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: seasonale attending: chief complaint: right thoracic pain and productive cough. major surgical or invasive procedure: 1. ivc optease filter through l common femoral vein by interventional radiology (dr. 2. r diagnostic thoracentesis by icu team (drs. and ) 3. r therapeutic thoracentesis by interventional pulmonology (dr. ) 4. new option ivc filter plaved via r internal jugular vein, inferior to the pre-existing optease filter by interventional radiology history of present illness: 50-year-old male with a past medical history of extensive peritoneal carcinomatosis s/p 9 cycles of gemcitabine and cisplatin (last ), hepatitis c, multiple pulmonary embolisms with the last while on lovenox, endocarditis who presents with right thoracic pain and productive cough x several days. . he notes that over the last few days he has developed fatigue, nausea and vomiting, productive cough with brown sputum, intermittent fevers and abdominal pain for the last week. he notes a tm of 103. this am he awoke with sharp right sided pleuritic chest pain. he also noted lightheaded at that time. he went to for scheduled chemotherapy and was found to have 02 saturation 87-88% on room air with recovery with 2l nc. rll revealed diminished breath sounds. labs were taken which show wbc 17.5 hct 25.8 creat 1.7. at that point admission to the hospital was recommended however the patient went home for a few hours prior to presenting to the ew for evaluation. . upon presentation to the ew, inital vitals show t 102.7, hr 121, bp 143/70, sao2 87%. at that time he was triggered for altered mental status. he had bilateral rhonchi r>l. he was noted to be pale and diaphoretic. he has 2+ edema of right leg. with supplemental o2 his oxygenation improved as did his mental status. he received vancomycin, cefepime and flagyl. a cta showed large right pe with new cavitation of rll suggestive of necrotizing pneumonia. r le had dvt. he was admitted to medical icu for further evaluation and management. . currently, feels much improved. past medical history: past oncologic history: he presented in with constipation and abdominal pain and was diagnosed with peritoneal carcinomatosis. pathology of an omental biopsy showed adenocarcinoma staining positive for ck7 and cdx2 and focal weakly positive for ck20, negative for ttf-1. findings were suggestive of pancreaticobiliary or upper gi tract primary. egd on was negative for a primary source of adenocarcinoma. his ca19-9 was elevated at 384 u/ml. given these findings, the presentation was most consistent with metastatic cholangiocarcinoma. mr. began systemic chemotherapy with gemcitabine/cisplatin on . his first cycle was complicated by left-sided pneumonia due to mssa, klebsiella, and enterobacter. he was not neutropenic. initially treated outpt with po abx but then hospitalized for iv antibiotics. cycle 2 was given . . past medical history: - chronic hepatitis c genotype 3. on , he was started on combination therapy of pegasys 180 mcg/ml sq weekly and ribavirin 1200 mg po daily. hcv rna was undetectable at week 4 from a baseline of 261,000 iu/ml. serum aminotransferases are normal. initially, he was tolerating therapy relatively well except for mood swings, irritability and insomnia and he was closely monitored by dr. in psychiatry. unfortunately, by early , he had been feeling more depressed with occasional suicidal ideation and racing thoughts. apparently, he was taking twice the prescribed dose of citalopram 20 mg a day; and he had also relapsed into drinking alcohol; about drinks per day for a few days. given these significant side effects, pegasys and ribavirin were eventually discontinued. . thoracic aortic aneurysm - ct angiogram on , demonstrated dilation of the ascending aorta to 4.3 cm- followed by dr. . . major depressive disorder polysubstance abuse h/o suicidal ideation h/o pericarditis, endocarditis, pneumonia social history: history of cigarettes for many years, now quit. history of polysubstance abuse including heroin but is currently clean. family history: substance abuse in greatgrandfather, maternal and paternal grandfathers and uncle. a grandmother had liver cancer. physical exam: icu admission exam: vitals: t: 96.7 bp: 145/103 p: 99 r: 25 o2: 92% on 5l nc general: somnolent, interactive, oriented, no apparent distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: decreased breath sounds rll, crackles/tubular breath sounds in rll. no wheezes. cv: tachycardic, regular rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-distended, epigastric abdominal tenderness with palpation, no rebound or guarding gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. r leg with 3+ edema. l leg without. . icu discharge exam: t 37.9 ??????c, hr 87, bp 122/65, rr 20, sao2 91% 2l general: pale, anxious-appearing, aox3 heent: mmm neck: supple, jvp not elevated, no lad lungs: decreased breath sounds at bases bilaterally. on r, decr bs up to way. dullness to percussion ??????way up r lung