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: shortness of breath major surgical or invasive procedure: placement of triple lumen central venous line transesophageal echocardiogram history of present illness: mr. is a 57 year-old man with no significant past medical history apart from hypertension. for the past year he has noticed increasing doe. he has an active job as a painter and was newly unable to climb 1 flight of stairs or walk across a building without stopping to catch his breath. dyspnea is occasionally accompanied by dry or slightly productive cough with white sputum, which he attributes to postnasal drip. he denies accompanying cp, palpitation, or wheezing. he saw his pcp for these complaints and was given an albuterol inhaler. he is not certain if this helped. . over the past two months, mr. has been feeling increasingly short of breath with less and less exertion. today, he was even having trouble breathing at rest so he presented to the ed. he denies any chest pain or palpitations. also for the past 2 months, mr. has noted testicular swelling and pain. this progressed to the point where he could hardly walk and had trouble positioning himself to urinate. he denies any pain with urination or defecation. he is not sexually active. for the past 2 days he has had increasing abdominal distention. he continues to have baseline abdominal pain at the site of his mesh that is unchanged, although he is uncomfortable from the distention. . of note, he also burned his l lower leg in the bathtub 2 weeks ago. for the past few days his entire l lower leg has become more painful and red. . in the ed, vital signs were initially: t 98.2, bp 100/77, hr 60 (unclear if correct ), rr 24, o2 sat 93% o n ra he was found to be in rapid afib to the 170s. his exam was also notable for apparent left lower extremity cellulitis. he had whole body including significant scrotal edema. lung exam demonstrated rales. labs were notable for lactate 2.6, inr 1.9, wbc 18, elevated lfts, and creatinine 1.5 (no prior electrolytes or lfts in our system). ct of torso was concerning for pneumonia vs volume overload as well as a subsegmental pe. . arterial line and central venous line were placed. for his persistent mild hypotension and rapid afib, he received 3 l ns. he was quite hypoxic with o2 sat falling to 80% on nc; thus facemask o2 was started with good o2 sat. because of the hypoxia, hypotension, amd evidence of (albeit small) pe, heparin gtt was started. he was also given vancomycin 1 g, unasyn 3 g, and levofloxacin 750 mg iv for both the cellulitis and pneumonia. for the atrial fibrillation, he was given 10 mg of diltiazem followed by a diltiazem drip that was initially as high as 15 mg/h, titrated down to 5 mg/h. he was admitted to the micu for further evaluation and management. his vital signs prior to transfer to were 101, 95/61, 20, 98% on nrb past medical history: 1. cardiac risk factors: -diabetes, -dyslipidemia, +hypertension 2. cardiac history: none -cabg: none -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: - anxiety - s/p hernia repair, pt describes complicated course of what sounds like dehiscence and redo x2 with mesh placement, last in 12/. - seasonal allergies - pt denies h/o ami, cabg, stents, lung disease, kidney, liver, or gi disease. social history: he is single and lives alone. he works as a painter at . he is a lifetime nonsmoker and denies illicit drug use. he does drink approximately bottle of wine about 3 times weekly and "a few beers" from time to time with friends. family history: father: h/o cva mother: h/o heart disease, arrythmia and had a pacer. deceased 82yo. physical exam: vs: t 98.9, hr 96, bp 107/76, o2 96% on face mask gen:the patient is in no distress and appears comfortable skin:no rashes or skin changes noted heent: jvp no assessible because of large neck chest: decreased breath sounds at bases bilaterally cardiac: irregular, no murmurs abdomen: distended and moderately firmm.. hyperactive bowel sounds. nontender. no rebound or guarding. extremities: 2+ peripheral edema b/l, l shin with 8 cm area of open, weeping wound. surrounding warmth and erythem extending to most of lower leg. genetalia: 2+ scrotal, perineal, penile edema neurologic: alert and appropriate. cn ii-xii grossly intact. bue , and ble both proximally and distally. no pronator drift. reflexes were symmetric. downward going toes. physical exam on admission to the floor 96.9 131/83 110 18 95% on ra large gentleman sitting at about 30 degree angle, pleasant, talkative, fair historian. speech normal, conversant. sclera clear, eomi. mouth moist appearing, no obvious lesions. jvd not apparent but limited by neck mass. no carotid bruits bilaterally. r triple lumen noted. breathing comfortably, no accessory muscle use, no labored breathing, speaking full sentences. has gross crackles up to mid lung field, also with transient high pitched inspiratory wheeze s1 s2 faint, difficult to auscultate but irregular without murmurs distended abdomen without tenderness to palpation. anasarca/edema noted on abdomen, thighs. ble with gross pitting edema up to abdomen. dp's not palpable. l anterior shin with palm sized burn mark with granulation tissue noted, not grossly purulent. scrotum and shaft of penis grossly edematous. pertinent results: admission labs: . 