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: iodine-iodine containing / shellfish derived attending: chief complaint: sob/weakness major surgical or invasive procedure: thoracentesis (left side) thoracentesis with pigtail drains (left and right) pleurex catheter placement (left) history of present illness: 71 f with h/o stage ii pancreatic cancer diagnosed in s/p pancreatoduodemectomy and adjuvant radiation and gemcitabine in p/w sob and generalized weakness for several days, worse with exertion. pt is s/p ir thoracentesis on w/ 2.5l of transudative effusion removed from the right side. after procedure went home and almost immediately began experiencing some sob particularly with exertion and standing which worsened to the point where her oncologist referred her to the ed today. pt noted lightheadedness and extreme weakness and palpitations when attempting to stand up with severe doe of just several steps. states these symptoms are similar to what she experienced prior to pleurocentesis but worse. pt states she has been able to keep up with po intake despite. denies n/v but has had diarrhea for the last 3 weeks s/p antibiotic course w/ ctx for e.coli bacteremia, course ending . stool is now loose for the last week but no longer watery and never with blood. denies abd pain/headaches. . of note, during her recent hospitalization she had a thoracentesis. fluid analysis showed transudate and path showed ?reactive. mesothelial cells (from ascitic tap). pt also with known portal vein thrombosis and at home on treatment dose lovenox. . ed course: initial vitals: 97.8 106 88/43 20 97%. triggered for hypotension but bp in the room was then 118/72. did not receive ivf at that time. ekg: sinus rhythm at 94 bpm, no ste, low voltage diffusely cxr: bilateral pleural effusions. labs pertinent for: na 123, k 5.3 ?hemolyzed, bun/cr 17/0.8, glucose 283. hct 42 (up from 29 recent b/l) wbc 6 with pmns 80%, lfts with ast/alt at 54/74 and alk phos stable but elevated at 362. ip was paged and will evaluate pt in the am. . pt was admitted to the . on arrival appeared comfortable on 3l nc with bp 110/84, 96, 98% 3lnc. pt stated she felt fine with breathing improved. denied pain of any kind. drank some juice. repeat labs in showed na of 128. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough or wheezing. denies chest pain, chest pressure. denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - t2, n1, stage iib pancreatic adenocarcinoma diagnosed in on ercp. s/p pylorus-preserving pancreaticoduodenectomy. s/p gemcitabine c/b thrombocytopenia and neutropenia. ct showed bilateral lung nodules. with development of ascites and ct with hypodensity in liver c/f mets vs perfusion abnormality. - infectious ibs - diabetes mellitus ii - on oral hypoglycemics and insulin - pancreatic insufficiency - on pancreatic enzyme replacement - portal vein thrombosis - on lovenox at home social history: lives in alone. her sister lives next door. she has a history of smoking many years ago and does not currently smoke. no etoh or ivdu. family history: family history of dm in her mother and sister. father died of cancer (unknown type) physical exam: on admission: vitals: t: af bp:111/60 p:90 r:22 95% o2:2l nc general: alert, oriented, no acute distress, cachectic female heent: sclera anicteric, mmm, oropharynx clear neck: supple, without discernable jvd lungs: diffuse crackles throughout inicreasing at the bases. left lower lung field with decreased air movement. no wheezing cv: regular rate and rhythm, normal s1 + s2, ?splitting of s1 vs ?s4 no murmurs, rubs, gallops abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. midline hernia adjacent to umbilicus easily reducible and nontender to palpation gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . on discharge: vitals: t: 98.4 bp:110/60 p:89 r:16 93% o2:ra general: alert, oriented, no acute distress, cachectic female heent: sclera anicteric, mmm, oropharynx clear neck: supple, without discernable jvd lungs: left lower lung field with decreased air movement. no wheezing cv: regular rate and rhythm, normal s1 + s2 abdomen: scaphoid soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. midline hernia adjacent to umbilicus easily reducible and nontender to palpation gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: cxr findings: single portable view of the chest is compared to previous exam from . when compared to prior, there has been significant interval enlargement of bilateral pleural effusions which are now moderate in size. underlying airspace disease is also