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: erythromycin base / shellfish derived / ciprofloxacin attending: chief complaint: weakness shortness of breath major surgical or invasive procedure: none history of present illness: 72 y.o. female w/ h.o. longstanding ra on chronic prednisone, a. fib not anticoagulated gi bld, ild ?ra, tachy-brady syndrome s/p ppm, initially seen at for sob s/p intubation for acute resp failure transferred for further respiratory management. . on review of pt's records as well as discussion with the husband it appears that ms. initially presented to on with a 3 week history of progressive dyspnea. per pt's family she had no cough, fevers, chills she had an oxygenation saturation in the low 80s which lead to her ed visit. in the ed she was noted to be hypoxic saturating mid 80s on ra, she placed on 4l n.c. which resulted in an increase to mid 90s. she has a baseline home oxygen requirement of 2l. for her work up she underwent a cxr which showed a rt effusion, left lung was clear. given the level of her hypoxia and history of immobilization she underwent a cta which showed no p. embolism but did show b/l effusion r>>l. rt effusion also showed left middle and lower lobe collapse. her initial hypoxia was thought to be her b/l effusions in addition to her underlying parenchymal disease. she appeared clinically dry on admission. it appears she underwent an echo which showed an ef of 50-55%, moderately reduced rv systolic function, moderate pul htn, 3+ tr. on it appears there was concern with her pco2 increasing to high 60s, pt was placed on bipap with no change in her pco2. she was intubated electively for possible hypercapneic failure. on review her ph at that time was 7.35-7.41, hco3 41-43. during intubation she was noted to go into a.fib with rvr with rates in the 130s and sbp in the 80s. . with regards to her a. fib, she was noted to go into rvr requiring amiodarone 150mg iv over 10 minutes x 2 and then a gtt with minimal improvement. metoprolol, diltiazem were held given hypotension. digoxin was also held given level of 2.75. after she was given her digoxin and restarted on her dilt and metoprolol she converted into sinus rhythm. . she was also noted to be hypotensive following intubation that was attributed to diuresis prior to intubation and anaesthesia medications. following intubation she was given ns boluses until her bp returned to 120s. it is unclear if the increase in bp was due to rate versus prior diuresis versus ?adrenal insufficiency. pt was given solumedrol stress dosing in addition to the bolus. . she underwent a diagnostic thoracentesis to determine the etiology of her effusions. effusion was exudative with cloudy, viscous material amber in colour. 4800 nucleated cells, 1% neutrophils, 30%lymphs, 69% monos, glc 108, tp 2.5, tgl 17, ldh 318. culture was pending at time of transfer, gram stain showed 0-1polys but no organisms. cytology pending, rh factor and complement levels were unable to be added. past medical history: afib-- not on couamdin due to recent ugib when supratherapeutic ild ra, on home o2 prn esp at night when supine, baseline 92% on 2l osteoporosis vertebral compression fraxtures of t5, t7, t8, t12 in ; ns saw at time, pt declined kyphoplasty, pacer for tachy-brady htn social history: lives with husband at house; has three grown children; 20 pack year smoking hx; denied etoh family history: family history is not significant for early coronary artery disease or stroke. 3 brothers with lung cancer physical exam: general: elderly caucasian female in bed intubated heent: perrl cardiac: s1, s2, no m/g/r, rrr lungs: diminished diffusely with crackles noted abdomen: no facial grimacing noted, nd, soft, +bs x 4 extremities: atrophy noted in lower extremities, 2+ edema noted in b/l wrists. skin: ecchymoses noted over right hand, left arm. pertinent results: admission labs: 03:54am blood wbc-9.9 rbc-3.28* hgb-9.4* hct-30.2* mcv-92 mch-28.6 mchc-31.1 rdw-15.5 plt ct-193 03:54am blood neuts-92.6* lymphs-2.8* monos-4.2 eos-0.3 baso-0.1 03:54am blood plt ct-193 . 02:02am blood ferritn-686* 04:43am blood hapto-296* 03:42am blood fibrino-206 . 12:50pm blood esr-5 . 03:54am blood glucose-157* urean-31* creat-0.2* na-139 k-4.0 cl-106 hco3-27 angap-10 03:54am blood calcium-7.4* phos-2.0* mg-2.3 . 04:43am blood ld(ldh)-376* ck(cpk)-55 totbili-0.6 . 02:02am blood cortsol-51.1* 02:02am blood crp-22.7* . 05:02am blood lactate-1.4 . 03:54am blood digoxin-1.5 . abg: 09:23pm blood type-art temp-37.5 rates-4/0 tidal v-400 peep-5 fio2-40 po2-72* pco2-50* ph-7.38 caltco2-31* base xs-2 -assist/con intubat-intubated . myoglobin, serum 270 h <=30 mcg/l aldolase 12.7 h <=8.1 u/l 07:27pm blood acetylcholine receptor modulating antibody-pnd acetylcholine rec binding <0.30 <=0.30 nmol/l . micro: bal neg cx neg blood and urine cx neg c. dif positive . imaging: cxr:these views are markedly limited secondary to difficulty in positioning patient and due to her large body habitus. the cardiac silhouette is markedly enlarged, but stable since study. there is a tracheostomy tube whose distal tip is approximately 2 cm from the carina; however, this may be distorted due to projection. there are bilateral effusions with a left retrocardiac opacity. there is an element of overload. there are severe degenerative changes of the right glenohumeral joint. a