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: no known allergies / adverse drug reactions attending: chief complaint: "pneumonia" major surgical or invasive procedure: - bronchoscopy with biopsy - pericardial window, chest tube placement history of present illness: ms. is a 62 year old female with a history of limited scleroderma/crest and recurrent pneumonia who was admitted for suspected pneumonia. she has been having persistent symptoms since summer when she was diagnosed with a pneumonia and completed a course of cefpodoxime/azithromycin. . during the week pta, the patient had progressively worsening cough, shortness of breath and fever. her fever curve hit maximum at 101.9. she wasn't able to perform her usual daily functions at home due to profound fatigue and decided to go to for further evaluation. on , the patient had a chest x-ray which showed a left lower lobe pneumonia with progression and worsening. she does report that over the past months it has gotten progressively more difficult for her to swallow. . in the ed, initial vitals 99.5 86 113/64 18 98% ra. she had a cxr concerning for pna and was given cefepime. they encouraged her to accept admission to the hospital. . currently, she is resting in bed but having ongoing cough and shortness of breath. . ros: (+) per hpi (-) denies headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: - scleroderma with crest syndrome - gerd/barrett's esophagus - raynaud's disease - osteonecrosis of jaw from reclast - osteoporosis - r rotator cuff injury s/p surgery - r wrist injury social history: lives with her husband. worked as a social worker and in information services at is now retired and stays at home. - tobacco history: 45 pack years, quit - etoh: social - illicit drugs: denies family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death - mother: had sarcoid, died at 81 - father: had wegener's granulomatosis, died at 84 - aunt has scleroderma physical exam: admission physical exam: vs - temp 98.8f, bp 114/60, hr 116, r 20, o2-sat 97% ra general - chronically ill appearing female heent - nc/at, perrl, eomi, sclerae anicteric, mmm, op with fullness and enlargement of the left posterior pharynx neck - supple, no thyromegaly, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions lymph - + cervical lad which is tender neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, steady gait . discharge physical exam: physical exam: vs: 96.7, 98/58, 78, 20, 100% on 4l general: chronically ill appearing woman in nad, comfortable heent: nc/at, sclerae anicteric, mmm, op clear neck: supple, no thyromegaly; + left anterior cervical lad; lungs: decreased bs at bases, o/w cta heart: rrr, nl s1-s2, no mrg abdomen: +bs, soft/nt/nd, no masses or hsm extrem: wwp, no c/c/e pertinent results: admission labs: 05:30am blood wbc-10.5 rbc-3.75* hgb-10.7* hct-32.5* mcv-87 mch-28.4 mchc-32.8 rdw-13.0 plt ct-506* 05:30am blood neuts-80.1* lymphs-14.4* monos-3.9 eos-1.1 baso-0.6 05:30am blood glucose-76 urean-14 creat-0.7 na-140 k-4.4 cl-101 hco3-26 angap-17 05:30am blood calcium-9.1 phos-3.7 mg-2.2 . microbiology: . sputum culture (expectorated): respiratory culture (final ): sparse growth commensal respiratory flora. gram negative rod(s). sparse growth. gram negative rod #2. sparse growth. pericardial fluid studies: no pmns or microorganisms, final fluid culture with no growth pericardial fluid: 4+ pmns, no microorganisms, prelim ngtd pleural fluid: 4+ pmns, no microorganisms, prelim ngtd blood cx: *** . cytology - pericardial fluid: negative for malignant cells. predominantly blood. - pleural fluid: pleural fluid, left side: positive for malignant cells, consistent with metastatic adenocarcinoma - pericardial fluid: pericardial fluid: atypical. rare atypical epithelioid cells. numerous neutrophils and lymphocytes - level 7: fna, level 7 lymph node: positive for malignant cells, consistent with metastatic adenocarcinoma. scattered lymphocytes suggestive of lymph node sampling. - left lower lobe mass: fna, left lower lobe mass: positive for malignant cells, consistent with adenocarcinoma. - 4r lymph node: fna, 4r lymph node: positive for malignant cells, consistent with metastatic adenocarcinoma. no definite evidence of lymph node sampling. - 11l lymph node: fna, 11l lymph node: positive for malignant cells, consistent with metastatic adenocarcinoma. scattered lymphocytes suggestive of lymph node sampling. 