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: zofran attending: chief complaint: resp failure & hypotension major surgical or invasive procedure: intubation/extubation thoracentesis breast biopsy history of present illness: 52 yo f with history of dm on insulin and htn who has been feeling generally unwell for months. she has been coughing up sputum and more trouble breathing for the past few months. she has been having so much trouble breathing that she has been unable to eat or drink for the past few days to a week; this prompted her to call 911 this am. one son thinks that she may have been having intermittent fevers. they were unaware of any weight loss. the note that she avoids seeing the doctor. in the ed, she was found to be in respiratory distress and quite hypoxic. initial vs were 97.9 94 135/94 24 98% on nrb. she was found to have a large breast mass and decreased breath sounds on the right on exam. she eventually required intubation for hypoxia. the intubation was complicated by the ett being placed in r main stem bronchus initially. in the setting of intubation, she became hypotensive to the 60s. she was given 4l of ivf and required levofed and neosyn at one point. prior to being transferred she was weaned down to levofed alone. in the setting of hypotension, she developed ste on ekg, which rapidly resolved with improvement in bp. interventional cardiology was called and evaluated the patient in the ed. they did not recommend any heparin or cardiac catheritization, but recommended cycling ce, ekgs and an echo if she remains unstable. ct torso shows a complex, likely malignant effusion, lung mass and breast mass; in the , urgent femoral line was placed, which was not done under completely sterile conditions. in the ed she was given levofloxacin 500mg iv x1 and ctx 1 gm iv x1 for presumed pna. for hyperkalemia she was given insulin d50, calcium chloride. she was also hyponatremic, presumed hypovolemic hyponatremia, butn not improved with ns boluses in ed. her glucose is also elevated to 400s. her vs prior to transfer are: 72 117/76 18 100%, a/c 450 x18 peep 5 60%. past medical history: diabetes mellitus, type ii, insulin dependent hypertension c-section x5 social history: social history: originally from ; most extended family in . she has one brother in us, lives nearby. she is married, separated, sons say they don't know her husband. lives in . had 5 children, the eldest son is disabled. worked as nurses aid up until , when she quit because she had been feeling ill. never smoker. no etoh. no drugs. family history: family history: sons do not know extended family history. not aware of any fhx of cancer. physical exam: on icu admission: gen: intubated, sedated. heent: perrl, anicteric, exopthalmus. lymph: + axillary lad. no supraclavicular or cervical lymphadenopathy, neck: jvp elevated. no carotid bruits chest: right fungating breast mass 10x5 cm, encasing entire right breast, with skin nodule 2.5 x 2.5 cm lateral to mass. resp: bilat rhonchorous breath sounds cv: rr, s1 and s2 wnl, no m/r/g abd: +b/s, soft, nd, nt, no masses or hepatosplenomegaly ext: mild non-pitting pedal edema, skin cool, 2+dp pulses bilat. no clubbing. skin: no rashes/no jaundice/no splinters gu: foley in place neuro: sedated, withdraws to pain in le bilat . on transfer from icu to floor : vitals: 99.3 140/90 72 22 99%4l nc gen: pleasant, aaox3 heent: perrl, anicteric lymph: + axillary lad. no supraclavicular or cervical lymphadenopathy, chest: right fungating breast mass 10x5 cm, encasing entire right breast, with skin nodule 2.5 x 2.5 cm lateral to mass. resp: bilat rhonchorous breath sounds cv: rr, s1 and s2 wnl, no m/r/g abd: +b/s, soft, nd, nt, no masses or hepatosplenomegaly ext: mild non-pitting pedal edema, skin cool, 2+dp pulses bilat. no clubbing. skin: no rashes/no jaundice/no splinters neuro: a & o x 3, cn ii - xii intact, difficulty abducting shoulder past 90degrees . on discharge: vitals: 97.4 120/70 72 18 97%ra gen: pleasant, aaox3, nad heent: perrl, anicteric, mmm lymph: + axillary lad. no supraclavicular or cervical lymphadenopathy chest: right fungating breast mass 10x5 cm, encasing entire right breast, with skin nodule 2.5 x 2.5 cm lateral to mass. resp: ctab, no wheezes or crackles cv: rrr, s1 and s2 wnl, no m/r/g abd: +b/s, soft, nd, minimally tender in mid abdomen, no masses or hepatosplenomegaly ext: + non-pitting pedal edema, skin cool, 2+dp pulses bilat. no clubbing. skin: no rashes/no jaundice/no splinters pertinent results: on admission: 03:50am blood wbc-6.5 rbc-5.84* hgb-17.6* hct-50.6* mcv-87 mch-30.1 mchc-34.7 rdw-12.9 plt ct-275 03:50am blood neuts-77.8* lymphs-13.5* monos-8.4 eos-0.3 baso-0.2 03:50am blood pt-12.8 ptt-26.7 inr(pt)-1.1 11:13am blood fibrino-530* 03:50am blood glucose-332* urean-28* creat-0.9 na-118* k-6.5* cl-79* hco3-27 angap-19 07:40am blood alt-56* ast-40 alkphos-87 totbili-0.5 07:40am blood lipase-52 11:13am blood ck-mb-23* mb indx-5.5 ctropnt-0.02* 07:40am blood albumin-2.9* calcium-9.6 phos-5.2* mg-2.1 07:40am blood osmolal-276 11:13am blood tsh-1.5 11:13am blood cortsol-23.5* 07:52am blood vanco-13.6 05:55am urine color-yellow appear-hazy sp -1.027 05:55am urine blood-lg nitrite-neg protein-150 glucose-250 ketone-neg bilirub-neg urobiln-1 ph-5.0 leuks-mod 05:55am urine rbc-0-2 wbc-21-50* bacteri-mod yeast-none epi- 05:55am urine castgr-0-2 09:58am urine amorphx-mod 05:55am urine ucg-negative 11:15am pleural wbc-450* rbc-220* polys-14* lymphs-15* monos-0 macro-12* other-59* 11:15am pleural totprot-2.1 glucose-200 ld(ldh)-147 on discharge: 06:50am blood wbc-4.3 rbc-3.58* hgb-10.7* hct-32.3* mcv-90 mch-29.8 mchc-33.1 rdw-16.1* plt ct-287 06:50am blood glucose-198* urean-18 creat-0.7 na-138 k-4.3 cl-99 hco3-32 angap-11 06:25am blood alt-39 ast-20 06:50am blood calcium-9.2 phos-4.3 mg-2.3 microbiology: blood culture, routine (final ): no growth. blood culture, routine (final ): no growth. urine culture (final ): gram positive bacteria. >100,000 organisms/ml. of two colonial morphologies. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. urine culture (final ): no growth. urine culture (final ): no growth. urine culture (final ): yeast. ~5000/ml. 11:53 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): yeast(s). respiratory culture (final ): rare growth commensal respiratory flora. yeast. moderate growth. 11:29 am pleural fluid pleural fluid. gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. 12:29 pm pleural fluid gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. pathology: right breast biopsy 1. right breast, frozen section, core needle biopsy (a): invasive ductal carcinoma. 2. right breast, permanent, core needle biopsy (b-c): invasive ductal carcinoma. high grade ductal carcinoma in situ, scant foci. addendum: fish assay for her-2/neu gene amplification was performed by us labs, , , : result: not amplified estrogen receptor: interpretation: positive (>1% of tumor cells positive) progesterone receptor: interpretation: positive (>1% of tumor cells positive) cxr : right middle and lower lobe consolidation with associated moderate effusion. mild interstitial edema. ct head w/o contrast : multiple areas of small hypodensities in the brain could represent small intracranial metastases. an mr may be obtained for further evaluation. ct chest/abdomen/pelvis : 1. findings consistent with right sided advanced breast cancer with metastases to both axillae, lung, bilateral adrenal glands and possibly liver. 2. moderately large right pleural effusion is intermediate in density. a malignant effusion cannot be excluded. 3. ct findings suggest right heart strain with enlargement of the right ventricle with obliteration of the right middle lobe pulmonary artery. this examination was not intended for evaluation of the pulmonary arteries. if further evaluation is of clinical concern, then a dedicated ctpa may be obtained. 4. the et tube terminates in the right mainstem bronchus and should be pulled back by 3 cm and a repeat radiograph should be obtained to document appropriate positioning. tte : the left atrium is elongated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). there is a mild resting left ventricular outflow tract obstruction. the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. there is at least mild to moderate pulmonary artery systolic hypertension. cta chest : 1. no pulmonary embolism or evidence for extrinsic pulmonary artery compression. the main pulmonary artery; however, is top normal in size, suggestive of mild pulmonary arterial hypertension. 2. progression of pulmonary edema. decreased right-sided pleural effusion. the right-sided pigtail catheter tip is in the pleural space, however, part of the loop of the pigtail is outside the pleural space as described. enlarged left pleural effusion. anasarca. 3. progression of right lower, and right middle lobe pneumonia. 4. rounded pulmonary nodules may be metastatic foci. wall thickening of the right main stem bronchus difficult to evaluate given underlying edema. both these findings should be re-evaluated when patient improves to evaluate for potential metastatic disease to the bronchi and lungs. 