left-sided pacemaker is identified. . tte: the left atrium is dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. there is an anterior space which most likely represents a fat pad. compared with the prior study (images reviewed) of , the degree of mitral regurgitation has decreased. the degree of tricuspid regurgitation has increased. the other findings are similar. brief hospital course: 72 y.o. female w/ longstanding ra, tachy-brady syndrome s/p ppm, a. fib with rvr not anticoagulated gi bld, s/p recent d/c for pna initially admitted to for dyspnea s/p intubation for hypercapneic resp failure w/ exudative effusions. . ##. hypercapneic respiratory failure s/p intubation: pt was electively intubated for concern of hypercapnea. given ph readings were 7.39-7.41 in the setting of pco2 of 69 suspect that pt may have chronic co2 retention from osa and obesity hypoventilation syndrome. the presumed etiology of initial decompensation was bilateral effusions. pt had thoracentesis at osh which showed exudative picture, however this was done after very aggressive diuresis. repeat thoracentesis was done and showed transudative effusions, more consistent with clinical picture which was chf. tte showed lvef>55% and stable mr. it was considered likely that forward flow was overestimated by tte, and mr significant contirbuting to reduced forward flow. patient was initially diuresed. repeat imaging showed effusions to be very mild in size, and unlikely to be causing continued inability to wean off vent. bronch showed clear secretions, all cx data negative. . patient was noted to be extremely weak, with strength 1/5 in extremities and very poor nifs. in speaking with family, patient's strength had been declicing insiduously at home for 6 months. patient had suffered compression fractures in that time. neurology was consulted and recommended tapered steroids for possible steroid myopathy. studies for myasthenia and myositis were sent. mri could not be performed due to pacemaker, so cord compression could not be evaluated. the team and family considered further evaluation of weakness, but given poor prognosis and unlikely chance of finding a diagnosis that would be treatable, cts and emgs were not done. ultimately, patient's central muscle weakness was thought to be the reason for her respiratory failure. patient was extubated and made cmo on . . ##. effusions: patient underwent u/s-guided thoracentesis. as mentioned above, transudative likely due to chf and poor forward flow in setting of mr. gram stain, culture and cytology were negative. glucose was not consistent with ra. she was initially treated empirically with vanco/zosyn until all cx returned negative. . ##. hyponatremia: pt was noted to be hyponatremic on admission to with 123, corrected with ivf. suspected this was hypovolemic hyponatremia given correction with hydration and h.o. decreased po intake over the past 3 weeks. . ##. a. fib with rvr: pt was noted to be in a. fib with rvr peri-intubation. unclear as to whether she her nodal agents were held in the setting of hypotension versus hypotension occuring in the setting of a. fib with rvr. pt converted to sinus spontaneously when placed on her home regimen of digoxin at osh. she was continued on digoxin, diltiazem and metoprolol. on , returned to af with rvr, started on diltiazem gtt. as this was not effective, patient was loaded with iv amiodarone and started on drip. rate control improved, but patient remained in af. . #. oliguria: patient had decreased urine output at home for weeks pta, with 300-400cc/day. patient continued to have poor uop, not responsive to diuretics. patient received conservative ivf boluses prn to maintain adequate uop. etiology was thought to be poor renal perfusion due to poor forward flow as above. . ##. ra: continued pt on home regimen of plaquenil. patient was treated with stress dose steroids given chronic prednisone use, and steroids were weaned q2 days. . ##. gerd: continued on home regimen of prevacid. . ##. uti: pt has +urine cx for enterococcus at osh, completed 10 day course of zosyn. . ##. fen: tf neutropulm with a goal of 40cc/hr. medications on admission: diltiazem xt 180mg prednisone 7.5mg daily hydroxychloroquine 200mg tylenol 500mg tid asa 325mg daily atenolol 100mg digoxin 125mcg daily senna daily discharge medications: deceased discharge disposition: expired discharge diagnosis: deceased discharge condition: deceased discharge instructions: deceased followup instructions: deceased md procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances thoracentesis thoracentesis diagnoses: acidosis obstructive sleep apnea (adult)(pediatric) esophageal reflux unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids adrenal cortical steroids causing adverse effects in therapeutic use hyposmolality and/or hyponatremia atrial fibrillation other chronic pulmonary heart diseases pulmonary collapse acute respiratory failure alkalosis intestinal infection due to clostridium difficile postinflammatory pulmonary fibrosis chronic systolic heart failure cardiac pacemaker in situ rheumatoid arthritis streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] obesity, unspecified sinoatrial node dysfunction toxic myopathy hypovolemia diseases of tricuspid valve oliguria and anuria other hyperalimentation 

Answer: The patient is high likely exposed to