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: penicillins / shellfish derived / simvastatin attending: chief complaint: sob, increasing lower extremity edema major surgical or invasive procedure: ivc filter placement 10u prbc transfusion midline placement history of present illness: 70 year old female with h/o ra previously on humera and mtx who was discharged on when she presented with r shoulder pain. her joint was tapped and it demonstrated an inflammatory joint fluid c/w with ra and negative for septic arthritis. she was discharged on ibuprofen prn. upon return home 3 days prior to presentation she felt very well but one day later noticed the gradual onset of dyspnea on exertion. she also had episodes of chest twinges overnight which resolved within minutes. + lower extremity edema. while in the hospital she was ambulatory. she went to over and returned on . she has not had any long trips or travel rides since then. at home she climbed 13 steps twice a day to get to her bedroom. she last had a mammogram one year ago and it was normal. her last colonoscopy was in and it was normal. + difficulty swallowing solids which began a few weeks ago. she saw her rheumatologist dr. today who referred her to the emergency room. . past medical history: ra on adalimumab and mtx htn hyperlipidemia s/p left bunionectomy/1st mt osteotomy atrophic vaginitis on premarin r eye scleritis social history: originally from . lives in with her husband. social etoh. no tobacco. she works as housecleaner 3x per week. no falls. her huband drives otherwise she is indpendent of iadls and adls. she has a son who lives in . she walks without a walker or cane. + glasses. no dentures or hearing aides. no recent falls. 1 glass/2 < once per month. 1 pk per week tobacco but quit "many years ago." family history: mother had diverticulosis. father had lung disease. sister had dm. no family h/o malignancy. first cousin with cancer of unknown type. physical exam: vitals: t99.2 125/80 93 18 93%ra pain: denies access: tlc r ij site c/d/i gen: nad, obese female, sitting up in chair heent: mmm cv: rrr, no m appreciated, no s3, s4 resp: ctab, slight bibasilar crackles, no wheezing abd; soft, very obese, no tenderness, no ecchymosis, +bs ext; +anasarca, 2+ lle edema, 1+ rle edema, 1+ rue edema neuro: a&ox3, grossly nonfocal skin: no changes psych: pleasant pertinent results: wbc 7.3->26.6->9.6 h/h 9.7/27.8 (s/p 1u ) (total 10u prbc, nadir hct 20, admission hct 31.2) inr 1.2 chem panel: bun 48->18, creat 3.2->1.5->0.7 (baseline) bnp 576 . ua 106 wbc, 826 rbc, no bacteria, ucx negative ua 32wbc, trace le, no bacteria, ucx negative ua 4wbc, no le blood cx x2 ntd . . imaging/results: . lenis : no evidence of lower extremity dvt. . lenis : impression: nonocclusive thrombus within the left common femoral and left superficial femoral vein, new when compared to prior exam. no evidence of thrombus within the right lower extremity . ue dopplers (r) : negative . cta : ct of the chest with and without intravenous contrast: there are bilateral segmental and subsegmental pulmonary emboli involving the right upper, middle and lower lobe pulmonary arteries, and the pulmonary arteries supplying the left upper lobe, lingula and the left lower lobe. no saddle pulmonary embolus is seen, and no evidence of right heart strain . tte : the left atrium is elongated. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 70%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). there are focal calcifications in the aortic arch. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. . ct abd/pelvis : 1. moderate-size left rectus sheath hematoma with extraperitoneal extension inferiorly along the left piriformis muscle. evidence of iv contrast extravasation suggesting active bleeding. no evidence of retroperitoneal hematoma. if serial hemacrit continues to drop, the bleeding site may be amenable to catheter embolization by interventional radiology. 2. large gallstone without evidence of acute cholecystitis. . ct a/p : 1. left retroperitoneal hematoma likely arises from the left psoas muscle and tracks along the left posterior pararenal fascia. there is no evidence of acute extravasation. 2. left rectus sheath hematoma is similar to . 3. cholelithiasis without evidence of cholecystitis.. renal us : no right hydronephrosis. pelvic hematoma. otherwise, extremely limited exam, did not visualize l kidney . cxr : no pulm edema . cxr : in comparison with the study of , the patient has been a very lordotic position which most likely accounts for the increasing prominence of the transverse diameter of the heart. no evidence of vascular congestion or pleural effusion. right ij catheter tip extends to the lower portion of the svc, and there is no evidence of pneumothorax. . ct head (prelim): no ich or mass. brief hospital course: 70year old female with h/o ra, htn, obesity, recent d/c after acute ra flare, presented with doe/le edema, found to have bilateral/multifocal pe. lenis were negative and tte was unremarkable for evidence of cardiac strain. she was started on a heparin drip on admission but subsequently developed a rectus sheath hematoma on . given the large clot burden, she was hemodynamically stable, and the thought that the hematoma was likely to tamponade itself off, heparin was not initially stopped, although the target ptt was changed to the lower end of therapeutic (althought ptts remained elevated up to 90s). she eventually developed worsening bleeding (extended retroperitoneum) with tachycardia