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: sulfonamides / demerol / haldol attending: chief complaint: syncope. major surgical or invasive procedure: permanent pacemaker placed. internal jugular central venous line placed. arterial line placed. procedures performed prior to arriving at : endotracheal intubation subclavian central venous line transvenous pacing wires interosseous line history of present illness: ms. is a 63 yo woman with history of hypothyroid, lupus, non-hodgkin's lymphoma s/p xrt and chemotherapy 17 years ago who presented to hospital earlier today after a syncopal episode at home. a couple of weeks ago, mrs. was in the bathroom during the night. she awoke her husband and could not get off the toilet. she felt faint. her husband helped her up, noticing that both of her legs and arms were cool. she lay back in her recliner - in which she has slept since her radiotherapy and lymphoma. her husband asked if he should call ems, but she didn't think it necessary. today, mrs. was at home. mr. went to work. during the morning she felt faint and called ems. they arrived to find that she had fallen from her chair to the floor, striking her head. per ed, she was unresponsive when the ems arrived, unable to answer questions. however, en route, she apparently complained of neck and back pain. she was bradycardic to the 20s and transcutaneous pacing was unsuccessful. dopamine increased her heart rate and atropine did little. on arrival the ed, she was described as lethargic but communicative, but soon after became 'suddenly ashen/cyanotic'. dopamine gtt was started. slow capillary refil was noted. ekg was interpreted as 'complete heart block with av dissociation'. an echo was performed, per the cardiology consult note, which noted global hypokinesis and lvef of 25-30% while paced. echos have previously been near normal. she was intubated for airway protection and sedation in the setting of bradycardia and placement of the temp wire. tranvenous pacing wires were placed via a right subclavian line under fluroscopy (the left actually has an adjacent 17-year-old port-a-cath, still in place from treatment of her lymphoma). given likely necessity for a ppm/icd and her hemodynamic instability, she was transferred to ccu. she arrived in a rigid neck collar - although ct head and neck had been performed at , was not completed. her vitals on arrival were 98.7 f, 85 bpm, 21 rr, 100%. blood pressure messurements varied widely, but were typically from 80s to 100s systolic. past medical history: - lupus, supressed, manifests as pleural effusions, on prednisone - hypothyroidism, s/p partial thyroidectomy w/ lymphoma of neck, chemoradiation plus resection, on levothyroxine - hypertension - gastroesophageal reflux disease - fibromyalgia, on oxycodone 7.5 mg - sleep apnea, diagnosed, but has not wanted cpap yet - depression, on fluoxetine - obesity - osteoporosis - cerebrovascular (small vessel) disease (on asa and plavix) social history: -tobacco history: none. -etoh: none. -illicit drugs: none. lives with husband in two family. daughter and son-in-law live upstairs with their son and a dog. significant discord with daughter and son-in-law at present. also grandchildren upstairs. family history: family history of heart disease, but not of early onset. physical exam: general: morbidly obese woman heent: pupils symmetrically and markedly dilated (s/p atropine), ears clear, tube in place, cannot inspect op neck: hematoma and echymosis on right lateral neck (later - central line in place in right ij), very thick neck, cannot evaluate jvp. cardiac: difficult to auscultate due to ventilator and habitus, near tachycardic and regular. lungs: symmetric air entry anteriorly with some transmitted upper airway sound and ventilator noise. abdomen: obese, non-tender to deep palpation. extremities: trace edema, io access in place at admission (later removed). extremities cool and dusky. skin: echymosis on neck, under panus and breasts. pulses: peripheral pulses barely palpable, but ulnar and radial arteries were dopplerable bilaterally. at the time of discharge, mrs. physical exam was unchanged but for the following: hematoma and bandage over pacer site, right subclavian, cleared, extremities well perfused, alert, oriented and appropriate, although drowsy at times. pertinent results: labs at admission 05:24pm blood wbc-10.9# rbc-4.37 hgb-14.7 hct-44.0 mcv-101* mch-33.8* mchc-33.5 rdw-12.3 plt ct-208 05:24pm blood neuts-76.4* lymphs-12.1* monos-9.3 eos-1.9 baso-0.3 05:24pm blood pt-12.8 ptt-23.4 inr(pt)-1.1 03:56am blood ret