field. bibasilar crackles. cv: rrr, nl s1/s2, no mrg abdomen: soft, non-tender, non-distended gu: no foley ext: wwp, 2+ pulses, no clubbing, cyanosis. l femoral access site w/bandage, r 3+ edema to mid-calf, l non-edematous. . omed accept exam: vitals: 96 (97.4) 142/78 98 20 96% on 3l nc gen: nad, lying in bed, lethargic heent: perrla. mmm. neck supple cards: rr s1/s2 normal. no murmurs/gallops/rubs. crisp s2 at upper r clavicular border pulm: r chest tube in place, without surrounding erythema, covered w/ clean/dry dressing. decreased lung sounds at left base. dullness to percussion at l base. scattered crackles b/l. abd: bs+, soft, nt/nd, no hepatosplenomegaly appreciated extremities: wwp, 2+ pitting edema to upper tibia bilaterally, distal pedal pulses b/l, no cords, no sign present neuro: cns ii-xii intact. 5/5 strength in u/l extremities. dtrs 2+ bl in achilles and patellar. pt sedated, closing eyes in the middle of conversation. aox2 ( , , ). . omed discharge exam: pertinent results: admission labs: 12:12pm wbc-17.5*# rbc-2.81* hgb-8.9* hct-25.8* mcv-92 mch-31.7 mchc-34.5 rdw-15.6* 12:12pm plt count-158# 12:12pm urea n-26* creat-1.7* sodium-132* potassium-3.8 chloride-95* total co2-28 anion gap-13 12:12pm glucose-134* 04:00pm pt-14.0* ptt-28.2 inr(pt)-1.2* 04:00pm wbc-15.9* rbc-2.63* hgb-8.3* hct-25.0* mcv-95 mch-31.7 mchc-33.3 rdw-16.6* 04:00pm neuts-83* bands-3 lymphs-3* monos-10 eos-0 basos-0 atyps-0 metas-1* myelos-0 . relevant labs: pleural fluid: wbc 1475, rbc 1500, pmns 96, lymphs 0, monos 4, ph 7.33 pleural fluid: 3+ pmns, no microorganisms; aerobic and anaerobic cx's pending blood cx x2 pending blood cx pending pleural fluid: gram stain- no pmns, no microorganisms, aerobic cx- no growth, anaerobic cx - no growth sputum: gram stain- >25pmns, <10epithelial cells, 2+ mixed oral flora, cx- rare growth of commensal respiratory flora, sparse growth of coag+ staph aureus , sparse growth of yeast. mrsa screen: negative serum galactomannan: 0.1 (negative); serum beta glucan: 49 (negative) . imaging: leni - indication: right lower extremity swelling. findings: -scale and doppler son were obtained of the upper extremity. occlusive thrombus is seen in the right femoral, popliteal, posterior tibial, and one of the peroneal veins. the thrombus does not extend proximally into the common femoral vein. impression: extensive dvt in the right lower extremity. . cta indication: question new pe. findings: contrast bolus timing is adequate for assessment of pulmonary arteries to the subsegmental level. acute thrombus is seen in the right main (3:56), right upper lobe (3:50), right middle lobe (3:65) and right lower lobe (3:67) pulmonary arteries as well as the right posterior basal branch (3:81). thrombus is also seen on the left in the lingula and pulmonary artery (3:62). despite the large thrombus burden, no ct evidence of right heart strain is seen. a loculated pleural effusion is seen in the right major fissure as well as effusions layering in the dependent right lung right pleural space. patchy peribronchovascular consolidations are seen in the left upper lobe. dense consolidation and air bronchograms are seen in the left lower lobe (3:89), right lower lobe and right middle lobe (3:81). a cavitary lesion is seen in the lateral basal segment of the right lower lobe (3:80). the heart and great vessels are of normal caliber and appearance. no mediastinal, hilar, or axillary adenopathy is present. the visualized portions of the upper abdomen are unremarkable. bone windows: there are no concerning lytic or sclerotic lesions. no fractures are identified. impression: 1. acute pulmonary embolism with marked thrombus load to the right main, upper, middle and lower pulmonary arteries as well as left lingula. 2. patchy and confluent areas of consolidation in the lower lungs with an area of cavitation in the right lower lobe. this appearance is suggestive of a very aggressive infectious process such as necrotizing pneumonia, although septic emboli can also cavitate. the distribution and appearance of the opacities is not consistent with pulmonary infarct, per se. . cxr: interval increase in loculated right pleural effusion is noted. there is also interval increase in left pleural effusion. bibasilar opacities are unchanged. port-a-cath catheter tip is at the level of cavoatrial junction. . cxr: findings: pa and lateral chest views were obtained with patient in upright position. analysis is performed in comparison with the next preceding ap single view chest examination of . the previously existing extensive loculated pleural effusion in the right hemithorax persists rather unchanged. no pneumothorax has developed. some amount of pleural effusion on the left base also unchanged. the previously described right subclavian approach central venous line remains in unchanged position terminating in low svc. impression: grossly unchanged findings with advanced loculated pleural effusions. no pneumothorax. . : ct chest with contrast: 1. increase in extent of the partly loculated right pleural fluid without evidence of pleural thickening or increased contrast uptake by the pleura. newly placed right chest tube with introduction of air into the loculated fluid. 