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 / morphine sulfate / lipitor attending: chief complaint: dyspnea major surgical or invasive procedure: ivc filter placement history of present illness: 69 yo f w/ history of cad and dm who presents with acute onset of shortness of breath this morning. she felt well when she first got out of bed, but felt acutely dyspneic after getting up from breakfast. she tried to leave the house but was out of breath getting into her car. she had no cough, chest pain, diaphoresis or calf pain. she has had no recent travel, surgeries or trauma, though her physical activity has been very limited by chronic back and left hip pain. she had superficial thrombophlebitis during her three pregnancies but has never had any other abnormal clotting. initial ed vital signs 98.3, 97, 122/68, 18 and 95ra. ed exam notable for mild tachycardia, guaiac negative. initial labs concerning for elevated ddimer > 1063 and mild anemia hct 34.7. ekg with sinus tachycardia, rbbb but no e/o rv strain. obtained cta that revealed large thrombus in right main pulmonary artery. given dilaudid 1mg iv, plavix 600mg po (for initial presumed acs), heparin bolus & gtt and integrillin bolus (did not continue on gtt). has gotten approximately 1l fluid in iv medications. no echo performed while in ed. of note, patient recently saw rheumatology for evaluation of a . initial labs revealed normal cbc, esr, crp and negative , anti-sm, rnp, ro and la. she was also recently told that she has iron deficiency anemia and should start taking iron. she has had chronic stable angina for over a decade that has not been an issue for the last 3 months, partly due to decreased activity. she has chronic back and left hip pain that restricts her movements. her right ankle occasionally swells, and was swollen yesterday. on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. past medical history: - cad, per kannum note has single vessel disease with a tight proximal coronary lesion - type ii dm - hypertension - hyperlipidemia - hypothyroidism - s/p laminectomy x2 - s/p appendectomy and cholecystectomy - s/p tah and oophorectomy - s/p multiple hernia operations - s/p total knee replacement - s/p tonsillectomy social history: lives with husband and son in . has three children and three grandchildren. -tobacco history: smoked 2-3 packs/day for 15 years, quit 20+ years ago. -etoh: rare etoh -illicit drugs: none family history: no family history of abnormal clotting. one brother died of an mi in his early 50s. father died of mi at 71, mother of leukemia at 63; otherwise non-contributory. physical exam: vs: t=98.9 bp=115/61 hr=95 r=20 o2 sat= 99% on 2l general: obese female breathing comfortably. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 6 cm. cardiac: pmi located in 5th intercostal space, midclavicular line. tachycardic but regular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: obese, soft, ntnd. no hsm or tenderness. no abdominal bruits. extremities: mild right calf pain, no left calf pain. no peripheral edema. skin: mild le venous insufficiency. no ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ pertinent results: 10:45am wbc-6.9 hct-34.7 plt count-242 coags: pt-12.1 ptt-25.0 inr(pt)-1.0 ce: ck-mb-6 ctropnt-0.03* ck(cpk)-206* 137 | 101 | 15 4.4 | 25 | 0.8 01:01pm d-dimer-1063* ucx (): proteus mirabilis 11:20 am urine source: cvs. **final report ** urine culture (final ): proteus mirabilis. >100,000 organisms/ml.. presumptive identification. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s discharge labs 07:00am blood wbc-10.3 rbc-4.11* hgb-10.8* hct-34.3* mcv-83 mch-26.2* mchc-31.5 rdw-16.3* plt ct-233 07:00am blood glucose-123* urean-14 creat-0.6 na-133 k-4.3 cl-98 hco3-25 angap-14 06:50am blood calcium-8.6 phos-3.1 mg-1.9 07:35am blood tsh-1.0 07:00am blood pt-14.8* ptt-89.5* inr(pt)-1.3* imaging cta chest w&w/o c&recons, non-coronary study date of 1:44 pm 1. large pulmonary embolus in the right main pulmonary artery extending into the lobar branches. no evidence of right heart strain or pulmonary infarct. 2. fatty liver. 3. prominent anterior mediastinal nodes not meeting ct criteria for pathologic enlargement; however, recommend ct followup in six months to ensure stability. lenis () 1. no evidence of acute dvt. 2. chronic thrombus within the greater saphenous vein on the right from the mid thigh to the calf. this has improved from prior. abd/pelvis ct non-contrast (): 1. large right proximal/medial thigh hematoma, located in the adductor compartment. no intra-abdominal retroperitoneal hematoma. 