2:59 pm pleural fluid pleural fluid. gram stain (final ): 3+ (5-10 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 (preliminary): no growth. anaerobic culture (preliminary): no growth. . pathology: - pericardium tissue: organizing pericarditis. there is no evidence of malignancy in this sample. - left pleural cell block: positive for malignant cells, consistent with metastatic adenocarcinoma; see note. note: by immunohistochemistry, the tumor cells are positive for ck7, ttf-1, -31, cea (absorbed), and b72.3, and are negative for leum1 (cd15), calretinin, and wti, with adequate controls. the findings are non-specific, but are compatible with a tumor of lung origin. correlation with clinical and radiographic findings is recommended. - lymph node fna's combined: positive for malignant cells, consistent with metastatic adenocarcinoma. . - pleural fluid diagnosis: pleural fluid, cell block: metastatic adenocarcinoma. . imaging: . - cxr: there has been progression of left-sided multifocal pneumonia, with dense consolidation in the left perihilar region, superior segment of the left lower lobe, and lateral basal segment of the left lower lobe. partial obscuration of the left hemidiaphragm is noted. there are no significant pleural effusions or pneumothorax. marked lymphadenopathy persists in the bilateral hilar regions, left greater than right; as well as in the subcarinal region, with splaying of the left and right main bronchi. the heart is normal in size. pleural parenchymal scarring persists at the lung apices, particularly in the lateral right upper lobe. multilevel degenerative changes are noted in the thoracic spine. impression: worsening multifocal left-sided pneumonia, with associated intrathoracic lymphadenopathy. recommend close clinical and imaging followup as an underlying malignancy is not excluded. consider pulmonary consultation. . ct chest: impression: 1. since , the left lower lobe consolidation has significantly progressed with unchanged bulk of the bilateral hilar and mediastinal lymph nodes. interlobular interstitial septal thickening in left lower lobe persists. 2. interval appearance of mild to moderate simple left pleural effusion and mild-to-moderate pericardial effusion without any element of pericardial tamponade. above ct features are worrisome for lung malignancy. bulky subcarinal lymph node can be approached for transbronchial biopsy. 3. 8.3-mm hypodense nodule in the left lobe is stable since , . suggest ultrasound of thyroid for further evaluation. 4. 7-mm hypodensity in the right lobe of liver is incompletely characterized. suggest usg abdomen for further evaluation. . tte: right ventricular chamber size and free wall motion are normal. there is a moderate pericardial effusion which measures up to 2 cm anterior to the right ventricle in the subcostal views and 1.4 cm adjacent to the inferolateral wall. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there is brief right atrial diastolic collapse. there is no right ventricular collapse. . cxr: impression: since , following left chest tube removal, there is a tiny residual left apical pneumothorax. bilateral moderate pleural effusions, lower lung atelectasis, and mid and lower lung opacities are unchanged in appearance. . mri head w and w/o contrast (): impression: 1. small, lacunar early subacute infarct in the left posterior frontal lobe. 2. no evidence of cerebral metastasis. . pet scan : impression: 1. in this patient with known left lung adenocarcinoma, high fdg uptake in the left hilar mass, and the resultant post-obstructive consolidation in the left lower lobe. 2. fdg avid mediastinal, both hilar and right supraclavicular adenopathy 3. midly increased uptake in the left adrenal gland, is concerning for a metastasis. recommended attention on follow up imaging. 4. interval worsening of multiple fdg avid right lung opacities, suggestive of multi-focal pneumonia. bilateral moderate pleural effusions. . cxr impression: unchanged left apical tiny pneumothorax. bilateral pleural effusions and associated atelectasis are stable since the previous exam. . discharge labs: 05:57am blood wbc-12.2* rbc-3.23* hgb-9.3* hct-28.4* mcv-88 mch-28.8 mchc-32.7 rdw-14.1 plt ct-592* 05:57am blood glucose-121* urean-5* creat-0.4 na-135 k-4.1 cl-91* hco3-37* angap-11 05:57am blood calcium-8.5 phos-3.9 mg-1.7 brief hospital course: ms is a 62yom with h/o limited scleroderma/crest and recurrent pna who initally p/w pna. after receiving a ct scan for the pna, she was found to have a pericardial effusion that was evaluated by ultrasound. she received a pericardial window for cardiac tamponade presumably from a malignant effusion, as well as a bronchoscopy which took several transbronchial biopsies. she was transferred to the micu, and was eventually called out to the cardiology floor, for management of new paroxysmal afib with rvr while the etiology of her left lung mass was being worked up. she was transferred to the oncology floor after her initial pathology results showed malignant cells c/w adenocarcinoma. . active problems by issues: . # malignancy adenocarcinoma: ct showed that since , her left lower lobe consolidation has significantly progressed with unchanged bulk of the bilateral hilar and mediastinal lymph nodes; interlobular interstitial septal thickening in left lower lobe persists. after pathology from her bronchoscopy (lymph node and lll mass bx's) were positive for