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: transfer from osh for leukocytosis major surgical or invasive procedure: 1. placement of r-ij pheresis line 2. placement of l-ij central line 3. pheresis 4. bone marrow biopsy , , 5. ivc filter placement history of present illness: 54 year-old spanish speaking female with a history of htn who was transferred from with a leukocytosis of 194k concerning for acute leukemia. . the patient reports 1 week of fevers, sore throat, nausea, vomiting, and abdominal pain. she also endorsed body aches, headache, dizziness, nightsweats and sob. she presented to ed and was diagnosed with pharyngitis and given antibiotics & pain meds and d/c'd home. she continued to feel ill and presented to . there she was noted to have a wbc count of 194k. her potassium was 1.6 and she reportly had runs of monomorphic narrow complex tachycardia at rates ~250 that lasted less then 10s. she was given 150mg iv amiodarone bolus. she had a fever to 103 so was started on zosyn empirically. she had a positive d-dimer and was started on a heparin gtt. a right ij cvl was placed. she was transferred to for further management. . in the ed initial vs: tm:102, hr:120, bp:120/75, rr:20, 95% 5l nc. labs were remarkable for wbc 185 with 83% blasts, hct 32.6, plt 103, k 2.8, ca 8.3, phos 2.3, uric acid 5.9, ldh 1052, and fibrinogen 319. the heparin gtt was stopped. bedside u/s showed a grossly enlarged spleen. peripheral smear showed large amount of blasts. she underwent a bone marrow biopsy in the ed and was started on hydroxyurea. she was given 1g vancomycin and 1 set of bcx were sent. additionally, her trop came back 0.28 with flat ck. she was transferred to the icu. past medical history: - htn - borderline diabetes (diet controlled) - h/o anemia - s/p c-section - s/p breast surgery for benign lump social history: the patient was born in and currently lives by herself. she is married and has a son and daughter-in-law that live in ma. she does not work. denies etoh, tobacco, or iv drug use. family history: father: arthritis brother: ra uncle: colon ca physical exam: admission exam: vs: t 102, hr 120, bp 120/75, rr 20, 95% 5l nc gen: ill appearing, tachypneic, uncomfortable, and in mild distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, dry mm, beefy tongue, erythema in the posterior pharynx and exudate on right tonsil neck: no jvd, carotid pulses brisk, no bruits, + cervical lymphadenopathy, trachea midline, rij cvl in place cor: tachycardic, normal s1 s2, no m/r/g pulm: bibasilar crackles, no w/r abd: soft, distended and tender to palpation, + splenomegaly, no r/g. ext: no c/c/e, no palpable cords neuro: alert, oriented to person, place, and time. cn ii ?????? xii grossly intact. moves all 4 extremities. strength 5/5 in upper and lower extremities. patellar dtr +1. plantar reflex downgoing. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. . discharge exam: vs: t 98, hr 80, bp 110/70, rr 18, 97-100% on ra gen: well-appearing woman in nad. heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, mmm. +mucositis on left buccal mucosa. neck: supple, no lad, jvp not elevated. cor: regular, normal s1 s2, no m/r/g. pulm: ctab. no w/r. abd: soft, nt/nd, nabs. ext: wwp, no edema. neuro: a&ox3, cn ii-xii intact, strength and sensation intact. gait normal. skin: no rash. pertinent results: admission labs: 11:40pm blood wbc-185.4* rbc-4.40 hgb-10.9* hct-32.6* mcv-74* mch-24.9* mchc-33.6 rdw-20.2* plt ct-103* 11:40pm blood neuts-3* bands-0 lymphs-3* monos-9 eos-1 baso-0 atyps-1* metas-0 myelos-0 nrbc-1* other-83* 11:40pm blood hypochr-2+ anisocy-1+ poiklo-normal macrocy-normal microcy-2+ polychr-occasional 11:40pm blood pt-17.4* ptt-47.3* inr(pt)-1.6* 11:40pm blood fibrino-319 02:25pm blood esr-29* 11:40pm blood glucose-256* urean-7 creat-0.7 na-138 k-2.8* cl-102 hco3-28 angap-11 11:40pm blood alt-28 ast-43* ld(ldh)-1052* ck(cpk)-45 alkphos-74 totbili-0.6 11:40pm blood lipase-19 11:40pm blood albumin-3.4* calcium-8.3* phos-2.3* mg-2.3 uricacd-5.9* ................................................................ pertinent labs: 11:40pm blood ck-mb-2 11:40pm blood ctropnt-0.28* 04:34am blood ck-mb-3 ctropnt-0.25* 12:22pm blood ck-mb-3 ctropnt-0.20* 03:00pm blood probnp-4844* 03:45pm blood -negative 04:34am blood %hba1c-9.5* eag-226* 04:30pm blood caltibc-146 vitb12-657 folate-7.2 hapto-419* ferritn-6433* trf-112* 12:00am blood tsh-1.4 12:00am blood cortsol-18.6 ................................................................ discharge labs: 12:00am blood wbc-2.3* rbc-3.11* hgb-9.3* hct-27.4* mcv-88 mch-29.9 mchc-33.9 rdw-16.4* plt ct-354 12:00am blood neuts-39* bands-0 lymphs-32 monos-27* eos-0 baso-0 atyps-0 metas-0 myelos-2* nrbc-2* 12:00am blood pt-15.3* ptt-36.4* inr(pt)-1.3* 12:00am blood gran ct-923* 12:00am blood glucose-107* urean-13 creat-1.0 na-141 k-3.9 cl-102 hco3-29 angap-14 12:00am blood alt-26 ast-30 ld(ldh)-167 alkphos-146* totbili-0.4 12:00am blood albumin-4.1 calcium-9.7 phos-4.9* mg-1.8 ................................................................ microbiology: b-glucan and galactomannan - negative blood cultures (multiple) - no growth mrsa screen (x2) - negative rapid respiratory viral screen & culture (x2) - negative and no growth catheter tip cx (cvl)- no growth throat culture - negative for b-strep viral culture - no hsv growth stool studies + c. diff - negative cmv vl - undetectable ................................................................ pathology: bone marrow biopsy: aspirate smear: the aspirate material is adequate for evaluation. it consists of several hypercellular spicules. the vast majority of the marrow cellularity is comprised of blasts and promonocytes morphologically similar to those described above. maturing erythroid and myeloid precursors are rare. megakaryocytes are present in markedly decreased numbers. based on a 500 cell differential: 91% blasts and promonocytes, <1% promyelocytes, <1% myelocytes, <1% metamyelocytes, 1% bands/neutrophils, 1% lymphocytes, 2% erythroid, 5% monocytes. . clot section and biopsy slides: the biopsy material is adequate for evaluation, and consists of fragmented trabecular bone, which appears osteopenic. the marrow cellularity is 80-90% and comprised mainly of sheets of large cells with abundant cytoplasm, vesicular and folded nuclei, and prominent nucleoli. maturing erythroid and myeloid precursors are markedly decreased. megakaryocytes are rare. marrow clot section is similar to the biopsy. . cytogenetics: no clonal cytogenetic aberrations were identified in metaphases analyzed from this unstimulated specimen. this normal result does not exclude a neoplastic proliferation. mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. note: fish was performed on a concurrent sample of neoplastic blood assessing for rearrangements of 15;17, 8;21, and 16q22. all results were normal. . peripheral blood flow cytometry: three color gating is performed (light scatter vs. cd45) to optimize blast and lymphocyte yield. b cells comprise approximately 27% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. t cells comprise approximately 55% of lymphoid gated events, express mature lineage antigens and have a normal helper-cytotoxic ratio of 1.4 (usual range in blood 0.7-3.0). the majority of the cells from this peripheral blood are located in the monocyte/promonocyte gate and express immature antigens, hla-dr, myeloid associated antigens cd33, cd13 (dim), dim cd15, cd117 (subset), monocyte associated antigens cd14 (variable subset), cd11c, and cd64, as well as cd56 (subset), cd71 and the lymphoid associated antigens cd4, cd7. cells lack lineage specific b and t cell associated antigens, are cd10 (calla) negative, and are negative for cd34 and cd41. blast cells comprise approximately 90% of total events. . right thigh skin biopsy: sparse perivascular inflammation and edema involving dermis and subcutis. the findings are non-specific and mild. there is focal perivascular inflammation with a few slightly enlarged mononuclear cells in a fat lobule, however, there is limited adipose tissue in the specimen. the possibility of an underlying panniculitis cannot be fully assessed. the changes are not those of a neutrophilic dermatosis. special stains (, pas, and gram) are negative for organisms. . right leg skin biopsy: mild perivascular inflammation and edema involving dermis and subcutis. there is slightly more inflammation observed than in the prior biopsy. while mild, the finding of perivascular mononuclear cells and edema within the dermis and subcutis is unusual. there is some erythrocyte extravasation, however, no definitive vasculitis is observed. focal basal vacuolization is observed. there is focal lipomembranous fat necrosis which may be observed as a non-specific finding. the findings are not sufficient for erythema nodosum. the changes are not those of a