and hypotension and dropping hct (nadir 20), and was tranferred to icu. she ended up requiring 9u prbc for the acute bleed (10u total during hospital course). heparin was stopped and pt underwent ivc filter placement on by ir without complications. her hct stabilized and she was transferred out of icu on . she remained stable in terms of her hct. however, developed asymmetrical l>r swelling and had a fever on . le dopplers checked which showed new l prox dvt. heme was consulted to help with decision on safety of resuming anticoagulation given significant clot burder and ongoing hypercoag that may not be protected by ivc filter alone. ct scan was repeated on which showed large l retroperitoneal bleed (resulting in above hct drop), but no active bleeding. she was given an additional 1u prbc (10 total) for hct 23.6 though it was not believed she had ongoing bleeding. after discussion with patient/husband regarding risks/benefit of anticoagulation, decision was made to resume heparin. as for her pes, she remained hemodynamically stable and was weaned off of o2. for her le edema and risk of posthrombotic complications, she was placed on teds and reccommeded to keep her legs elevated. as for the cause of her hypercoagubility, no clear precipitant: no self-reported history of immobility (last flight ), no history of malignancy (up to date with /pap/cscope), no personal or family history of blood clots, no recent surgery. only possible trigger identified was her recent ra flare, but this was no longer an issue so did not explain her ongoing hypercoaguable state (lle dvt formed in-hosp). another concern was her longstanding use of humira, which can be associated with secondary malignancy. her ct c/a/p did not mention any abnormal masses or lad to suggest lymphoma, and as per above she is up to date on cancer screening. she needs outpt further w/u for malignancy and hyper coag w/u. hospital course also complicated by arf, thought to be prerenal, s/p ivfs and blood tranfusions, now back to baseline. her fe studies were c/w low fe stores, however she likely got enough fe load with the blood transfusions and this can be rechecked as outpt. her b12 was low normal and she was started on supplementation. her humira and mtx were held in the acute setting but were resumed once pt stabilized. her bp meds were kept the same except norvasc was not resumed due to well controlled bp off this. . . see note below for details. # bilateral pes/vte: significant clot burden on cta but echo w/o rv strain. le doppler/ct a/p w/o thrombus on . as above, taken off heparin given significant rectus sheath/rp hematoma. underwent ivc filter . repeat dopplers (feverw w/u) with l fem dvt suggesting she continues to be hypercoaguable which is concerning. heme consulted to assess whether appropriate to resume heparin. hct stable and ct with subacute hematoma (known bleed) but no active bleeding. weaned off o2. heme felt risk outweighed benefit, and pt was agreeable to resuming heparin gtt on . she was monitored over 2 days and coumadin was started the evening of . she will need to be bridged with heparin gtt (titrate to ptt 60-80) until therapeutic on coumadin. discharged on heparin gtt at 1700 u/hr. should have twice daily ptts given recent massive bleed. given no clear precipitant of vte episode (except perhaps prior ra flare) and clot formation while here in her left leg, she will need an outpatient hypercoaguable work up. she also should wear teds for at least 6 months to prevent post-dvt complications. likely will need lifelong anticoagulation. phone number for outpatient hematology follow up in 6 months was given in the discharge paperwork. . . # rectus sheath and rp hematoma: spontaneous bleed while on heparin gtt (highest ptt 97). no recent injury, trauma, or surgery in that site. hemodynamic unstable bleed (transferred to icu), heparin gtt stopped, required 9u prbc at the time. no ir intervention, appears to have tamponaded finally. last t/f for slowly drifting hct. has been stable. repeat ct ab/pelvis on as above showing new rp bleed as of , which represents the 10u bleed (subacute) rather than active bleed. heparin gtt was restarted on with close monitoring. pt will need close monitoring of her ptt/inr while titrating in coumadin (twice daily ptt, daily inr). will not resume asa or nsaids on discharge. would transfuse for hct less than 23 and repeat ct scan abdomen/pelvis to eval for new bleed if hct drops to less than 22. hct was 28 at discharge. . # fever: temp spike . ua/cxr unremarkable. blood cx x2 negative (tlc and peripheral). no leukocytosis. did have some loose stools, but c diff negative. another concern was for dvt and le dopplers confirm l prox dvt which may be cause. low grade temp of 100.1 on . again, no clear source other than blood clots. afebrile completely on night prior to and day of discharge. . # anasarca: likely large ivfs and blood in icu. cxr w/o pulm edema though does have significant anasarca (especially l>r le, r>l ue edema). albumin low at 2.5. started nutrition supplements. . # arf: normal creat at baseline. developed arf in icu, peak creat 3.2, bun 50s. ddx: prerenal vs hematoma resorption vs cin vs atn from hypotension. received fluids/blood, improved to baseline of 0.6-0.7 at discharge. . # nausea: ct head negative for mass, lfts/lipase normal. written for zofran as needed. vomiting/nausea noted after pt received her mtx on , which is felt to be the likely etiology of her symptoms. . #acute diastolic chf: noted wheezing and elevated jvp