malignant cells consistent with adenocarcinoma, heme-onc was consulted and she was transferred to the oncology floor. she began her chemotherapy regimen which is to be continued as an outpatient. . # pericardial effusion: ct thorax showed evidence of pericardial effusion. pt c/o sob, and tte showed evidence of tamponade physiology. she was urgently brought to the cath lab for pericardiocentesis. there, 200cc of bloody fluid was taken out, and a drain was put in with another 230cc drainage over the next 12 hours. drainage then tapered off to nothing. repeat tte showed evidence of returned pericardial effusion with evidence of loculation and tamponade physiology. pt also continued to complain of sob, and had tachycardia. ct surgery was consulted and agreed that patient needed urgent pericardial window operation. . pericardial window was performed on . likely etiology of the effusion was malignancy in the context of lll consolidation and pleural effusion with likely post-obstructive pna. after call-out to the cardiology floor, her chest tube drainage decreased and the tube was removed on . repeat cxr's continued to show stable effusions. the pt c/o constant dyspnea and was maintained on several l of o2 with sats in the mid-90's; she was started on low doses of morphine to treat dyspnea and air hunger on , which gave her significant symptomatic improvement. . # pneumonia: she likely had a post-obstructive pneumonia due to the lung mass seen on ct chest one month ago. a repeat ct chest was performed and showed the mass was amenable to bronchoscopic biopsy. pulmonology was consulted and performed a biopsy and bronchoscopy with washings sent for cultures. she was treated with cefepime and metronidazole for 10 days each for concern for anaerobes and resistant gram negatives. her cough and lung exam initially improved, but on her dyspnea increased, she had persisting opacities on cxr and slowly increasing wbc, and so zosyn, and levofloxacin were started. she tolerated this regimen and her symptoms improved. she still has intermittent dyspnea and coughing that is well controlled with morhpine. . # paroxysmal afib: new onset this admission in micu on morning of . since undergoing surgery for placement of pericardial window, pt has been intermittently in atrial fibrillation with rvr to 130s. denies any cardiac history or known h/o afib. patient was symptomatic during rvr episodes with dyspnea, with systolic blood pressures 90-100s (baseline sbp appears to be 100s-120s). given that she currently has a pericardial drain in place and is going for transbronchial biopsy, anticoagulation was deferred. on the cardiology floor, metoprolol was continued at 12.5mg q6hr given relatively low bps; she self-converted into sinus with hr in the 70-80's. deferred starting anticoagulation with aspirin given chads2-vasc score of one in setting of recent procedures. tsh was normal. during her stay on the cardiology floor, she remained in sinus rhythm with hr in 70-80's. the cardiologists decided that the isolated episodes of afib were likely d/t the pericardial drain. throughout the remainder of her stay, she had no further episodes of afib. she was continued on the metoprolol nonetheless. . # normocytic anemia: hct was in low 30's during admission (recent baseline 30-35), mcv 85, rdw 13. stable from previous admission 1 month ago. likely anemia of chronic inflammation; retic count, ferritin, b12/folate are all wnl. also could be concerned for hemolysis as she has known autoimmune disease (crest), but tbili normal and high ldh. deferred iron replacement for now given acute illness. . # lymphadenopathy: she had tender cervical lymphadenopathy and also posterior pharynx adenopathy. this is likely related to the mass in her lung and biopsies are pending. . # lacunar stroke: the patient was incidentally found to have a small lacular infarct on mri. she exhibited no symptoms. it was thought that the hypercoagulable state along with the brief afib may have been the cause. nonetheless, neurology was made aware, and they recommended a carotid series and aspirin initiation. the patient is also to have an echo done as an outpatient. . chronic problems by issue: . # limited scleroderma with crest syndrome: her symptoms are moderately controlled with calcium channel blockers at home. she had some symptoms of worsening esophageal dysmotility due to this. she was continued on nifedipine and her proton pump inhibitor for esophageal involvement. . # osteonecrosis of the jaw: history of osteonecrosis secondary to zolandronate. she was continued on her calcium and vitamin d for prevention as well as ibuprofen for pain control, taken especially with meals. also, she was continued on her chlorhexidine mouth washes. . transitional issues: medications on admission: - vitamin d 500-calcium 500 daily - vitamin c 500 mg daily - multivitamin - fish oil - chlorhexidine gluconate oral rinse - robitussin with codeine - penicillin 500 mg q6hrs - nifedipine cr 60 mg daily - lansoprazole 30 mg daily - ibuprofen 400 mg q6h prn for pain - vagifem 10 mcg prn - probiotic daily - magnesium supplement daily - metrogel for rosacea - levofloxacin (since monday) - albuterol inhaler (since monday) discharge medications: 1. ibuprofen 400 mg tablet sig: one (1) tablet po every six (6) hours as needed for pain . 