neutrophilic dermatosis. the changes are not suggestive of infection. rare large atypical cells are seen in dermal perivascular distribution in a background of edema. the morphological findings are suspicious for treated leukemia cutis. upon additional sections for immunostains, these cells are no longer present and cannot be definitively characterized. cd3 highlights scattered t-cells, a subset of which are reactive for cd4. cd20 reactive b-cells are rare. cd33 is non-contributory. . bone marrow biopsy: aspirate smear: the aspirate material is adequate for evaluation. it consists of scant hypocellular spicules composed of stromal cells, histiocytes, lymphocytes, and clusters of plasma cells. rare hemophagocytic histiocytes are present. erythroid precursors are rare in number with normoblastic maturation. myeloid precursors appear rare. megakaryocytes are present in decreased numbers. based on a limited 100 cell differential shows: 0% blasts, 1% promyelocytes, 2% myelocytes, 2% metamyelocytes, 0% bands/neutrophils, 17% plasma cells, 59% lymphocytes, 19% erythroid. . clot section and biopsy slides: the biopsy material is adequate for evaluation and consists of fragments of trabecular bone that appears osteopenic, with an overall cellularity of <10%. a small poorly formed lymphohistiocytic granuloma is seen. eosinophilic debris is present consistent myeloablative chemotherapy. erythroid precursors are rare in number and exhibit maturation. myeloid precursors are rare in number and exhibit normal maturation. megakaryocytes are absent. . cytogenetics: tissue cultures were established to obtain cells for cytogenetic and fish analyses. however, the lack of cells in the specimen provided precluded the ability to perform either analysis. . bone marrow biopsy: pending ................................................................ imaging: tte: left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality due to body habitus. left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. the right ventricle is not well seen. no significant valvular abnormality. unable to assess pulmonary artery systolic pressures. . cxr: mild cardiomegaly, mediastinal and hilar prominence are most consistent with vascular engorgement, but could be mimicked by adenopathy. there is no pleural effusion and no pneumothorax. impression: probable mild cardiac decompensation. no evidence of pneumonia. followup chest radiographs recommended. . cxr: as compared to the previous radiograph, the patient has received a new right-sided double-lumen dialysis catheter and a new left internal jugular vein catheter. the tip of the first catheter projects over the right atrium, the tip of the left catheter projects over the mid svc. the lung volumes are small and unchanged. mild areas of atelectasis at the left lung base. borderline size of the cardiac silhouette without evidence of pulmonary edema. no evidence of complications, notably no pneumothorax. . u/s bilateral le veins: 1. no evidence of dvt bilaterally. 2. lymphadenopathy. . cta chest: 1. several segmental pulmonary emboli associated with multiple sites of apparent pulmonary infarcts. clot burden and site of most proximal emboli may be underestimated due to poor vascular enhancement. 2. infiltrative lymphadenopathy especially of the bilateral hila and infra-hilar regions. . ct abd & pelvis with contrast: 1. hypodensities within the spleen as described, differential includes either infarctions or involvement with this patient's aml, unfortunately no prior studies to allow assessment for interval change. 2. other than the above, no other abnormalities which may be acute are appreciated. 3. note of a fatty liver, probable cyst within the right kidney, fibroid uterus, prominent right inguinal lymph node. 4. lung bases appear unchanged compared to the chest ct from one day earlier, including findings raising the suspicion of pulmonary infarctions. . ct neck w/contrast: multiple enlarged lymph nodes compatible with history of aml. soft tissue density between the right common carotid and jugular veins with differential as discussed above. this could represent a nodal lesion versus phlegmonous tissue. no evidence for abscess is seen. there is no evidence for vascular thrombosis. . renal u/s: no hydronephrosis, hydroureter, or evidence of renal calculi. . transvaginal u/s: 1. markedly thickened and heterogeneous endometrial stripe with apparent increased vascular flow. findings are consistent with hemorrhage within the cavity possibly from degeneration of a submucosal fibroid, but possibly from other mass, polyp, or vascular malformation. mri would be best for further characterization. 