2. degenerative change in lumbar spine. superior endplate depression at l2 which is unchanged from prior mri. portable tte (complete) done at 11:06:09 am final the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). the right ventricular cavity is moderately dilated with focal basal free wall hypokinesis. there is abnormal diastolic septal motion/position consistent with right ventricular volume overload. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. compared with the prior study (images reviewed) of , the right ventricle is more dilated with basal hypokinesis and evidence of volume overload. the left ventricular function is similar. brief hospital course: # pulmonary embolism: patient w/ acute onset shortness of breath, cta showed large amount of clot in the right main pulmonary artery extending into the lobar branches. patient was hemodynamically stable and was oxygenating well on nasal cannula. she was started heparin gtt to maintain ptt between 60 and 100 seconds. she was started on bridge to coumadin on . tte on showed right ventricle dilated with basal hypokinesis and evidence of volume overload. the left ventricular function was similar to prior study in . bilateral lower extremity ultrasound showed no dvt but a large thrombus in the right saphenous vein, present on prior study in , thought to be improved. vascular and interventional cardiology were contact about the possibility of this chronic superficial thrombus being the culprit for her large pe. as this was a possibility, an ivc filter was placed on . patient remained stable and was transferred to the floor on . patient continued to have pain at right groin after procedure that was caused by a large thigh hematoma. of note she is up to date on breast and colon cancer screening, is not taking hrt, is a non-smoker and has no family history of clotting. most likely contributing factor is immobilization after lumbar surgery and chronic pain issues. she will need at least 6 months of anticoagulation for an unprovoked pulmonary embolus. a hypercoagulable workup is not indicated at this time as patient has already started heparin. # right thigh hematoma: patient complained pain the morning of and had a tense ecchymosis on the underside of her right thigh. her hct fell overnight from 34 to 28, so a non-contrast abdominal and pelvic ct was done, revealing a 11 by 11cm hematoma in her right thigh. a total of 4u prbc were transfused. a tensor bandage was also placed on . once hct stable, warfarin was resumed and physical activity was advanced without evidence of further bleeding. # coronaries: patient had no chest pain and cardiac enzymes were negative. she was continued on aspirin and simvastatin. home doses of diltiazem and lisinopril were initially held in setting of acute pe. # pump: there were no signs of rv overload on physical exam or on cta. tte showed ef>55% stable from last echo in . # rhythm: patient had sinus tachycardia on telemetry throughout most of stay in ccu and mildly sinus tach on 3 (hr 90s), likely compensatory. # hyponatremia: patient became hyponatremic in the ccu. urine lytes showed an osm of 616 and na 52. ua showed glucose, could partially explain high osms but dilution by osmosis outwards would also be expected. in summary, pt likely in siadh which was treated with fluid restriction (<1600cc free water, broth and fortified drinks). her na at time of d/c was 133. # diabetes mellitus: patient reports that she is well controlled with insulin and metformin. on admission, metformin was held for 72 hours after dye load of cta. continued home doses of insulin nph as well as humalog insulin sliding scale. # microcytic anemia: no melena or brbpr. patient was started on ferrous sulfate. # chronic back pain: patient was continued on home doses of vicodin and gabapentin for chronic back pain s/p laminectomies. pt also preferred stay in a chair to manage her back pain. # hyperlipidemia: continued simvastatin 20mg qdaily and ezetimibe 10mg qdaily # gerd: continued omeprazole 20mg # hypothyroidism: tsh was normal. continued levothyroxine 137 mcg. # lymphadenopathy on ct: ct showed prominent anterior mediastinal nodes not meeting ct criteria for pathologic enlargement; however, recommend ct followup in six months to ensure stability. medications on admission: alendronate 70 mg tablet one tablet(s) by mouth every week bd 31g needles for humulin pen as directed clomipramine 50 mg capsule 2 (two) capsule(s) by mouth once a day diltiazem hcl 120 mg capsule, sust. release 12 hr 1 tab capsule(s) by mouth twice a day ezetimibe-simvastatin ] 10 mg-20 mg