on , s/p 10 u prbc in the days prior. she was given lasix 10 mg iv daily on with resolution of wheezing and good urine output. . # htn: resumed home dose of lisinopril 40, toprol 50, bp well controlled. not resuming amlodipine . # ra: humira and mtx held since last admission () given concern at that time for septic shoulder joints (negative fluid cx). were not resumed on last discharge with plan for f/u rheum for resuming. rheum/dr. does not feel there is any contraindication as of , so humira and mtx were resumed on (mtx received , humira received ). . # anemia, acute and chronic: see above for acute drop 2/2 hematoma. also has h/o fe def and b12 def (93 in ). received good fe load with transfusion for now, f/u fe studies in 2 months. continued b12 supplements. hct stable at 28 at time of discharge. . # hyperlipidemia: continued pravastatin 20, holding asa 81 . # nac study: ed protocol. infusion finished . # access: midline placed medications on admission: confirmed medications with patient. amlodipine 5 mg tablet 1 tablet(s) by mouth once a day esomeprazole magnesium 40 mg capsule, delayed release(e.c.) 1 capsule(s) by mouth once a day folic acid 1 mg tablet 1 tablet(s) by mouth once a day (prescribed by other provider) ibuprofen 800 mg tablet 1 tablet(s) by mouth three times a day prn lisinopril 40 mg tablet 1 tablet(s) by mouth once a day metoprolol succinate 50 mg tablet sustained release 24 hr 1 tablet(s) by mouth once a day pravastatin 20 mg tablet 1 tablet(s) by mouth at bedtime * otcs * aspirin 81 mg tablet, chewable 1 tablet(s) by mouth once a day calcium citrate-vitamin d3 - 2 t . discharge medications: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 4. calcium 600 + d(3) 600-400 mg-unit tablet sig: one (1) tablet po twice a day. 5. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 6. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 8. ferrousul 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 9. cyanocobalamin 250 mcg tablet sig: one (1) tablet po daily (daily). 10. methotrexate sodium 2.5 mg tablet sig: eight (8) tablet po qfri (fr). 11. heparin flush (10 units/ml) 1 ml iv prn 12. senna 8.6 mg tablet sig: two (2) tablet po daily (daily) as needed. 13. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 14. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 15. humira 40 mg/0.8 ml kit sig: 0.8 ml subcutaneous every 2 weeks (). 16. warfarin 3 mg tablet sig: one (1) tablet po once daily at 4 pm. 17. heparin (porcine) in d5w 25,000 unit/250 ml parenteral solution sig: 1700 (1700) units intravenous per hour: titrate to ptt of 60-80. 18. heparin flush (10 units/ml) 2 ml iv prn line flush mid-line, heparin dependent: flush with 10 ml normal saline followed by heparin as above, daily and prn per lumen. 19. acetaminophen 500 mg tablet sig: two (2) tablet po q 8h (every 8 hours). discharge disposition: extended care facility: - discharge diagnosis: bilateral pulmonary embolism severe rectus sheath and retroperitoneal hematoma s/p 10u prbc hypercoag state of unclear etiology rheumatoid arthritis anemia chronic disease, fe def, and acute blood loss discharge condition: stable discharge instructions: you were admitted with leg swelling and shortness of breath. you were diagnosed with multiple pulmonary embolisms. . you were started on heparin for anticoagulation but developed a complication of massive bleeding into your muscle and within the abdomen for which you recieved 10 units of blood. your heparin was held for several days and you underwent ivc filter for protection from further pulmonary embolism. you developed another left leg clot while here. hematology was consulted and after careful consideration and discussions with you, decision was made to restart heparin. . you need to have your blood counts carefully monitored. you will be followed by hematology after discharge for further workup of why you developed these clots. you are started on some new medications. from your previous list, you will not restart norvasc. you also were started on coumadin to help thin your blood. also your ra meds, humira and methotrexate were held for the most part, but were restarted prior to discharge. . call your doctor or return to the er for any worsening shortness of breath, new leg or arm swelling, chest pain, fainting, palpitations, fevers, lightheadedness, or any other concerning symptoms. followup instructions: 1. please follow up with dr. 2 weeks after discharge from rehab . 2. please follow up with dr. of hematology in 6 months to help work up the reason why you formed all of these blood clots. his number is ( and you can call in 5 months to arrange for follow up. . 3. please follow up with dr. of rheumtology after your discharge from rehab. fax ; phone procedure: venous catheterization, not elsewhere classified interruption of the vena cava transfusion of packed cells angiocardiography of venae cavae diagnoses: congestive heart failure, unspecified unspecified essential hypertension acute posthemorrhagic anemia acute kidney failure, unspecified other and unspecified hyperlipidemia iron deficiency anemia, unspecified rheumatoid arthritis unspecified accident primary hypercoagulable state nontraumatic hematoma of soft tissue acute venous embolism and thrombosis of deep vessels of proximal lower extremity injury to bladder and urethra, without mention of open wound into cavity acute diastolic heart failure other pulmonary embolism and infarction hemoperitoneum (nontraumatic) 

Answer: The patient is high likely exposed to