aut-1.2 05:24pm blood glucose-120* urean-8 creat-0.7 na-140 k-3.8 cl-103 hco3-27 angap-14 05:24pm blood alt-58* ast-90* ld(ldh)-488* ck(cpk)-299* alkphos-62 totbili-2.3* 05:24pm blood ck-mb-14* mb indx-4.7 ctropnt-1.20* 05:24pm blood albumin-3.6 calcium-9.1 phos-2.6* mg-1.3* 03:56am blood hapto-18* 05:39am blood vitb12-559 folate-8.2 05:24pm blood t4-8.1 06:14am blood free t4-1.5 05:00am blood c3-122 c4-23 10:17pm blood type-art po2-142* pco2-36 ph-7.44 caltco2-25 base xs-1 10:17pm blood lactate-2.0 10:17pm blood o2 sat-98 10:47am blood freeca-1.01* 05:24pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg cardiac enzymes and 05:24pm blood ck-mb-14* mb indx-4.7 ctropnt-1.20* 12:49am blood ctropnt-1.02* 06:14am blood ck-mb-7 ctropnt-0.56* 08:45am blood -negative labs prior to discharge 04:35am blood wbc-10.7 rbc-3.35* hgb-11.4* hct-35.2* mcv-105* mch-34.1* mchc-32.5 rdw-15.0 plt ct-493* 08:25am blood neuts-77.2* lymphs-13.1* monos-6.3 eos-3.2 baso-0.2 08:27am blood pt-15.5* ptt-27.0 inr(pt)-1.4* 04:35am blood glucose-91 urean-12 creat-0.7 na-140 k-3.4 cl-98 hco3-35* angap-10 05:39am blood alt-39 ast-45* alkphos-61 totbili-1.4 04:35am blood calcium-8.9 phos-4.0 mg-2.2 02:47pm blood lactate-1.4 k-3.9 speech & swallowing assessment, functional oral intake scale (fois) rating of 6. recommendations: 1. suggest a po diet of thin liquids and soft, moist solids. 2. small bites and sips. 3. meds crushed w/ purees esophageal strictures. 4. tid oral care. ekg sinus rhythm. left axis deviation. right bundle-branch block with left anterior fascicular block. there are q waves in the inferior leads consistent with prior myocardial infarction. there is lack of r waves in the anterior and anterolateral leads consistent with possible prior myocardial infarction. non-specific st-t wave changes. low voltage in the precordial leads. compared to the previous tracing right bundle-branch block, left anterior fascicular block and evidence of myocardial infarction are new. rate pr qrs qt/qtc p qrs t 87 170 134 398/445 60 -63 105 echo regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are not well seen. there is a trivial/physiologic pericardial effusion. impression: very limited study. grossly preserved biventricular systolic function. unable to comment on any valvular vegetations. if clinical suspicion of endocarditis persists, recommend obtaining a transesophageal study. ct chest, abdomen, pelvis impression: 1. markedly low lung volumes, with asymmetric left basilar consolidation, with air bronchograms. this may represent atelectasis, though pneumonia is certainly not excluded. clinical correlation is advised. 2. adequate positioning of supportive and monitoring devices including endotracheal tube, swan-ganz catheter, and ng tube. 3. marked fatty infiltration of the liver. 4. fatty involution of the pancreas. 5. sigmoid diverticulosis without diverticulitis. small bowel diverticulosis. ekg sinus rhythm. left axis deviation. anteroseptal, anterior and inferior myocardial infarction. intraventricular conduction delay. compared to the previous tracing of there is no significant change. rate pr qrs qt/qtc p qrs t 81 174 108 426/ 44 cxr comparison: chest radiograph one day prior and multiple previous. examination is somewhat limited by patient positioning and difficulty penetration. however, there is persistent left basilar atelectasis and pleural effusion with possible airspace infectious consolidation superimposed. the right lung remains clear. a right chest pacing device appears in unchanged position since the most recent radiograph. the bony thorax is difficult to evaluate. impression: persistent left effusion with atelectasis and possible superimposed airspace consolidation. ct head impression: 1. no acute intracranial process. 2. sequelae of small vessel disease and old lacunar infarcts in the left basal ganglia. 3. complete opacification of the sphenoid sinus with inspissated secretions, essentially unchanged since , consistent with chronic sinusitis, with possible contribution of fungal colonization. brief hospital course: in summary a 63 yo woman with h/o lupus, morbid obesity, h/o large cell lymphoma and hypothyroidism who presented with syncope in the setting of bradycardia and hypotension. syncope likely due to bradycardia with conduction block. she has been presyncopal numerous times recently, suggestive of intermittent heart block. she was hypotensive and bradycardic in the osh, and tranvenous wires were required with restoration of blood pressure by pacing to 70 bpm. transcutaneous pacing was not successful given