5. stable appearance to the right breast mass, and axillary metastases. mri head : 1. 7mm focus of enhancement over the right frontal extra-axial convexity may represent artefactual venous enhancement. tiny meningioma or a dural based metastasis is not ruled out. follow up is recommended. 2. no evidence of intra-axial metastatic disease. 3. microangiopathic small vessel disease kub : impression: non-specific air-filled loops of large bowel. no definitive signs of obstruction. right shoulder x-ray : impression: limited evaluation of the right shoulder demonstrates no gross abnormality. if there is concern for metastasis, recommend further evaluation with mri. cxr : findings: as compared to the previous radiograph, the bilateral pleural effusions have minimally increased in extent. the subsequent areas of mild retrocardiac atelectasis are unchanged. minimal interstitial fluid overload. unchanged moderate cardiomegaly. no other abnormalities have appeared in the interval. pleural fluid : negative for malignant cells. reactive mesothelial cells. pleural fluid : atypical. rare atypical epithelioid cell. pleural fluid : negative for malignant cells. mesothelial cells and lymphocytes. ekg: 3:52 - nsr hr 90, rad with s1, q3, t3, poor baseline. 1/2mm ste in v3 & v5. 7:15 - nsr 92, rad, ste in v3-v5 and also in inferior leads. 7:23 - nsr 64, rad resolution of ste in v3 & v5, still present in v4, and slight elevation in iii & ? avf. 11:13: nsr 69, q wave in v3, v4 with upsloping st segment otherwise resolution of st changes. brief hospital course: 52 y/o f with history of dm on insulin and htn who presented with sob and developed respiratory failure thought pleural effusion and widely metastatic breast malignancy. # respiratory failure, hypercarbic: pt required intubation upon arrival to ed given hypoxia and tachypnea. respiratory failure was most likely to large effusions and extensive malignant involvment of lungs. pna was also a possibility given leukocytosis at presentation. she was treated empirically with 8 days of cefepime + vancomycin. she had no culture growth. ip was consulted and 800cc of transudative pleural fluid were drained from the right chest, fluid cytology was negative for malignant cells, pleurex catheter was left in place. she was extubated briefly but then re-intubated for worsening hypercapnea and increased work of breathing, likely due to increased dead space and mucus plugging. it was felt that fluid retention was contributing to the patient's poor repsiratory status and inability to wean off ventilation. lasix drip was used to diurese her and she was eventually transitioned to boluses of lasix. she was re-extubated and tolerated this well. she had weakness that led to hypercarbia and severely elevated bicarbonate, which could have been contraction alkalosis and hypoventilation 2/2 pleural effusions. niv was used to bridge her during the day. she used a schedule of 2 hours on and 2 hours off niv, and over 2 days she was able to extend her times off of niv so that she only used it at night. pleurex catheter was later found to be in subcutaneous space and was removed. her improved respiratory status and strength coupled with her starting taxol (likely causing hco3 leak from the kidney), improved her bicarbonate level. pleural effusion reaccumulated in the interim, requiring another pigtail catheter that drained initially 2l daily. it was pulled when she was draining 400cc daily. repeat chest xray showed minimal reaccumulation of pleural effusion by time of discharge and ip inserted pleurex catheter on day prior to discharge for further drainage. multiple pleural fluid samples were analyzed; they were largely transudative without malignant cells. her pleural effusions and le edema were attributed largely to chf and improved with diuresis. kidney function remained stable while being diuresed. hypercarbia resolved by time of discharge and bicarb levels were normal. she did not require bipap by time of discharge. she was discharged on po lasix for further diruesis. she was on room air and satting in 90s even with ambulation by discharge. # metastatic breast cancer: records from osh showed that right breast biopsy showing infiltrating ductal carcinoma with ductal carcinoma in situ, tumor grade ii/iii, in 5 of 6 biopsies. she was found to be estrogen/progesterone receptor positive at that time. she