2. slight progression of a cavitary right lower lobe lesion with increase in size. the overall extent of the parenchymal opacities in the right lung may have minimally decreased. 3. unchanged extent of parenchymal opacities in the left lung, with a small newly appeared left pleural effusion. 4. unchanged reactive lymphadenopathy. 5. no evidence of right heart strain, but given the examination protocol, embolic load after pe cannot be determined. 6. no changes in the abdomen. . cxr: a right loculated effusion along the chest wall is slightly smaller compared to the prior examination with evidence of aerated lung behind it. there is mild adjacent opacity likely representing atelectasis. a small left effusion is noted as well. the cardiomediastinal silhouette and hilar contours are normal. a right chest tube and svc line terminating in the mid svc are appropriate. . cxr: interval placement of a right basilar chest tube. tip of the chest tube does project over the right mid and lower lung peripheral opacity although satisfactory positioning should be based on the clinical assessment as the tube appears to have a central lucency suggestive of air rather than fluid.pleural-based opacity at the right mid to lower lung remains overall unchanged. right subclavian port-a-cath remains in place with its tip in the superior vena cava. patchy airspace opacity at the left lung base also seen and may reflect patchy atelectasis and/or pleural effusion. pneumonia cannot be entirely excluded. cardiac and mediastinal contours are stable. no pneumothorax is appreciated. no evidence of pulmonary edema. . cxr: right basilar pleural catheter remains in place. the previously seen pleural-based triangular opacity is no longer visualized. there is a small loculated pneumothorax. residual linear opacity at the right lung base likely reflects subsegmental atelectasis. there also continues to be patchy opacity at the left base with associated effusion, likely reflecting compressive atelectasis, although superimposed pneumonia cannot be excluded. no evidence of pulmonary edema. stable cardiac and mediastinal contours. right subclavian port-a-cath with tip in the superior vena cava. . cxr: findings: as compared to the previous radiograph, the position of the right basal pleural drain is in unchanged position. the previously seen lateral pneumothorax is now filled with fluid. there is no evidence of tension. the parenchymal opacities surrounding the right chest tubes are unchanged. unchanged left pleural effusion and left atelectasis. normal size of the cardiac silhouette, no pulmonary edema. unchanged right port-a-cath. . cytology: pleural fluid cytology: negative for malignant cells . labs on discharge: none, patient . many more studies done to view in omr, patient on discharge. brief hospital course: ==================================================== brief hospital summary ==================================================== 50-year-old male with history of cholangiocarcinoma on chemotherapy who present pneumonia and pulmonary embolus. ==================================================== active issues ==================================================== # pulmonary embolus: pt found to have a large r-sided pulmonary embolus while on lovenox for home anticoagulation, suggesting failure of the lovenox therapy. this is his third thromboembolus in the past five months while on lovenox. however, further history reveals pt was taking lovenox qweek rather than qd, no he was not truly anticoagulated. given his underlying cholangiocarcinoma and history of dvt/pes he remains is chronically hypercoagulable and in need of anticoagulant therapy. in the icu he was on a heparin drip. he was also found to have significant r leg dvts and an ivc filter was placed by radiology. subsequently on imaging, it was discovered that his ivc filter was inverted, so he had an additional ivc filter placed on . he had been transferred to the floor, but due to worsening hypoxia was sent back to the icu, where interventional pulmonology changed his chest tube. since his effusion had significant loculations, he was given doses of tpa via chest tube to break up the loculations and thereby allow more drainage. while on the floor, it is likely that the pt had a second pe on lovenox in the second week of (rh strain, hypoxemic event). due to , did not perform cta to protect kidneys. transitioned pt from lovenox to heparin drip. . # pneumonia: initially imaging showed additional pulmonary processes in the r lower lobe, included multi-loculated pleural effusions and possible necrotizing pneumonia. cough was productive. pulmonary infarct and/or pulmonary hemorrhage secondary to his large r pe was considered as a possibility, so a diagnostic thoracentesis was performed. pleural fluid was exudative with elevated wbc and