11:45am blood wbc-17.5*# rbc-4.28* hgb-13.6* hct-41.1 mcv-96 mch-31.8 mchc-33.1# rdw-14.5 plt ct-257 10:14pm blood wbc-14.3* rbc-3.97* hgb-12.1* hct-38.1* mcv-96 mch-30.4 mchc-31.7 rdw-14.9 plt ct-206 11:45am blood neuts-86.8* lymphs-9.3* monos-3.6 eos-0.1 baso-0.2 11:45am blood pt-20.9* ptt-27.1 inr(pt)-1.9* 07:30pm blood pt-21.0* ptt-27.6 inr(pt)-1.9* 11:45am blood glucose-100 urean-50* creat-1.5* na-131* k-4.5 cl-95* hco3-20* angap-21* 10:14pm blood glucose-106* urean-46* creat-1.2 na-130* k-4.6 cl-99 hco3-22 angap-14 11:45am blood alt-168* ast-242* ck(cpk)-119 alkphos-188* totbili-2.8* 10:14pm blood alt-152* ast-203* ld(ldh)-370* alkphos-177* totbili-2.4* 11:45am blood lipase-40 11:45am blood ck-mb-7 11:45am blood ctropnt-0.03* 07:30pm blood ck-mb-notdone ctropnt-0.02* probnp-8547* 10:14pm blood albumin-3.7 calcium-8.2* phos-3.7 mg-2.0 01:28am blood calcium-9.1 phos-3.6 mg-1.6 cholest-115 06:59am blood calcium-9.1 phos-3.7 mg-1.8 iron-42* 06:59am blood caltibc-363 ferritn-315 trf-279 01:28am blood %hba1c-6.4* eag-137* 01:28am blood triglyc-64 hdl-26 chol/hd-4.4 ldlcalc-76 10:14pm blood tsh-7.9* 07:39am blood t3-114 free t4-1.3 04:16am blood hbsab-positive hbcab-negative 05:50am blood hiv ab-negative 07:39am blood digoxin-0.7* 04:16am blood acetmnp-neg 10:14pm blood ethanol-neg 04:16am blood hcv ab-negative 11:44am blood lactate-3.0* 03:21pm blood o2 sat-87 03:21pm blood lactate-2.1* discharge labs 05:50am blood wbc-7.8 rbc-3.81* hgb-11.7* hct-37.6* mcv-99* mch-30.6 mchc-31.1 rdw-14.9 plt ct-156 05:50am blood neuts-62.5 lymphs-24.7 monos-10.2 eos-2.3 baso-0.3 05:50am blood pt-16.9* ptt-34.9 inr(pt)-1.5* 05:50am blood glucose-122* urean-16 creat-0.8 na-139 k-4.6 cl-99 hco3-34* angap-11 05:50am blood alt-61* ast-40 ld(ldh)-264* alkphos-174* totbili-1.4 05:50am blood calcium-9.3 phos-4.7* mg-1.7 ekg atrial fibrillation with rapid ventricular response. poor r wave progression suggests prior anteroseptal myocardial infarction. diffuse st-t wave changes that are non-specific. compared to the previous tracing of atrial fibrillation is new. read by: , intervals axes rate pr qrs qt/qtc p qrs t 164 0 94 302/484 0 61 -21 . cxr the lungs show a small right-sided pleural effusion. no focal consolidation or pneumothorax is present. the cardiac silhouette is enlarged. the mediastinal silhouette is unremarkable. impression: small right-sided pleural effusion. cardiomegaly. . ct chest abd pelvis chest: within the right lower lobe, there is a small filling defect in a subsegmental pulmonary artery seen on series 3a, 65, consistent with subsegmental pulmonary embolism. there is no definite evidence of right heart strain. note is made of enlarged ivc and hepatic veins, though these findings were present on the prior abdominal ct from and the acuity is indeterminate. however, they do suggest some right-sided heart failure. no other area of pe is seen. within the left atrial appendage, there is an apparent filling defect along the medial most aspect. this could represent a thrombus. it is possible that this represents volume averaging and is artifactual, but this is not favored. the left atrium is enlarged. there are focal areas of ground-glass opacification in the anterior left greater than right upper lobes. differential diagnosis includes some focal pulmonary edema or infection. there is slight increased right-sided pleural effusion and new left pleural effusion. there is dependent airspace disease in the right lower lobe, which may represent compressive atelectasis, though pneumonia could not be excluded here as well. there are scattered prominent mediastinal lymph nodes, though they are not enlarged by ct criteria and may be reactive in nature. abdomen: the liver appears normal. there is mild gallbladder wall thickening which is likely due to third spacing as the gallbladder is not distended, and is unchanged from prior. the pancreas, spleen, right adrenal gland, and kidneys appear normal. there is a stable small left adrenal nodule, which measures 1.7 cm, unchanged from . there is a small hiatal hernia. there is some slightly increased ascites compared to prior study. the small bowel loops appear normal. pelvis: there is diverticulosis, but no evidence of diverticulitis. the appendix appears normal. there is slight increase in the free fluid seen in the pelvis as well. the scrotal edema has decreased from the prior study, but is still present. there is no gas within the peritoneum. prominent bilateral external iliac chain lymph nodes are noted and stable from prior, perhaps minimally increased in size from . impression: 1. subsegmental right lower lobe pulmonary embolism. clinical significance uncertain given small size. 2. an enlarged ivc and hepatic veins, which can be seen in right-sided heart failure. however, it is unlikely that these findings are related to the pulmonary embolism and more likely related to intrinsic cardiac disease. 