habitus. ekg significant for large voltages and prolonged qrs, normal pr, suggesting hisian disease, rather than calcific (cxr does not show marked calcification), infiltrative disease (voltages only slightly low in precordial leads but otherwise normal), or rickettsial disease (intermittent rather than progressive). however, past mi is suggested by ekg, which may be responsible for block. ep planned to place a pacer, but she became febrile and hypotensive briefly on hd2, delaying placement. eventually a permanent pacemaker was placed. she was not pacemaker dependent during most of her admission, only intermittantly engaging her device. pacemaker placement was complicated by right subclavian hematoma - stable and without pain (this does increase the risk of post-device infection, however, so suspicion should remain for this if she develops a fever and inflammation around the site). she will follow-up with electrophysiology. head injury upon syncope she had a contusion on her occiput upon arrival. c-spine and head cleared per osh ct's - discussed with osh radiologist. given delirium and recent fall, her head ct was repeated late in the admission, for concern of slow subdural bleed. this repeat head ct was also without any bleeding. respiratory failure patient was intubated prior to arrival to secure airway and also because of hypoxia. unclear etiology of hypoxia, but despite negative sputum favor respiratory infection(see below). however, primary cardiac process, including hisian disease could account for respiratory failure, hypotension, hypoxia. endocarditis was also considered given old hardware, arrhythmia, and low grade temp. very high doses of fentanyl, versed and proprofol were required for sedation, likely due to partitioning into lipid in a very large volume of distribution. dexmedetomidine was used a bridge to extubation with anesthesiology present. this was successful and she remained comfortable on nasal cannula and then room air soon afterward. although not taking bronchodilators at home, she was given ipratropium and albuterol nebulizer treatments in hospital - these may later be discontinued. sedation, mental status, delerium high doses of sedative medications were used, as described above. she also takes both opioids and benzodiazepines at home and has long suffered depression. as she recovered from sedation, delirium was prominent, along with some hallucinations and delusions. psychiatry was consulted and recommended zydis if absolutely necessary (not needed) and restarting home benzodiazepines (at a lower dose). during her early recovery from sedation haloperidol was also required, particularly given some outburst - she thumped her husband and grabbed the respiratory therapist. however, she had qt prolongation in response to this medication and it was discontinued. by the time of discharge she was pleasant, cooperative, without delusions and hallucinations, was remebering environmental events accurately, but was still drowsy at times during the day. coronary artery disease evidenced by ekg changes, with impression of normal echo in a limited study. continued aspirin (also indicated by cerebrovascular disease) and statin. consolidation on chest x-ray no clinical correlate. daily body temperature maximum was typically 99s, but no infection was identified and pneumonia was not suspected upon physical examination. however, breath sounds are difficult to appreciate and she was intubated for several days, so this should be followed. yeast was found in sputum and urine, but infectious diseases recommended not treating this as they did not feel she clinically had an infection. hypotension and hypertension in context of fever, mild leukocytosis, considered sepsis. swan-ganz initially demonstrated increased calculated co and decreased svr c/w sepsis. treated broadly for seven days, with suspicion much lower immediately after initiation of antibiotics (vancomycin, cefepime, and flagyl) - however, given somewhat fragile patient we felt that continuing treatement was most prudent. sites of infection considered included endo/myocarditis, bacteremia, aspiration pneumonia/itis, along with some infected hardware given placement of a port-a-cath (left subclavian) that was never removed 17 years ago after chemotherapy. urine lytes and physiology was then most consistent with a pre-renal, dehydrated state and blood pressures overshot after fluid resuscitation was given (also in the context of increase of steroids for lupus to stress-doses). hypertension is treated at home with propranolol, likely given desirable anxiolytic