low ph, suggestive of an infectious exudate. he was treat with broad coverage antibiotics vs hcap including vancomycin, cefepime and flagyl. sputum cultures grew staph aureus, which was sensitive to gent; blood cultures had no growth, pleural fluid preliminarily had no growth. interventional pulmonology placed a pigtail catheter, connected to suction, on to drain his loculated r effusions, and this was replaced on . he was given tpa with hopes of lysing some clots he maintained o2 saturation >90% on 2l nc at time of icu discharge. cytology of the pleural fluid showed no malignant cells. pt completed course of antibiotics for hap. in the third week of , pt became more hypoxemic with a rising white count and patient was reinitiated on broad spectrum antibiotics for a second hap. #hypoxemic events: pt had a number of hypoxemic events in the third and fourth week of , most likely secondary to mucous plugging and/or aspiration in the setting of existing significant lung disease (effusions and pna). pt recovered with high flow o2 via facemask +/- deep suctioning. # anemia: hct 19 on admission, decreased from recent baseline 25. no evidence of active bleeding on exam but hemorrhage into a r pulmonary infarct or cavitary pneumonia was considered. hematocrit improved to 25 with transfusion of 2 units prbcs and was stable thereafter. hematocrit remained stable while on floor in the mid-20s. . # acute kidney injury: on admission his creatinine had increased to 1.5 from baseline of 0.8, but it improved to 1.1 after ivf. have been secondary dehydration or to transient decrease in cardiac output from pulmonary embolus. pt's cr drifted upward to 2.1 throughout hospitalization, although laboratory results pointed toward a pre-renal cuase, ivf did not improve his cr. . #pain: difficult to manage requiring multiple modifications of pain regimen including methadone titration, dilaudid titriation, and use of pca. . #altered mental status/encephalopathy: mr. became encephalopathic towards the end of his hospitalization. initially thought to be due to oversedation with narcotics, this subsequently was attritubed to progressive disease. # cholangiocarcinoma: patient recently received chemotherapy. he was followed in the icu by the oncology team who felt that treatment was contraindicated at this time. pt was followed closely while on the omed service by primary oncologist, dr. . we were considering initiating a round of palliative chemotherapy, but mr. further chemotherapy. his clinical status then further , making him no longer a candidate for chemotherapy. after multiple meetings with the patient, and then his partner and mother, decision was made to focus on comfort. mr. during his hospitalization. medications on admission: - benzonatate 200 mg po tid - clonazepam 1 mg po qid - dexamethasone 4 mg po daily x4 days following chemo - enoxaparin 80 mg subcutaneous injection q12hour - hydromorphone 12 mg po q4hours prn pain at night - lactulose 10 gram/15 ml po q4-6 hours - lorazepam 0.5 mg po q4-6 hours prn - methylphenidate 5 mg tablet po tid - olanzapine 15 mg po qhs prn - omeprazole 20 mg po daily - ondansetron hcl 4-8 mg po q8 hours prn - oxycodone 50mg po q4-6hours prn pain during day - oxycodone er 160mg po q8hours - oxycodone er 40mg po qhs (total of 200mg qhs dose) - vardenafil 10 mg po prn - docusate sodium 100 mg po bid - magnesium hydroxide 400 mg/5 ml suspension 30 ml po q12hrs prn - polyethylene glycol 3350 17 gram/dose po daily prn - sennosides 8.6 mg po bid discharge medications: none discharge disposition: facility: house discharge diagnosis: primary diagnoses: death pneumonia (x2) empyema pulmonary embolism (x2) deep vein thrombosis secondary diagnoses: pain crises metastatic cholangiocarcinoma discharge condition: patient was . discharge instructions: patient was . followup instructions: patient was . procedure: insertion of intercostal catheter for drainage interruption of the vena cava interruption of the vena cava injection or infusion of thrombolytic agent thoracentesis thoracentesis diagnoses: chronic hepatitis c without mention of hepatic coma acute kidney failure, unspecified thoracic aneurysm without mention of rupture cachexia major depressive affective disorder, single episode, unspecified methicillin susceptible pneumonia due to staphylococcus aureus personal history of noncompliance with medical treatment, presenting hazards to health primary hypercoagulable state do not resuscitate status acute venous embolism and thrombosis of deep vessels of proximal lower extremity encephalopathy, unspecified other disorders of neurohypophysis other pulmonary embolism and infarction empyema without mention of fistula neoplasm related pain (acute) (chronic) secondary malignant neoplasm of retroperitoneum and peritoneum malignant neoplasm of intrahepatic bile ducts foreign body in main bronchus inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation other specified forms of effusion, except tuberculous 

Answer: The patient is high likely exposed to