possible. superiorly, however, the lungs are grossly clear. cardiac silhouette is difficult to assess given the size of effusions. osseous and soft tissue structures are unchanged. impression: significant interval increase in the bilateral pleural effusions since prior exam with possible underlying airspace disease not excluded. . ekg low voltage, sr at 90bpm no st changes prior ecg without such low voltage in lateral precordial leads . cta abd w&w/o c & recons; ct pelvis w/contrast ct of the abdomen: the visualized heart is normal. the pericardium demonstrates no evidence of effusion. small left pleural effusion is decreased in size compared to the most recent prior examination. there has been interval resolution of right-sided pleural effusion. bilateral pigtail drains are noted in appropriate position. a 6 mm nodule in the right lung base is present (series 2, image 1). additional nodularity within the right lung base measuring approximately 10 mm (series 2, image 10) and 6 mm linear density within the right lung base (series 2, 8) represent atelectasis versus infectious process. pleural-based nodularity at the left lung base measures approximately 6 mm. there is moderate intrahepatic bile duct dilation predominantly involving left lobe of the liver with new pneumobilia compared to , which may be secondary to hepaticojejunostomy. a 12-mm enhancing focus in the right lobe of the liver demonstrates arterial enhancement and is isodense on the venous phase and may represent enhancing metastasis versus perfusion abnormality. hypodense area involving the right and left lobes of the liver extending from the porta hepatis to the periphery is new since most recent prior examination and may represent infiltrative tumor or metastases versus perfusion abnormality. the patient is status post pylorus-preserving whipple with hepaticojejunostomy. the gallbladder is surgically absent. the remaining pancreatic tail appears unremarkable. the spleen and bilateral adrenal glands appear unremarkable. both kidneys enhance and excrete contrast symmetrically. the upper poles of bilateral kidneys demonstrate thinned cortex similar to and may represent prior ischemic injury. persistent thrombus of the main portal vein, right and left portal veins, the upper portion of the superior mesenteric vein and the splenic vein is again noted. there is mild calcification at the origin of the celiac artery. there is minimal irregularity of the common hepatic artery. the sma, and bilateral renal vessels appear unremarkable. there is stranding of the mesentery which may represent edema versus tumor involvement. there is no evidence of pneumoperitoneum. retroperitoneal and mesenteric lymph nodes do not meet ct size criteria for pathology. ct of the pelvis: the bladder, uterus is unremarkable. pelvic lymph nodes do not meet ct size criteria for pathology. there is mild anasarca. osseous structures: no focal lytic or sclerotic lesions suspicious for malignancy are identified. impression: 1. bilateral pigtail catheters in appropriate position with resolution of right and improved small left pleural effusion. 2. 6 mm nodule at the right lung base. additional nodular densities within the right lung base may represent atelectasis or infections. 3. moderate intrahepatic bile duct dilatation especially in the left lobe, not significantly changed from . new pneumobilia within the left lobe of the liver may be secondary to hepatojejunostomy. 4. persistent occlusion of main portal vein, right and left main portal veins, upper portion of the smv and the splenic vein. 5. large area of low density involving the right and left lobes of the liver extending from the porta hepatis to the periphery may represent infiltrative tumor or metastases versus perfusion abnormality. mri is suggested for further evaluation. 6. small enhancing focus in segment vi of the right lobe of the liver measuring 12 mm may represent enhancing metastases versus perfusion abnormality. 7. stranding of the mesentery may represent edema versus tumor infiltration. 