2. large fibroid uterus. brief hospital course: 54 year old woman with a history of htn and borderline dm who initially presented to an osh with fevers, sore throat, nausea, vomiting, and abdominal pain. she was found to have a leukocytosis of 194k concerning for acute leukemia, so she was transferred to for further evaluation and was found to have aml. brief hospital course by problem: . # aml: admission labs at revealed wbc 185k with differential notable for 83% blasts. bone marrow biopsy from was consistent with aml m5 with npm-1+ and flt-3- cytogenetics. a pheresis catheter was placed and she underwent leukopheresis. she was started on allopurinol and hydroxyurea. tte was normal. she started 7+3 chemotherapy (daunorubicin + cytarabine) on . repeat bone marrow biopsy at day 14 () demonstrated an empty bone marrow, consistent with myeloablative therapy, and her ancs rebounded nicely thereafter. anc upon discharge was 923. she developed severe oral mucositis, requiring tpn for a short period of time, but this resolved with routine oral care and she is now able to tolerate pos, though her appetite is still depressed. she currently has a small well-healing area of mucositis in the left buccal mucosa. she had a 3rd bone marrow biopsy on but results are pending at this time. she will continue her oncology care with dr. , with whom she has an appointment on . . # neutropenic fever: on admission she was started on vanco/cefepime/azithro for questionable cap. a ct chest was performed given her hypoxia, which showed pe with basilar infarcts. her coverage was broadened to vanco/zosyn/levo/amphotericin. fungal markers (galactomannan and b-glucan) were ultimately negative and she was switched from amphotericin to voriconazole. she developed rigors and a non-painful and non-pruritic diffuse body rash and antibiotics were switched to vanco/meropenem. oral lesions were consistent with mucositis but suspicious for viral infection (hsv) and she was started on iv acyclovir. viral culture was ultimately negative. she was transferred from the icu to the bmt floor on vanc//voriconazole/acyclovir. she remained afebrile and all cultures were negative so the antibiotics were eventually stopped. she was discharged home on prophylactic fluconazole and acyclovir. . # hypoxia/pe: she was initially diuresed with gentle iv furosemide boluses as her high respiratory rate and cxr findings were felt secondary to fluid overload given aggressive hydration as part of chemo. due to concern for pe, cta was performed and demonstrated bilateral pes and pulmonary infarction in addition to considerable lymphadenopathy. she had negative bilateral le dopplers and a ct of the neck and ct abdomen and pelvis showed no evidence of venous thrombosis peripherally or in the more central veins. an ivc filter was placed on given the inability to start anticoagulation due to thrombocytopenia. . # anemia/thrombocytopenia/menorrhagia: initial platelet count was 103 but she became profoundly thrombocytopenic after initiation of chemotherapy. in the icu she required several platelet infusions though she did not appear to be bumping appropriately. blood bank was consulted who recommended infusion of only o+ platelets. this trend continued while on the floor, exacerbated by vaginal bleeding. gyn was consulted and a transvaginal u/s showed multiple fibroids and a hypervascular endometrium. they deferred endometrial biopsy due to her neutropenia, and deferred hormonal therapies given the prothrombotic risks in someone with a pe. she was treated conservatively with continued transfusions and hematocrit/plt checks. her bleeding slowed markedly and her bone marrow began to recover with decreased need for transfusions. she currently has only scant menorrhagia. . # rash: patient developed several quarter sized areas of hyperpigmented, raised lesions on her legs shortly after chemotherapy was completed. dermatology was consulted and two separate biopsies were obtained, but findings were non-specific. the quantity of the infiltrate was not consistent with leukemia cutis but due to the few enlarged perivascular cells and the fact that this did not fit with any typical dermatitis, hemepath was asked to review. immunostains