2. chlorhexidine gluconate 0.12 % mouthwash sig: five (5) ml mucous membrane (2 times a day). 3. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for cough. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 5. fluconazole 100 mg tablet sig: one (1) tablet po once a day for 3 days: last dose thursday . 6. albuterol sulfate 0.63 mg/3 ml solution for nebulization sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. 7. ipratropium bromide 0.02 % solution sig: one (1) nebulizer treatment inhalation every six (6) hours as needed for shortness of breath or wheezing: inhalation every 6 hours pas needed for shortness of breath or wheezing. 8. morphine 15 mg tablet sig: 0.5-1 tablet po q2h (every 2 hours) as needed for pain, sob. disp:*90 tablet(s)* refills:*2* 9. morphine 15 mg tablet extended release sig: one (1) tablet extended release po every eight (8) hours. disp:*90 tablet extended release(s)* refills:*2* 10. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for temperature >38.0. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 12. benzonatate 100 mg capsule sig: two (2) capsule po tid (3 times a day) as needed for cough. 13. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 14. dextromethorphan-guaifenesin 10-100 mg/5 ml liquid sig: ten (10) ml po q6h (every 6 hours) as needed for cough. 15. lorazepam 0.5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for nausea, anxiety. disp:*90 tablet(s)* refills:*2* 16. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 17. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day). 18. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 19. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q4h (every 4 hours) as needed for nausea. 20. morphine 15 mg tablet sig: 1-2 tablets po mwf: please give 30-60 minutes before pleurex drainage on mwf. if still in pain after pleurex, can repeat this dose as necessary. disp:*90 tablet(s)* refills:*2* discharge disposition: extended care facility: nursing & therapy center - ( center for rehabilitation and sub-acute care) discharge diagnosis: primary diagnoses: post-obstructive pneumonia adenocarcinoma secondary diagnosis: limited scleroderma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , . you were admitted to the hospital because you were having fevers, fatigue, and persistent cough after your last treatment for pneumonia. we think the reason that your pneumonia continued is because you had a mass in your lung which was making it difficult for your lungs to clear out the infected mucus. . a bronchoscopy was performed to evaluate this mass, and the results of the biopsy showed adenocarcinoma. you were given antibiotics for treatment of the pneumonia, and you were transferred to the oncology floor for further management of your cancer. while there, you were started on your chemotherapy regimen. a pleurex a placed for palliative purposes. your chemotherapeutic regimen was terminated. . the following changes were made to your medications: - stop taking levofloxacin - stop taking penicillin - stop taking nifedipine - start metoprolol - start albuterol and ipratropium - start fluconazole which you will take for 2 more days followup instructions: building - hem onc 3:30 pm on dr. procedure: insertion of intercostal catheter for drainage pericardiocentesis pericardiocentesis thoracentesis closed [endoscopic] biopsy of bronchus other incision of pleura biopsy of lymphatic structure pericardiotomy injection or infusion of cancer chemotherapeutic substance central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified congestive heart failure, unspecified atrial fibrillation secondary malignant neoplasm of other specified sites secondary malignant neoplasm of pleura personal history of tobacco use paroxysmal ventricular tachycardia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure iatrogenic pneumothorax osteoporosis, unspecified primary hypercoagulable state encounter for palliative care acute diastolic heart failure accidents occurring in residential institution cerebral artery occlusion, unspecified with cerebral infarction secondary and unspecified malignant neoplasm of intrathoracic lymph nodes malignant neoplasm of lower lobe, bronchus or lung anemia in neoplastic disease other drugs and medicinal substances causing adverse effects in therapeutic use acute pericarditis, unspecified cardiac tamponade malnutrition of moderate degree systemic sclerosis malignant pleural effusion aseptic necrosis of bone, jaw 

Answer: The patient is high likely exposed to