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: adhesive tape / percocet attending: chief complaint: altered mental status, tachycardia major surgical or invasive procedure: lumbar puncture attempted history of present illness: hpi obtained from patient, medical records and brother. ms. is a 61f with pancreatic adenocarcinoma s/p whipple now with metastatic recurrence to liver s/p placement of biliary stents x 2 currently undergoing chemotherapy cycle 2 day 17 capecitabine/oxaliplatin admitted with altered mental status. per brother who lives with patient, she woke up this am around 9 and initially seemed normal but he realized within approxiamtely one hour around 9am that she was having balance and gait difficulty as well as difficulty speaking coherently and in complete sentences. she was also repeating phrases. he did not note slurred speech. this episode was similar to although less severe than prior episode in attributed to narcotics. since last admitted , he has been monitoring her narcotic use and she has only take dilaudid 2mg po x 2 and morphine 15mg po x 1 last 24 hours. she also took compazine, zofran, and meclizine. he does not think she took any other narcotics or had any other ingestions. she has had no new medications other than recently being restarted on lasix. otherwise, he states she developed dry cough today and has had rash/sores on lower extremitites since right after she started 2nd cycle of chemo but denies fever, chills, any recent change in lower extremity edema. in the ed, initial vs were: 98.2 118 183/76 18 97%ra. exam was significant for confusion, asterixis, and erythema bilateral r>l les concerning for cellulitis. ct head was unremarkable and cxr revealed small to mdoerate right pleural effusion. she received vancomycin, azithromycin and ceftriaxone for pulmonary vs skin/soft tissue infection, lactulose for asterixis and elevated ammonia and potassium for hypokalemia k 3.1. she was reportedly persistently tachycardic sinus with hr 130s despite 1.5l ivf. there was concern she would trigger on the floor so she was admitted to micu. vs prior to transfer: 98.2 157/55 121 30 98%ra. on the floor, she states "i'm fine, thank you" repeatedly or "i'm ok". she perseverates on words and repeats phrases. her ros is completely negative. past medical history: oncologic history: - diagnosed with pancreatic adenocarcinoma in , in the context of an 80 lb. weight loss - whipple --> well differentiated t3n0 tumor. - adjuvant chemoradiation with xeloda and standard external beam radiotherapy, completed in - 4 cycles of adjuvant gemcitabine chemotherapy with the final dose on - adnexal mass on surveillance imaging - obstructive jaundice, dual biliary drains placed; she was found to have recurrent adenocarcinoma - tah/bso: adnexal mass was thought to be metastatic pancreatic ca - palliative chemotherapy with gemzar three out of four weeks - dose was reduced by 25% with her third cycle, due to thrombocytopenia, but she was still unable to get the third of three doses - starting with her fourth cycle she received gemzar on two of a three week cycle - last dose of gemcitabine given on - started xelox on , currently c1d13 past medical history: - 2 metal biliary stents placed on - h/o asthma/rhinitis - hypertension: currently resolved, as per pt - l4-l5 fusion: fell 10 years ago and broke l4 - cholecystectomy 3 years ago - duodenal ulcer (per patient): resected as part of whipple surgery - recurrent pancreatitis - hives (treated with benadryl prn) - h/o c. difficile social history: the patient lives with her brother. she was previously caring for her elderly father but he passed away recently. before caring for her father, she worked as a medical technologist in the blood bank at both and the hospitals. she denies ever using iv drugs. no etoh or tobacco. uses walker at baseline. family history: father with type i dm, several other family members with type 2 dm. no family history of pancreatitis or pancreatic cancer. her mother had endometrial cancer and her father's mother had cervical cancer. her maternal aunt had cancer of some type. physical exam: admission physical exam general: appears scared, intermittently crying, agitated, gripping siderails, only oriented to brother's name. does not state her own name, states she is at "" and unable to state date, year or month. heent: sclera anicteric, mm dry, no thrush or mucositis, oropharynx clear neck: supple, jvp not elevated, no lad lungs: faint crackles r base and occ scant exp wheezes. cv: tachycardic. regular rhythm, normal s1 + s2, no murmurs, rubs, gallops. + pericardial rub. abdomen: soft, tender periumbilically whic pateint states is old, slightly distended, bowel sounds present, no rebound tenderness or guarding, enlarged liver and spleen palpated just below costal margin ext: 3+ pitting edema b/l ;warm, well perfused, 2+ pulses, no clubbing, cyanosis skin: erythematous papular rash anterior shin with left more confluent with surrounding erythem and warmth neuro: able to raise both arms symmetrically. no pronator drift. + asterixis. perrl although dilated approx 5->4mm. tongue protrusion midline. moving lower extremitites symmetrically. follows some commands. discharge physical exam general: nad, alert and oriented x 3 heent: sclera anicteric, lungs: clear to auscultation anteriorly bilaterally, limited posterior exam given pt's difficulty/pain with sitting up and turning cv: regular rate and rhythm, no murmurs, rubs, gallops. abdomen: mildly distended, mild tenderness in epigastric region, no rebound tenderness or guarding, + ascites, skin: no erythema, 1+ edema bilaterally gu: erythematous groin/buttock rash back: no rash evident pertinent results: 07:11pm lactate-3.6* 07:12pm ammonia-142* 07:15pm pt-18.1* ptt-25.8 inr(pt)-1.6* 07:15pm plt smr-normal plt count-172 07:15pm hypochrom-occasional anisocyt-2+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-1+ pencil-1+ 07:15pm neuts-62 bands-0 lymphs-23 monos-15* eos-0 basos-0 atyps-0 metas-0 myelos-0 07:15pm wbc-4.2# rbc-2.93* hgb-9.1* hct-27.1* mcv-93 mch-31.1 mchc-33.6 rdw-24.5* 07:15pm asa-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 07:15pm tsh-2.6 07:15pm osmolal-278 07:15pm caltibc-168* ferritin-405* trf-129* 07:15pm albumin-3.0* calcium-8.3* phosphate-3.1 magnesium-1.7 iron-79 07:15pm lipase-14 07:15pm alt(sgpt)-19 ast(sgot)-48* ld(ldh)-327* alk phos-129* tot bili-1.4 07:15pm estgfr-using this 07:15pm glucose-114* urea n-18 creat-1.1 sodium-134 potassium-3.1* chloride-101 total co2-21* anion gap-15 08:40pm urine mucous-few 08:40pm urine hyaline-* 08:40pm urine rbc-* wbc-* bacteria-few yeast-none epi- 08:40pm urine blood-lg nitrite-neg protein-25 glucose-neg ketone-15 bilirubin-sm urobilngn-neg ph-6.5 leuk-tr 08:40pm urine color-amber appear-clear sp -1.022 08:40pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg 08:40pm urine uhold-hold 08:40pm urine hours-random brief hospital course: 61f with metastatic pancreatic cancer on palliative chemotherapy admitted to icu for altered mental status and tachycardia, found to have cellulitus, who developed gi bleed and oliguria during hospital course, with transfer to oncology floor , discharged to . # altered mental status: most likely secondary to infection vs med effect. sources of infection include lower extremity cellulitus vs c diff as outlined below. no fevers. head ct on admission negative. patient has had recent admission for similar complaint attributed largely to medication effect although narcotic regimen was reduced at that time. on admission, tsh 1.1, folate 15.1, b12 1111 . narcotics were withheld initially and her mental status gradually improved. she is a&o x 3 on discharge. her pain regimen at discharge consists of morphine sr (ms contin) 15 mg po q12h, tylenol prn pain, and oxycodone 5 mg q6 prn severe pain. . # gib: pt developing maroon stools morning of x1 and an episode of bloody emesis later that day. received 1 u and vitamin k. hct remained stable at 28.4. gi was consulted and recommended conservative management with no need for endoscopy/colonoscopy. of note, pt with hx of diverticulosis, and hemmorhoids on prior c-scope which could be contributing cause of gi bleed. no further episodes of gi bleeding throughout hospital course. hcts stable. . # oliguria: patient developed oliguria prior to transfer from to the floor on . likely in setting of gib and blood loss. pt with poor urine output despite multiple fluid boluses and maintenance fluids. she was > 11l positive for los upon transfer from to floor. cr also elevated. renal team was consulted and recommended aggressive diuresis. she was initially diuresed with lasix and after an initial cr bump, her oliguria resolved and her cr trended down. she had low potassium levels and was switched from lasix to torsemide. spironolactone as added as well. she was placed on standing potassium supplements. will discharge on tosemide, spironolactone, and potassium. please check potassium levels in 1 week and adjust accordingly. . # sinus tachycardia: tachycardic on admission to . likely multifactorial secondary to anxiety/pain, hypovolemia, infection with sources of infection including cellulitis and pna. no leukocytosis or fever. tsh 2.6. lenis negative. resolved as infxn was treated. . # rash: patient reportedly developed sores on lower extremities after starting 2nd cycle of chemo. rle also appeared superinfected as it was warm and mildly ttp c/w cellulitis. capecitabine also causes rash in 27-37% of patients. resolving on right leg and slightly worsening on left. completed course of bactrim/dicloxacillin for cellulitis. resolved prior to discharge. . # le edema: bilateral lower extremity edema. unclear baseline. diuresed as above. continues to have le edema upon discharge. . # metastatic pancreatic cancer: on admission, was on cycle 2 palliative chemo capecitabine/oxaliplatin. outpatient oncologists dr. and were contact and saw patient intermittently during hospital stay. no further chemotherapy. patient intermittently complains of abdominal pain that is abated with redirection and/or tylenol. . #ascites: likely secondary to metastatic pancreatic cancer as well as volume overload. a diagnostic paracentesis was performed and was negative for infection and malignancy. patient intially had blood discharge from site of paracentesis, which resolved over several days. further paracentesis for therapeutic benefit was not performed given prognosis and lack of respiratory or severe abdominal symptoms. # pleural effusion: patient has new right pleural effusion and ? pneumonia on cxr but no focal infiltrate and no fever or leukocytosis. lack of cough, sob, or sputum production also argued against pna. could be secondary to metastatic disease or sympathetic effusion from abdominal processes. pleural effusion stable in size. diuresed as above. . # coagulopathy: likely nutritional in additional to capecitabine. patient was given vitamin k with little improvement in inr. dic labs were trended for several days and remained negative. smear showed abnormal burr cells but no schistocytes. stool studies for e.coli were negative. no interventions made. stable at discharge. . # asthma/rhinitis: continued fluticasone inhaled and nasal spray, albuterol inhaler prn . #thrush: treated with nystatin swish and swallow . #buttock rash: treated with miconazole powder medications on admission: 1. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal daily. 2. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation (2 times a day). 3. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). disp:*60 tablet sustained release(s) *refills:*0* 4. capecitabine 500 mg tablet sig: two (2) tablet po twice a day for 10 days: please take as directed by dr. . 5. please note we discontinued your lasix. this will need to be re-assessed by your doctor at your next appointment. 6. lorazepam 0.5 mg tablet sig: one (1) tablet po every eight (8) hours as needed for anxiety or nausea: please note we decreased the frequency to every 8 hours instead of 6. 7. hydromorphone 2 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain: please note we decreased the dose to 2mg from 4mg. please read your pill bottles at home carefully. disp:*30 tablet(s)* refills:*0* 8. mirtazapine 7.5 mg tablet sig: one (1) tablet po at bedtime: please note we decreased the dose from 15mg. disp:*30 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. recently restarted back on lasix, unsure of dose discharge medications: 1. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal (2 times a day). 2. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation (2 times a day). 3. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q12h (every 12 hours). 4. lorazepam 0.5 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea or anxiety. 5. hydromorphone 2 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain. 6. mirtazapine 7.5 mg tablet sig: one (1) tablet po at bedtime. 7. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: inhalation q4h (every 4 hours) as needed for sob or wheezing. 9. torsemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. spironolactone 25 mg tablet sig: two (2) tablet po daily (daily). 12. potassium chloride 20 meq tab sust.rel. particle/crystal sig: three (3) tab sust.rel. particle/crystal po twice a day: please hold for k >5.0. 13. zofran odt 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every 4-6 hours as needed for nausea. 14. outpatient lab work please check chem 7 in 1 week. discharge disposition: extended care facility: house rehab & nursing center - discharge diagnosis: primary: altered mental status, nos gi bleed, nos arf, likely pre-renal cellulitis, bilateral lower extremity c diff infection coagulopathy, likely nutritional secondary: metastatic pancreatic carcinoma asthma discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure participating in your health care. you were admitted to for altered mental status. you were found to have a gastrointestinal bleed, low urine output, lower leg cellulitis, and c. diff infection. you were treated with antibiotics and fluids. you were transfused 1 unit of blood. you were treated with vitamin k for bleeding. you were given diuretics to help remove excess fluid from your body. the fluid in your stomach was removed during a procedure called a paracentesis and the cytology results were negative for cancer. your potassium level was consistently low because of the diuretics and you were given potassium supplements. . please start the following medications: zofran 8 mg every 4-6 hours as needed for nausea torsemide 60 mg twice a day spironolactone 50 mg daily pantoprazole 40 mg daily potassium 60 meq twice a day please continue all other home medications. please be cautious when taking pain medications. followup instructions: please schedule a follow-up appointment with heme/onc clinic (). please see your physician as needed. procedure: spinal tap incision of lung percutaneous abdominal drainage central venous catheter placement with guidance diagnoses: acidosis thrombocytopenia, unspecified anemia, unspecified malignant neoplasm of liver, secondary unspecified pleural effusion unspecified essential hypertension acute kidney failure, unspecified hyposmolality and/or hyponatremia asthma, unspecified type, unspecified candidiasis of mouth hypopotassemia cellulitis and abscess of leg, except foot alkalosis intestinal infection due to clostridium difficile antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use paralytic ileus dermatitis due to drugs and medicines taken internally other ascites altered mental status do not resuscitate status hemorrhage of gastrointestinal tract, unspecified other and unspecified coagulation defects tachycardia, unspecified malignant neoplasm of pancreas, part unspecified secondary malignant neoplasm of ovary 

Answer: The patient is high likely exposed to