8. mild anasarca. mri abdomen w/o & w/con mri abdomen findings: the previously noted bilateral pleural effusions have resolved. there is small volume ascites. the patient is status post whipple resection and reconstruction. there is persistent portal vein occlusion with nonenhancing thrombus seen extending into the right anterior, right posterior,left and main portal vein. the thrombus is also seen extending into the proximal portion of the smv. the thrombus in the smv is well demonstrated as a hyperintense structure on the t1-weighted imaging (8:74). no evidence of thrombus enhancement to suggest tumor thrombus. there is persistent biliary dilatation, more pronounced in the left hepatic lobe. this biliary dilatation has progressively increased over interval studies over the last 12 months. there are significant peribiliary varices, secondary to the portal vein occlusion, which may be contributing to some stenosis at the level of the hepaticojejunostomy (1002:62). there is pneumobilia (6:11), which suggests patency of the hepaticojejunostomy, however. on the post-contrast images, there is perfusional abnormality involving the left hepatic lobe. these areas are non-mass-like and likely reflect altered perfusion following the longstanding portal vein thrombosis. no evidence of a concerning mass-like hepatic lesion to suggest a metastasis. there is abnormal soft tissue, however, encasing the celiac axis and involving the sma. this soft tissue extends along the proximal sma as an abnormal soft tissue cuff (1002:65). the abnormal soft tissue is difficult to accurately measure, but abuts the left adrenal gland, abuts the ivc and extends into the porta hepatis. an approximate measurement is best estimated on the delayed post-contrast sequences (:54) measuring 4.7 x 2 cm in maximal axial dimension. narrowing and encasement of the celiac trunk is best appreciated on image (1001:50). the spleen is normal in size measuring 10 cm in long axis. normal appearance of both kidneys, which enhance symmetrically. incidental note is made of small tarlov cysts in the lower sacrum (4:22). no concerning marrow abnormality identified in the thoracic or lumbar spine. impression: 1. thrombosis of the intra- and extra-hepatic portal vein and smv. 2. signal change in the liver following contrast likely reflects perfusion changes secondary to chronic portal vein thrombosis. 3. no evidence of metastatic tumor to the hepatic parenchyma. 4. abnormal soft tissue encasing the celiac axis extending inferiorly to involve the sma resulting in vessel narrowing. these features are highly concerning for local tumor recurrence. 4. progressive, predominantly left-sided intrahepatic biliary dilatation with prominent peribiliary varices . admission: 06:20pm blood wbc-6.0# rbc-5.02# hgb-12.7 hct-42.9# mcv-85 mch-25.3* mchc-29.6*# rdw-17.8* plt ct-367# 03:05am blood wbc-4.7 rbc-4.57 hgb-12.0 hct-37.8 mcv-83 mch-26.3* mchc-31.9 rdw-17.9* plt ct-237 06:20pm blood neuts-80.6* lymphs-8.5* monos-8.1 eos-1.5 baso-1.2 06:20pm blood pt-13.3* ptt-40.8* inr(pt)-1.2* 06:20pm blood plt ct-367# 06:20pm blood glucose-283* urean-17 creat-0.8 na-123* k-5.3* cl-89* hco3-24 angap-15 06:20pm blood alt-54* ast-74* alkphos-362* totbili-0.8 07:49am blood alt-42* ast-34 ld(ldh)-157 alkphos-314* totbili-0.5 06:20pm blood lipase-9 06:20pm blood albumin-3.0* calcium-8.5 phos-3.1 mg-2.0 06:55am blood ferritn-51 07:10am blood triglyc-82 06:45am blood cortsol-32.4* 05:55am blood cortsol-21.2* 06:55am blood hbsag-negative hbsab-negative hbcab-negative hav ab-negative 06:55am blood -negative 06:55am blood igg-794 06:55am blood hcv ab-negative 05:06pm blood ph-7.52* comment-pleural fl 03:20am blood lactate-1.4 ca -9 test result reference range/units ca -9 337 h <37 u/ml on discharge: 06:55am blood wbc-3.3* rbc-3.56* hgb-9.3* hct-29.8* mcv-84 mch-26.2* mchc-31.3 rdw-18.5* plt ct-76* 06:55am blood neuts-71.5* lymphs-16.9* monos-8.9 eos-2.5 baso-0.2 07:05am blood hypochr-1+ anisocy-2+ poiklo-1+ macrocy-normal microcy-1+ polychr-1+ ovalocy-1+ schisto-occasional 01:10pm blood lmwh-0.62 06:55am blood glucose-195* urean-17 creat-0.7 na-132* k-4.5 cl-102 hco3-22 angap-13 06:55am blood alt-50* ast-30 alkphos-315* totbili-0.7 06:55am blood calcium-8.3* phos-2.7 mg-2.0 brief hospital course: reason for icu admission patient is a 71 y/o f h/o pancreatic cancer s/p whipple, recent pleurocentesis with large volume fluid removal from r lung now presents with several days worsening sob and generalized weakness found to have bilateral pleural effusions on cxr. hospital course #pleural effusions/dyspnea - reaccumulation of pleural fluid in setting of known portal vein thrombosis with recurrent transudative ascites and pleural effusions. left pleural effusion is new this admission. she was maintained on her home dose of diuretics after last discharge however she has reaccumulated fluid quickly. ip was consulted who originally placed bilateral pigtails with a massive amount of drainage on a daily basis from both. she would match out in her lungs whatever fluid was given through the iv or po. she was tried on steroids empirically without