tablet 1 tablet(s) by mouth once a day fexofenadine 60 mg tablet one tablet(s) by mouth twice a day gabapentin 300 mg capsule one capsule(s) by mouth three times a day insulin lispro 100 unit/ml solution per sliding scale four times a day levothyroxine 137 mcg tablet one tablet(s) by mouth daily lisinopril 20 mg tablet 1 tablet(s) by mouth once a day metformin 500 mg tablet two tablet(s) by mouth twice a day nitroglycerin 0.4 mg tablet, sublingual 1 tablet(s) sublingually once a day omeprazole 20 mg capsule, delayed release(e.c.) one capsule(s) po daily polyethylene glycol 3350 17 gram (100 %) powder in packet one packet by mouth twice a day * otcs * aspirin 325 mg tablet one tablet(s) by mouth daily calcium carbonate 600 mg (1,500 mg) tablet 1 tablet(s) by mouth twice a day insulin nph human recomb 100 unit/ml suspension 22 units every morning, 42 units at night psyllium 0.52 gram capsule one capsule(s) by mouth daily discharge medications: 1. outpatient lab work please check your inr on and call results to dr. office at 2. clomipramine 50 mg capsule sig: two (2) capsule po once a day. 3. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 4. gabapentin 300 mg capsule sig: one (1) capsule po twice a day. 5. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 6. diltiazem hcl 120 mg capsule, sustained release sig: one (1) capsule, sustained release po bid (2 times a day). 7. polyethylene glycol 3350 100 % powder sig: one (1) packet po daily (daily) as needed for constipation. 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 10. psyllium packet sig: one (1) packet po bid (2 times a day). 11. hydrocodone-acetaminophen 5-500 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: do not take more than 8 tablets per day. cause drowsiness, no driving . disp:*30 tablet(s)* refills:*0* 12. warfarin 2.5 mg tablet sig: three (3) tablet po once daily at 4 pm. disp:*90 tablet(s)* refills:*2* 13. vytorin 10-20 mg tablet sig: one (1) tablet po once a day. 14. alendronate 70 mg tablet sig: one (1) tablet po once a week. 15. calcium 600 600 mg (1,500 mg) tablet sig: one (1) tablet po twice a day. 16. lovenox 100 mg/ml syringe sig: one (1) syringe subcutaneous twice a day. disp:*6 syringes* refills:*2* 17. lisinopril 20 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: vna discharge diagnosis: pulmonary embolisism right thigh hematoma (adductor compartment) diabetes mellitus type 2 hypertension hypothyroid discharge condition: stable, ablt to ambulate hct 34, na 133, inr 1.3 discharge instructions: you had a large blood clot in your lungs that caused you to be short of breath. you were started on a heparin drip and transitioned to coumadin, a strong blood thinning pill. you will need to be on coumadin for at least 6 months and probably longer. it is important that the coumadin level (inr) be between 2.0 and 3.0. until your coumadin level is 2.0 or more, you will need to take lovenox injections twice daily. your coumadin dose will need to be adjusted by dr. office. you should call dr. if your breathing worsens again or if you develop chest pain. also call dr. for any fevers, chills, bloody or dark stools, vomiting blood, a racing pulse or any other concerning symptoms. medication changes: 1. lovenox 110 mg twice daily 2. coumadin 7.5 mg daily 3. vicodin for pain. please take only as needed, will make you constipated so eat fiber and take colace and senna as needed. no driving while taking this medicine. there were enlarged lymph nodes noted in your chest. these are probably not significant but the radiologist has recommended that a chest cat scan be repeated in 6 months. followup instructions: please follow-up with your pcp . on at 11:30 am. you can reach her office at: please follow-up with your cardiologist, dr. on at 11 am. you can reach his office at: . you also have an appointment with your psychiatrist, dr. on at 10:40am. you can reach her office at: you also have an appointment with your orthopedic physician, . on at 9:30am. you can reach his private office at md, procedure: interruption of the vena cava diagnoses: other chronic pain coronary atherosclerosis of native coronary artery esophageal reflux unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hyposmolality and/or hyponatremia unspecified acquired hypothyroidism hematoma complicating a procedure other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure other and unspecified angina pectoris iron deficiency anemia, unspecified lumbago enlargement of lymph nodes other pulmonary embolism and infarction 

Answer: The patient is high likely exposed to