were unremarkable. the rash resolved without intervention. . # diarrhea: patient noted frequent stools without abdominal pain. c. diff toxins, c. diff pcr, and stool studies were negative throughout hospitalization. etiology likely secondary to chemotherapy and had resolved by discharge. . # : creatinine peaked at 2.7 and the nephrology service was consulted. urine sediment showed muddy brown casts, consistent with atn, but urine electrolytes were more consistent with contrast-induced nephropathy vs. pre-renal etiology. numerous nephrotoxic medications including amphotericin-b, acyclovir, and voriconazole were also implicated. renal u/s negative. her creatinine began to improve markedly and trended toward baseline as her condition improved. discharge creatinine was 1.0. . # type 2 diabetes: previously diet-controlled. admission glucose was 256 and subsequent blood glucoses were significantly elevated. hba1c 9.5%. she intermittently required an insulin gtt while in the icu. she was transitioned to nph and iss prior to transfer to the floor, which was transitioned to lantus qhs once d5w was discontinued for treatment of hypernatremia. she was briefly started on glyburide , but due to poor appetite and po intake, her blood sugars were low and the glyburide and insulin was stopped. she will require close follow up and blood sugar monitoring once her appetite improves and she is eating regularly. she may require oral dm meds in the future. . # htn: the patient was not on any anti-hypertensive medications upon admission but did require treatment during this hospitalization. she was discharged on metoprolol tartrate 50mg . . # pending results: bone marrow biopsy from . # code status: full code . **a copy of this summary was faxed to dr. ** medications on admission: none discharge medications: 1. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*0* 2. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*0* 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 4. prochlorperazine maleate 5 mg tablet sig: one (1) tablet po every six (6) hours as needed for nausea. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: - acute myelogenous leukemia . secondary diagnoses: - pulmonary emboli - acute kidney injury - diabetes mellitus - hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , it was a pleasure taking part in your care at the . you were initially admitted to the intensive care unit with fevers, nausea, and vomiting. lab testing and a bone marrow biopsy showed that you have leukemia which was treated with chemotherapy. you were also found to have a small clot in your lungs which we treated by placing a filter in one of your veins. you had some vaginal bleeding which required some blood transfusions, but this is resolving. after your chemotherapy your white blood cells are trending upward toward normal levels. you will be following up with dr. for further management of your leukemia and for further chemotherapy. please see below for details on your future appoitments. your blood sugars have been high suggesting that you likely have diabetes. you should speak with your primary care doctor about this. . we started the following medications: - acyclovir for your leukemia - fluconazole for your leukemia - metoprolol for your blood pressure - prochlorperazine for your nausea followup instructions: department: bmt/oncology unit when: saturday at 8:30 am building: fd building (/ complex) campus: east best parking: main garage . department: dr. (oncology) when: monday at 2:45 pm location: procedure: parenteral infusion of concentrated nutritional substances interruption of the vena cava biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow therapeutic plasmapheresis closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified acidosis subendocardial infarction, initial episode of care acute kidney failure with lesion of tubular necrosis unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled unspecified septicemia sepsis hypopotassemia alkalosis hypoxemia diarrhea obesity, unspecified hyperosmolality and/or hypernatremia other pulmonary embolism and infarction neutropenia, unspecified acute myeloid leukemia, without mention of having achieved remission fever presenting with conditions classified elsewhere excessive or frequent menstruation submucous leiomyoma of uterus erythema nodosum stomatitis and mucositis, unspecified 

Answer: The patient is high likely exposed to