did not receive follow-up care after this diagnosis. biopsies were taken here on showing invasive ductal carcinoma, high grade. additional imaging studies showed metastases in the lungs, possibly liver, both adrenal glands, and also possibly in the brain. she was er/pr positive and her-2/neu negative. she was started on taxol on with good response. she received her next doses on and and tolerated chemotherapy well. she will follow up with her new primary oncologist who also followed her during her hospital course. # blood pressure instability: pt became hyoptensive to systolic 60s following intubation, requiring pressors in the icu. cause not entirely clear, likely pre-load dependent d/t right sided failure to malignancy related pulmonary hypertension. echo and cta chest shows mild rv dilation and hypokinesis and mild to moderate pah (likely to malignant infiltration), but no indication to stent pa. her tte and cta did not suggest enough rv failure to fully explain her hypotension. adrenal insufficiency was ruled out with normal stim test. patient had episodes of bradycardia followed by hypertension with sbps in low 200s, thought to be response to levophed, so it was dc??????ed in favor neosynephrine. midodrine was then started and were able to wean off neosynephrine. her blood pressures stabilized, and she was able to be taken off of the midodrine as well. of note, pt does have history of htn and was on diovan-hctz and diltiazem prior to admission. however, bp was stable, systolic 110s-120s, after her transfer from icu to the floor and prior to discharge. her home bp medications, therefore, were discontinued. # cardiac ischemia (resolving)/1st degree av block: on pt had episode of rapidly reversing st elevations in course of 5 mins that were consistent with possibly thrombo-embolic phenomenon. ces were negative. unlikely to be acs. unusual to see ste with demand ischemia, but possible. history and time course seems most c/w demand. resolved quickly with tx of hypotension and hypoxia. on , had episode of chest discomfort with 4.7sec pause on telemetry. cardiology fellow was consulted. agreed that patient has 1st degree heart block, but thought the pause was unrelated to chest pain and was result of pvc causing reset. aspirin 325mg was continued and she was started on simvastatin. she had another episode of chest pain on . described the pain as right sided, near her breast mass, and was tender on palpation of epigastrium towards the right. ekg showed st elevation in v2 and nonspecific twis; trop was 0.03 and downtrended to 0.02. she reported no further chest discomfort for remainder of hospital stay. # social issues: there were several social issues complicating patient's care. social work and palliative care were very involved in the case. she is the single mother to five teenage children. the oldest son is incapacitated and being taken care of at home by his uncle. she also has two sons in college. several family meetings were held to assist the family while mother was in the hospital, particularly with care of the oldest son. also complicating pt's care was mistrust of the healthcare system. she often refused therapeutic interventions (e.g. bipap), became frustrated at blood draws and other procedures, and refused discharge to rehab as recommended by pt. after transfer from icu to the floor, she gradually became more trusting of the medical team and with discussion and negotiation was amenable to appropriate therapeutic interventions. however, she adamantly refused rehab and was discharged home with vna services; documents were also submitted for additional services including personal care attendant, the ride, and home pt. medications on admission: medications at home: (per sons, need to confirm with pharmacy) diovan-hydrochlorothiazide 160-12.5mg po daily dilt-xr 240mg po daily multivitamin 1 tab po daily nph & regular insulin 70/30 mix - , dosage unknown discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 4. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for gas, constipation. disp:*120 tablet, chewable(s)* refills:*0* 5. oxycodone 5 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for pain: do not drive or operate machinery while on this medication. disp:*30 tablet(s)* refills:*0* 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily) as needed for constipation. disp:*30 packet* refills:*0* 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 8. metronidazole 1 % gel sig: one (1) appl topical (2 times a day). disp:*1 tube* refills:*0* 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): to right shoulder 12 hr on and 12 hr off. disp:*30 adhesive patch, medicated(s)* refills:*0* 10. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 11. multivitamin tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 12. insulin nph & regular human 100 unit/ml (70-30) suspension sig: sixteen (16) units subcutaneous twice a day. disp:*1 month supply* refills:*0* 13. insulin syringe 1 ml 29 x syringe sig: one (1) syringe miscellaneous twice a day. disp:*2 box* refills:*0* 14. hospital bed please give 1 hospital bed discharge disposition: home with service facility: homecare discharge diagnosis: primary: metastatic breast cancer respiratory failure pneumonia acute congestive heart failure secondary: dm discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: it was a pleasure taking care of you in the hospital. you were admitted with respiratory failure and found to have fluid in your lungs. this fluid was removed through several procedures and your respiratory function improved remarkably. you also were given a medication to help you remove that fluid through increased urination. you will continue this medicine at home until you see your doctor. you will need a repeat chest x-ray in two weeks to see if the fluid in your lungs has reaccumulated. biopsies of your right breast were consistent with invasive cancer. additional scans showed that the cancer had spread to your lungs, your adrenal glands and possibly your liver. chemotherapy was initiated while you were in the hospital and you tolerated this well. you will continue chemotherapy as outpatient. the following changes were made to your medications: 1) stop diltiazem: please discuss with your primary care provider when this should be restarted 2) stop diovan/hctz: please discuss with your primary care provider when this should be restarted 3) continue your insulin 70/30, twice a day as you were doing previously according to your blood sugar 4) start lasix 40mg twice a day 5) start oxycodone 2.5mg every 6 hours as needed for pain. do not drive or operate machinery while on this medication 6) start docusate 100mg twice a day for constipation 7) start aspirin 325mg daily 8) start simvastatin 40mg daily 9) start simethicone 80mg four times a day as needed for gas 10) start polyethylene glycol 17grams daily as needed for constipation 11) start metronidazole gel twice a day for your breast. you will need prior authorization for this medication for your insurance. please discuss prior authorization details with your primary care doctor 12) start lidocaine (700mg/patch) 12 hours daily (take off for 12 hours daily). you will need prior authorization for this medication for your insurance. please discuss prior authorization details with your primary care doctor 13) start senna 8.6mg twice daily as needed for constipation followup instructions: you have the following appointments scheduled for you: department: when: friday at 3:50 pm with: , md building: sc clinical ctr campus: east best parking: garage **dr. is your new physician in and dr. works closely with dr. , both will be involved in your care. department: radiology when:thursday at 10:00 am walk in appointment for chest x-ray, building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: thursday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: friday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: friday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube insertion of endotracheal tube enteral infusion of concentrated nutritional substances thoracentesis thoracentesis arterial catheterization other incision of pleura other incision of pleura injection or infusion of cancer chemotherapeutic substance closed [percutaneous] [needle] biopsy of breast diagnoses: pneumonia, organism unspecified hyperpotassemia malignant neoplasm of liver, secondary unspecified pleural effusion unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hyposmolality and/or hyponatremia other chronic pulmonary heart diseases acute respiratory failure hypotension, unspecified secondary malignant neoplasm of brain and spinal cord alkalosis long-term (current) use of insulin hypoxemia secondary malignant neoplasm of lung first degree atrioventricular block polycythemia vera secondary malignant neoplasm of adrenal gland malignant neoplasm of breast (female), unspecified carcinoma in situ of breast estrogen receptor positive status [er+] 

Answer: The patient is high likely exposed to