effects. this was restarted during the admission and blood pressure will need to be followed. aggressive treatment did not occur as some hypertension was likely secondary to steroids and there was still quite some variation. leukocytosis resolved now. neutrophilia and leukocytosis, fever, hypotension on hd2, together concerning for sepsis. she was broadly covered with vancomycin, cefepime, metronidazole, completing a seven day course despite spontaneous resolution of fever (short latency, unlikely antibiotic effect). together concerning for sepsis/occult infection. could well be gram negative sepsis. recrudescence of lymphoma seems unlikely. cardiac enzyme leak ldh could be cardiac, ck partially cardiac and tropt obviously so. tropt and ckmb trended down, so we attributed this to pacing in context of hypotension and hypoxia. however, recent missed mi would be consistent with ekg findings and offer an explanation for her heart block (ekg changes were also septal). sleep apnea this has been diagnosed by sleep study in the past and noticed again during the admission. we discussed this with her and mr. and recommended that they follow-up in the future with sleep medicine to start cpap at home. elevated total bilirubin biliary and hemaptic processes were considered, ruq ultrasound negative. most likely secondary to hemolysis within hematoma in neck after central line placement on arrival. anemia hct drop from 40 to 32. elevated direct bili and decreased haptoglobin, but felt to be more likely secondary to hemotoma than hemolysis given resolution. however, did consider dic in septic picture, which later did not fit the clinical picture. most likely dilutional change plus blood breakdown in hematoma. lupus manifested only as pleural effusions in past. inactive during the admission. her rheumatologist, dr. , saw her during the admission and explained that here is supressed on prednisone. she will follow-up with dr. in . complement also within normal limits. insulin sliding scale was used with stress dose steroids, but not needed when steroids were reduced. nutrition tube feeds were given while she was intubated. speech and swallow deemed soft solids and thin liquids safe for her about 24 hours after extubation. this can likely be progressed soon, however, she has long had difficulty swallowing, reports an esophageal diverticulum and crushes pills at home. access venous access was very difficult. a central line (internal jugular) was placed and removed after pacer placement to reduce chance of infection. a subclavian line (right) was placed at the osh for transvenous pacing. this was removed and right subclavian access used for pacer wires and pacer pocket. port-a-cath of 17 years standing occupies the left subclavian position. placement of arterial line was difficult also. peripheral venous access was maintained. hypothyroidism and past lymphoma per mrs. : had a 'large cell' lymphoma of the neck that was attached to the thyroid, resulting in partial resection. chemoradiotherapy was also given. she now requires levothyroxine. tsh was suppressed at 0.16 during the admission, suggesting that levothyroxine might be later adjusted downward after chronic pain chronic low back pain and fibromyalgia were treated at home with percocet 7.5/500 mg up to four times daily (typically two). we changed this to standing tylenol with oxycodone breakthrough on discharge, ensuring that her intake of tylenol is controlled. depression and anxiety treated with fluoxetine throughout the admission. trazadone is also given at a dose with some antidepressant efficacy, possibly, on the cusp of sedative/antidepressant doses (75 mg). trazadone, fluoxetine, propranalol and xanax are her anxiolytic medications. hemoptysis brief self-limited hemoptysis after extubation was thought to be due to endothelial scratch during ett removal. there was only one episode. hypokalemia typically received 20-40 meq per day in hospital. she is written for 20 meq daily, but this will need to be followed, perhaps in three to four days. dvt prophylaxis mrs. was given 7500 heparins tid. code status and health care proxy she was full code throughout the admission. her hcp is her very helpful, nice and supportive husband, . osteoporosis vitamin d and calcium were restarted at discharge. alendronate should be resumed as prior to the admission. hypercholesterolemia atorvastatin was continued at home dose during the admission. given likely cad, patient may warrant uptitration of this medication as an outpatient. cerebrovascular disease continued plavix and aspirin given