resolution of drainage. as her lengthy hospital course continued, the output from her right drain decreased and this was pulled. however, her left drain continued with output, so a pleurex catheter was placed by ip. the etiology of her pleural effusions is unknown. due to her portal hypertension, it was presumed secondary to hepatic hydrothorax, but throughout her admission we noted that she had minimal to no ascites and yet would put out 4-5 liters daily from the pleural space. we attempted to do an intraabdominal tracer study to prove hepatic hydrothorax, however the tracer was unintentionally injected into the bowel without any clinical consequences. renal, cardiac and liver disease were ruled out. the pleural and ascitic fluid from previous taps over the last few months have all consistently been extremely transudative without any evidence of malignancy. when her pancreatic cancer was found to have reoccurred via mri (done to better evaluate her portal vein thrombosis ?bland thrombus vs tumor thrombus), we felt that her effusions might have been related to a capillary leak paraneoplastic process, because after starting chemotherapy her effusions slowed. she will follow up with pulmonary as an outpatient to determine the ongoing need for a pleurex catheter. # stage iib pancreatic adenocarcinoma ?????? ca -9 had been rising as an outpatient for the past few months, without clear evidence of a recurrence. finally mri of the abdomen was done which showed a suspicious soft tissue mass in the resection bed. she started chemotherapy with gemcitabine on . next chemotherapy is due on . # hypotension/volume status - a major issue and the main driver of her lengthy hospitalization. we were unable, through any intervention (colloid or crystalloid), to improve her volume status without causing significant pleural output into both lungs. she was placed on an octreotide drip for possible hepatorenal syndrome (noted due to orthodeoxia when standing, however after further analysis we noted that her orthodeoxia was more likely due to hypoperfusion because of extreme orthostasis (sbp in the 40s while standing)). octreotide provided no benefit and so it was stopped. cardiology, interventional pulmonary and liver were all consulted, who all agreed that her orthostasis was due to severe hypovolemia, so she was uptitrated to max dose florinef, salt tabs and midodrine. after taking these medications, she was able to stand without symptomatic hypotension and walk with minimal assistance. she will be discharged on florinef, salt tabs and midodrine and the patient was encourage to stand up slowly. she was also chronically hyponatremic throughout her hospital course, typically 128-132, despite the salt tabs. # - c/w likely somewhat pre-renal etiology although unusual that feurea is 45%. still pt appears dry on exam and history c/w volume depletion (recent diarrhea and limited mobility/access to po intake). she was volume resuscitated in the with resultant worsening of her pleural effusions. her creatinine stabilized. #pancreatic insufficiency - diabetes and enzyme deficiency. issues with hyperglycemia when on steroids requiring aggressive uptitration of her insulin regimen. when off of steroids and after starting octreotide (an inhibitor of pancreatic function) she developed severe symptomatic hypoglycemia requiring discontinuation of her insulin. after stopping octreotide, she was restarted on an humalog insulin sliding scale. she also had large volumes of diarrhea due to her pancreatic enzyme deficiency s/p whipple. her home zenpep was continued. #portal vein thrombosis - likely hypercoagulability from malignancy. has had asictes requiring taps over the last several months but no ascites on presentation. liver was consulted who felt that she should not have portal hypertension without cirrhosis, however her cirrhosis workup was negative and she has known grade ii esophageal varices. her factor xa level was barely therapeutic after once daily dosing of lovenox, so she was switched to dosing. we attempted to find an intervention to remove/lyse this clot, however in discussion with many different services found no options (the clot was present for too long to be lysed with tpa via ir, and would require an open abdominal surgery with reconstruction via vascular/transplant). transitional issues - please continue to drain 500-1500cc of fluid from the pleurex catheter as needed for comfort. - she will need to return for follow up appointments with hem-onc (see appointment within this discharge summary) medications on admission: - enoxaparin 