3. probable filling defect in the left atrial appendage concerning for thrombux. differential diagnosis would include artifact from volume averaging. however, further evaluation with echocardiogram to exclude thrombus is recommended, particularly given the provided history of atrial fibrillation. 4. bilateral upper lobe left greater than right ground-glass opacities. differential diagnosis includes infection or focal pulmonary edema. 5. increasing moderate right pleural effusion and new left pleural effusion. 6. increasing ascites consistent with third spacing. 7. decreased but persistent scrotal edema. no evidence of gas in the peritoneum. 8. prominent bilateral external iliac chain lymph nodes, which may be minimally increased from . 9. no change in small left adrenal nodule from . . tte findings left atrium: marked la enlargement. right atrium/interatrial septum: moderately dilated ra. left ventricle: normal lv wall thickness. mildly dilated lv cavity. severe global lv hypokinesis. no lv mass/thrombus. no resting lvot gradient. right ventricle: moderately dilated rv cavity. severe global rv free wall hypokinesis. aorta: normal aortic diameter at the sinus level. mildly dilated ascending aorta. aortic valve: normal aortic valve leaflets (3). no as. trace ar. mitral valve: normal mitral valve leaflets. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets with trivial tr. normal pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: very small pericardial effusion. general comments: the rhythm appears to be atrial fibrillation. echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. conclusions the left atrium is markedly dilated. the right atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is severe global left ventricular hypokinesis (lvef = 25%). no left ventricular thrombus seen. the right ventricular cavity is moderately dilated with severe global free wall hypokinesis. the ascending aorta is mildly dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a very small pericardial effusion. impression: dilated ventricles with severe biventricular systolic dysfunction, most consistent with a global process (toxic, metabolic, tachycardia-related, etc.). no clinically-significant valvular disease seen. . tee left atrium: no spontaneous echo contrast in the body of the la. no thrombus/mass in the body of the la. mild spontaneous echo contrast in the laa. depressed laa emptying velocity (<0.2m/s) definite thrombus in the laa. right atrium/interatrial septum: no spontaneous echo contrast or thrombus in the body of the ra or raa. depressed raa ejection velocity (<0.2m/s). dynamic interatrial septum. pfo is present. right-to-left shunt across the interatrial septum at rest. left ventricle: depressed lvef. right ventricle: mildly dilated rv cavity. rv function depressed. aorta: normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. aortic valve: normal aortic valve leaflets (3). no as. no masses or vegetations on aortic valve. filamentous strands on the aortic leaflets c/with lambl's excresences (normal variant). trace ar. mitral valve: mildly thickened mitral valve leaflets. no mvp. no mass or vegetation on mitral valve. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. no mass or vegetation on tricuspid valve. mild tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. no vegetation/mass on pulmonic valve. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. local anesthesia was provided by benzocaine topical spray. the posterior pharynx was anesthetized with 2% viscous lidocaine. no tee related complications. echocardiographic results were reviewed by telephone with the md caring for the patient. results were reviewed with the cardiology fellow involved with the patient's care. conclusions no spontaneous echo contrast or thrombus/mass is seen in the body of the left atrium. mild spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). a 1cm long mural thrombus is seen in the left atrial appendage. no spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. the right atrial appendage ejection velocity is depressed (<0.2m/s). the interatrial septum is intact but dynamic and demonstrates periodic right-to-left shunting on color flow doppler through a patent foramen ovale at rest. overall left ventricular systolic function is depressed. the right ventricular cavity is mildly dilated with global free wall hypokinesis. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. no masses or vegetations are seen on the aortic valve. there are filamentous strands on the aortic leaflets consistent with lambl's excresences (normal variant - clip ). trace aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: left atrial appendage thrombus as described above. biventricular hypokinesis. intact interatrial septum with periodic right-to-left shunting across a patent foramen ovale at rest. trace aortic regurgitation. . stress test interpretation: this 57 year old man with a pmh of htn, biventricular failure ef 25%, paf and shortness of breath was referred to the lab for evaluation. due to recent non-cardiac surgery and recent laa thrombus identified by tee on he was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. no arm, neck, back or chest discomfort was reported by the patient throughout the study. there were no st segment changes(in the setting of digoxin therapy). the rhythm was atrial fibrillation without ectopy. appropriate hemodyanmic response to the infusion. the dipyridamole was reversed with 125 mg of aminophylline iv. impression: no anginal type symptoms or st segment changes (on digoxin therapy). nuclear report sent separately. . perfusion scan interpretation: the image quality is satisfactory. left ventricular cavity size is enlarged. the calculated left ventricle end diastolic volume is 192 ml. rest and stress perfusion images reveal fixed inferior wall defect in the left ventricle myocardium. gated images reveal normal wall motion. the calculated left ventricular ejection fraction is 33%. no prior studies available for comparison. impression: 1. fixed defect in the inferior wall of the left ventricle. no obvious evidence of ischemia. 2. dilated left ventricle with edv of 192 ml and ef of 33%. brief hospital course: mr. is a 57 year-old man with a history of hypertension who presents with progressive dyspnea, total body edema, and hypoxia and found to have new dilated cardiomyopathy and biventricular systolic heart failure with ef 33%. . # chf: the most likely cause of hypoxia and total body edema was heart failure. cxr showed bilateral effusions but no florid pulmonary edema. transthoracic echo the day after admission demonstrated dilated cardiomyopathy wtih ef 25%. diuresis was initially not possible given borderline blood pressures. as bp improved with rate control (see below) and ivf, diuresis was begun with prompt improvement in hypoxia and edema. after just 10 mg iv lasix x 3 over 24 hours, patient transitioned from fask mask o2 requirement to room air. on the floor, pt was continued on minimal amounts of diuresis as he was autodiuresing well. regarding the cause of dilated cardiomyopathy, the differential included idiopathic dilated cardiomyopathy, alcohol related cardiomyopathy, advanced ischemic disease, or less likely tachycardia-induced cardiomyopathy after longstanding atrial fibrillation. iron studies were normal, ruling out hemochromatosis. hiv was negative. the cardiology consulting service followed along in the micu. when clinically stable and no longer hypoxic, patient was transferred to the cardiology service for further management. pt had a stress perfusion study which showed a fixed perfusion defect in inferior wall of lv. however, the images from his stress test were reviewed with dr. and it was thought that he likely had some attenuation artifact more consistent with a diagnosis of nonischemic cardiomyopathy. the pt was started on a heart failure regimen which he tolerated well and was discharged on carvedilol, lisinopril, and lasix. # atrial fibrillation with rvr and thrombus in laa: duration of afib was unclear, although most likely recent onset given acute worsening of chronic heart failure symptoms. in the ed he initially became hypotensive with diltiazem boluses and was admitted to the icu on a diltiazem gtt with hr 100-110 (from 170s in ed). due to continued hypotension, amiodarone was loaded per the advice of the cardiology service. rhythm control was not achieved, although bp improved sufficiently to allow diuresis (as above), and rate remained >100. pt was switched from amiodarone to digoxin due to a thrombus seen in the pt's left atrial appendage, and cards recommended using an that would not risk spontaneously converted the pt to sinus rhythm. plans were made for a tee guided cardioversion, however, approximately 12 hours after digoxin load finished, patient was noted to convert to nsr in the 80s. po digoxin was started and he was transferred from the micu to the cardiology service. heparin gtt was started on admission for prevention of embolization. pt underwent tee which did visualized the thrombus and cardioversion was not performed. the pt was continued on his heparin gtt, then started on/discharged with lovenox and coumadin with follow up arranged with the . the pt was discharged in afib with rate controlled with po digoxin and carvedilol. he will need 4-6 weeks of anticoagulation with a repeat tee to be performed to evaluate for thrombus resolution and possible electrical vs chemical cardioversion if possible. # le cellulitis: patient had l anterior shin abrasion and surrounding cellulitis, likely initiated by recent burn injury and worsening secondary to subcutaneous edema. he was given vancomycin and zosyn and meticulous wound care, called out to the floor on unasyn and switched to a po keflex by time of discharge to complete a two week course of abx. all cultures including blood, urine, and