ct evidence and history of cerebrovascular disease and stroke. yeast cutaneous infection resolved during the admission with cleansing and topical antifungal. gerd she was diagnosed with gerd in , but without active treatment. she was maintained on famotidine throughout the admission, starting at intubation. this was stopped at discharge. disposition she remained in the ccu throughout the admission for nursing support and was transferred directly to acute rehabilitation for physical therapy and to return to baseline before returning home. medications on admission: - alendronate 70 mg once weekly - alprazolam 2 mg qhs - atorvastatin 10 mg qday - clopidogrel 75 mg qday - ergocalciferol 50,000 unit qweek - fluoxetine 60 mg qday - levothyroxine 200 mcg qday - nystatin cream prn - percocet 7.5-500 qid prn - potassium chloride 20 meq tid - prednisone 6 mg qday - propranolol 80 mg qday - trazodone 75 mg qhs - asa 325 qday - cyanocobalamin 100 mcg qday - multivitamin qday discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: 7500 (7500) units injection tid (3 times a day). 2. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. therapeutic multivitamin liquid sig: five (5) ml po daily (daily). 6. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). 7. prednisone 1 mg tablet sig: six (6) tablet po daily (daily). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day) as needed for constipation. 10. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every six (6) hours as needed for shortness of breath, wheezing. 12. acetaminophen 650 mg/20.3 ml solution sig: one (1) po q8h (every 8 hours). 13. propranolol 80 mg capsule,sustained action 24 hr sig: one (1) capsule,sustained action 24 hr po daily (daily). 14. fluoxetine 20 mg capsule sig: three (3) capsule po daily (). 15. oxycodone 5 mg/5 ml solution sig: 7.5 mg po q8h (every 8 hours) as needed for pain. 16. vitamin d 50,000 unit capsule sig: one (1) capsule po once a week. 17. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for redness at skin folds. 18. alprazolam 0.25 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 19. trazodone 50 mg tablet sig: 1.5 tablets po hs (at bedtime). 20. potassium chloride 20 meq tab sust.rel. particle/crystal sig: one (1) tab sust.rel. particle/crystal po once a day. 21. alendronate 70 mg tablet sig: one (1) tablet po once a week: weekly on empty stomach with full 8oz of water, do not eat or lie down for 30 min after taking . discharge disposition: extended care facility: courtyard - discharge diagnosis: primary diagnoses: syncope symptomatic bradycardia secondary diagnoses: - lupus - hypothyroidism - hypertension - gastroesophageal reflux disease - fibromyalgia - sleep apnea - depression - obesity - cerebro-vascular disease discharge condition: mental status: confused - sometimes - patient is usually clear during the day but sometimes becomes confused at night. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. patient requires assistance of a to get out of bed to chair. discharge instructions: you were admitted to the hospital because you fainted and were found to have a very slow heart rate. you had a permanent pacemaker placed. you will need to follow-up in the pacemaker device clinic and with an electrophysiologist (a cardiologist who specializes in pacemakers). followup instructions: please call the cardiology department at on tuesday to get the dates and times of your device clinic and electrophysiology appointments. please attend these follow-up appointments with your primary care doctor and your rheumatologist: 02:45p , w. (, ma), internal medicine (nhb) 01:00p , (rheum lmob) lm , rheumatology lmob west (sb) procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances initial insertion of dual-chamber device initial insertion of transvenous leads [electrodes] into atrium and ventricle arterial catheterization diagnoses: systemic lupus erythematosus thrombocytopenia, unspecified anemia, unspecified esophageal reflux other postoperative infection unspecified essential hypertension unspecified septicemia unspecified acquired hypothyroidism hematoma complicating a procedure unspecified transient mental disorder in conditions classified elsewhere sepsis dysthymic disorder acute respiratory failure other specified cardiac dysrhythmias atrioventricular block, complete pneumonitis due to inhalation of food or vomitus unspecified sleep apnea osteoporosis, unspecified other respiratory complications myalgia and myositis, unspecified personal history of hodgkin's disease 

Answer: The patient is high likely exposed to