70 mg subcutaneous daily - furosemide 40 mg po daily - glimepiride 4 mg tablet sig: one (1) tablet po once a day. - insulin aspart four (4) units sc three times a day: please use before meals . - insulin glargine 12 units subcutaneous once a day - spironolactone 100 mg po daily - lipase-protease-amylase 5,000-17,000 -27,000 unit capsule, delayed release(e.c.) sig: three (3) cap po qid (4 times a day). discharge medications: 1. lipase-protease-amylase 5,000-17,000 -27,000 unit capsule, delayed release(e.c.) sig: three (3) capsule, delayed release(e.c.) po four times a day. 2. zenpep 20,000-68,000 -109,000 unit capsule, delayed release(e.c.) sig: capsule, delayed release(e.c.) po asdir (as directed): 3 caps with meals 2 caps with snacks. 3. sodium chloride 1 gram tablet sig: two (2) tablet po bid (2 times a day). 4. fludrocortisone 0.1 mg tablet sig: two (2) tablet po daily (daily). 5. midodrine 5 mg tablet sig: two (2) tablet po tid (3 times a day). 6. enoxaparin 40 mg/0.4 ml syringe sig: one (1) syringe subcutaneous q12h (every 12 hours). 7. loperamide 2 mg capsule sig: two (2) capsule po qid (4 times a day) as needed for diarrhea. 8. oxycodone 5 mg tablet sig: 0.5 tablet po q4h (every 4 hours) as needed for pain. 9. opium tincture 10 mg/ml tincture sig: four (4) drop po every four (4) hours as needed for constipation. 10. ondansetron hcl 4 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for nausea. 11. ranitidine hcl 150 mg capsule sig: one (1) capsule po twice a day. 12. diphenoxylate-atropine 2.5-0.025 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for diarrhea. 13. insulin please see attached insulin sliding scale discharge disposition: extended care facility: at the discharge diagnosis: pleural effusions s/p pleurex catheter placement portal vein thrombosis pancreatic cancer (recurred) orthostatic hypotension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at . you were admitted for shortness of breath and found to have a reaccumulation of the fluid around your right lung as well as a new fluid collection around your left lung. as you know, we had extreme difficulty preventing water from accumulating around your lungs; eventually we had to place a pleurex catheter in your left lung due to the speed of reaccumulation of fluid. you will need the pleurex catheter drained between 500-1500cc of fluid periodically for comfort. extra vacuum bottles have been sent with you at discharge. complicating this was your low blood pressure when standing. we gave you new medications to raise your blood pressure. please note the following changes to your medications: stop lasix spironolactone enoxaparin 70mcg start salt tabs 2g twice per day enoxaparin 40mg twice per day florinef 0.2mg daily midodrine 10mg three times per day, please take the last dose at least 4 hours before bed, and the first dose as soon as you wake up prior to standing please see discharge summary for more details regarding your new medications. followup instructions: department: hematology/oncology when: friday at 10:00 am with: , rn building: campus: east best parking: garage department: hematology/oncology when: friday at 10:00 am with: , rn building: campus: east best parking: garage department: hematology/oncology (please obtain a chest xray on the same day just prior to this appointment) when: thursday at 11:00 am with: , md building: sc clinical ctr campus: east best parking: garage procedure: insertion of intercostal catheter for drainage thoracentesis thoracentesis thoracentesis other bronchoscopy injection or infusion of cancer chemotherapeutic substance diagnoses: malignant neoplasm of liver, secondary urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site acute kidney failure, unspecified hyposmolality and/or hyponatremia other chronic pulmonary heart diseases loss of weight diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin other ascites hypoxemia diarrhea streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] secondary malignant neoplasm of lung hypovolemia personal history of malignant neoplasm of other gastrointestinal tract other and unspecified coagulation defects personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health chronic diastolic heart failure irritable bowel syndrome orthostatic hypotension nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] portal vein thrombosis malignant neoplasm of other specified sites of pancreas body mass index less than 19, adult other specified forms of effusion, except tuberculous hepatopulmonary syndrome 

Answer: The patient is high likely exposed to