central line tip were negative. # pna: a small rll infiltrate was apparent. antibiotics were administered as above. pt with elevated wbc count and sputum production on admission, fever to 101 noted in micu however defervesced and did not have fever through rest of course. wbc's trended down. . # elevated lfts: lfts mildly elevated, likely secondary to congestive hepatopathy, but inr elevation indicates some degree of synthetic dysfunction. last lfts nl at in . hepatitis panel was checked and found to be negative and lft's trended down to almost normal values by discharge. lft's should be checked at follow up as an outpt. # pe: a subsegmental pe was visualized on cta, but was felt very unlikely to be clinically meaningful. medications on admission: diazepam 2 mg prn diovan 160-25 mg qd percocet prn valium 2 mg "occasionally" discharge medications: 1. lovenox 120 mg/0.8 ml syringe sig: one (1) injection subcutaneous twice a day. disp:*10 syringes* refills:*2* 2. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 3. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. cephalexin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 8 days: please take for 8 more days until , . disp:*72 capsule(s)* refills:*0* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 7. coumadin 2.5 mg tablet sig: three (3) tablet po once a day: please take 7.5 mg daily for two days (thus and fri ) until you follow up with the anticoagulation clinc. if for any reason you are unable to make your appointment, drop your dose down to 2 tablets daily until you can follow up. . disp:*90 tablet(s)* refills:*2* 8. lasix 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* 10. morphine 15 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain for 1 weeks: please do not take if you feel oversedated as this can decrease your respiratory rate. take for the next week and readdress at follow up. . disp:*40 tablet(s)* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: primary: nonischemic dilated cardiomyopathy atrial fibrillation left atrial appendage thrombus secondary: hypertension discharge condition: mental status: clear and coherent level of consciousness: alert and interactive activity status: ambulatory - independent discharge instructions: you were admitted for difficulty breathing. you were found to be in congestive heart failure from a very enlarged heart. this can be caused by many things, but based on your stress test we do not think this is related to a missed heart attack. you were started on several new medications, including lasix, which will help draw the excess fluids off of your body. please monitor your weight daily, and if you have weight gain of >3 lbs, or have any difficulty urinating, please call your doctor. you also have a new finding of an irregular heart rhythm called atrial fibrillation. through your evaluation you were found to have a clot in your heart for which you will need to be anticoagulated for at least 4-6 weeks, after which a repeat esophageal echocardiogram will be needed to assess for clot resolution. lastly, you were treated with antibiotics for a skin infection of your leg. please keep your legs elevated when you are not walking. the following changes have been made to your home medication regimen: 1. start lasix 20 mg daily 2. start carvedilol 12.5 mg twice daily 3. start digoxin 250 micrograms daily 4. start coumadin 5 mg daily, except 7.5 mg on 2 days (thurs and fri ). you will need to follow up with the closely for these meds (see below). 5. start lisinopril 5 mg daily 6. start cephalexin (keflex) 500 mg daily every 6 hours until next wednesday 8. start morphine 15 mg, 1-2 tablets every 6 hours as needed for pain 9. start lovenox 120 mg injections twice a day. you should take these injections until you follow up with the . if your coumadin levels are therapeutic, they may recommend stopping this medication. followup instructions: please come to the laboratory in the building on friday morning, , to have your inr (blood coagulability), chemistries, and blood counts checked. the anticoagulation management service will help you monitor your coumadin levels and will call you to set up care. please follow up with , md on at 1:45pm on the of the building, . if you cannot make this appointment, please call to reschedule. please follow up with dr. in cardiology on thursday, at 9:00am on the of the building. you will need a repeat echocardiogram to evaluate your heart for a clot and possible cardioversion. md procedure: venous catheterization, not elsewhere classified arterial catheterization diagnoses: pneumonia, organism unspecified other primary cardiomyopathies congestive heart failure, unspecified unspecified essential hypertension atrial fibrillation systolic heart failure, unspecified cellulitis and abscess of leg, except foot acute on chronic systolic heart failure other pulmonary embolism and infarction other specified hypotension other ill-defined heart diseases edema of male genital organs 

Answer: The patient is high likely exposed to