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: history of present illness: this 73-year-old female with the below past medical history had lower extremity edema and visited her primary care physician, . , on . a workup was deferred at that time to evaluate a 1.5 cm thyroid nodule. this was though possibly to be a neoplasm, which might have explained a neuropathy that the patient had which had defied workup with the consideration that it might be a perineoplastic phenomenon. on , the patient had a fine needle aspiration of the nodule, which eventually showed a solid 3.4 x 2.2 x 1.9 cm mass, not a multinodular goiter but simply a hyperplastic nodule. however, the patient had a resultant mediastinal hematoma with respiratory distress which was first noticed at home post procedure. the patient returned to the emergency room and was intubated in the emergency room for airway protection. a ct scan showed that she had airway stenosis distal to the endotracheal tube, so she was sent to the operating room for mediastinal exploration. at that time, 350 cc of blood were drained and an additional 500 cc of blood were lost. she sustained a 3.5 gm hemoglobin drop from 11.9 to 8.4. the patient was doing well on a t-piece trial on 35% face mask after her original intubation. however, after receiving blood and fluids, the patient had respiratory distress. she was given further mechanical ventilatory support and was transferred to for further management of airway problems. laboratory data before transfer were notable for a white blood cell count of 65,400 and a platelet count of 847,000. past medical history: 1. polycythemia times 25 years, followed by dr. of hematology oncology: her baseline cbc included a white blood cell count of 40,000, hemoglobin of 13, hematocrit of 38 and platelet count of 700,000. 2. hypo. 3. hip fracture with two arthroplasties. 4. perioperative myocardial infarction and cerebrovascular accident at , thought related to high hematocrit and leukocytes earlier this year at the time of her second hip arthroplasty. 5. polyneuropathy with a negative workup. 6. status post clipping of cerebral aneurysm in . social history: the patient quit smoking 44 years ago. she drank rare alcohol. the daughter is closely involved with the patient's care; her name is , intensive care unit nurse . the patient also has a son, who is an anesthesiologist. she has been engaged for several years. family history: the family history was noncontributory. allergies: the patient had allergies to codeine, demerol and possibly contrast, but she received a ct scan without difficulty at the other hospital. laboratory data: on admission, the patient had a white blood cell count of 43,700 with a hemoglobin of 8.2, hematocrit of 24.8 and platelet count of 579,000 with an mcv of 85. prothrombin time was 26.6 and inr was 1.3. there was a sodium of 142, potassium of 4, chloride of 105, bicarbonate of 22, bun of 28, creatinine of 1.2 and glucose of 129. ck was 305. albumin was 3.4. calcium was 8.1, phosphate was 4.8 and magnesium was 1.6. uric acid was 8.6. fine needle aspiration original results showed insufficient cellular material for analysis. radiology data: a portable chest x-ray dated showed the nasogastric tube to be in good position with a left sided picc line at the superior vena cava. the heart size was stable with slight upper zone redistribution, right basilar atelectasis and the left costophrenic angle off the film. the lungs were otherwise clear with mild congestive heart failure. on , a chest x-ray showed further improvement since in infiltrates with no new abnormalities, the nasogastric tube in place and the picc at the right atrial and superior vena cava junction. on , the chest x-ray showed mild pulmonary edema. a head ct scan dated showed an aneurysm to be present with a hypodense left frontal lobe, consistent with encephalomalacia, a low density of the right periventricular region and no acute processes or bleed. a chest ct scan dated showed bilateral effusions with atelectasis, peripheral right upper lobe and lingular pulmonary embolisms, neck hematoma which was not compressive and mediastinal drains in place and interval enlargement of the hematoma. cardiac studies: an echocardiogram of showed marked left atrial enlargement, moderate right atrial enlargement, septum bowed to the right atrium, no atrioseptal defect, a left ventricular ejection fraction of greater than 55%, normal size, right ventricular volume and pressure overload, moderate right dilation, mild aortic stenosis, trace aortic regurgitation, 1 to 2+ mitral regurgitation, 3+ tricuspid regurgitation, mild pulmonic regurgitation, trivial effusion; from the prior study, this noted new tricuspid regurgitation and moderate to severe pulmonary hypertension. hospital course: 1. pulmonary: the patient was continued on assist-control ventilation and later weaned to pressure support ventilation. a ct scan was performed to follow the neck hematoma with the cardiothoracic surgery service following and this showed that it was relatively stable. solu-medrol was given for tracheal edema. a ct scan of the neck performed on showed a noncompressive hematoma. a ventilation perfusion scan was performed on after the pulmonary hypertension noted on echocardiogram was evaluated and this showed moderate probability for pulmonary embolus, which was felt very suggestive, given her history of polycythemia . a ct angiography was performed on , which was positive for peripheral pulmonary embolus and the patient was then anticoagulated. on , the patient was extubated in the operating room with the assistant of the high risk airway team. since then, she was placed on face mask oxygen with humidification. on or , the last - drain in the neck wound was removed. on , the patient desaturated to 88%, but recovered with supplemental oxygen. she continued on face mask oxygen. she reported some shortness of breath when her oxygen briefly slipped off on . vigorous chest physical therapy and incentive spirometry were provided. on and , decreased subjective shortness of breath and fewer secretions were noted. on , the chest x-ray looked substantially improved. the patient felt that her shortness of breath might have just been anxiety. ativan p.r.n. was given for this. antibiotics were discontinued on . thereafter, the patient remained stable. she had a slight desaturation to the low 90s on , but was mouth breathing at the time and not taking her nasal cannula oxygen. a chest x-ray showed mild pulmonary edema, thought to be related to fluids given at the time of her peg placement and she was given 20 mg of lasix. she was saturating well and was comfortable at the time of discharge. 2. cardiovascular: for her coronary artery disease, beta blockade was titrated up slowly and her cholesterol was checked. aspirin was held for a question of platelet dysfunction with the polycythemia . the patient had an echocardiogram on , which showed pulmonary hypertension with a gradient of greater than 66 and tricuspid regurgitation with an ejection fraction of greater than 55%. hypertension became an issue after earlier stable blood pressures, at some points even needing intravenous fluids for low blood pressures. as her blood pressure rose, eventually norvasc, captopril and lopressor were titrated up to provide control. the cardiology service thought that her high blood pressure might be related to her pulmonary hypertension as well. the patient had two episodes of paroxysmal supraventricular tachycardia on and with lowering of her blood pressure with the first episode. the cardiology service was reconsulted on and they felt that the problem was either atrioventricular nodal reentrant tachycardia or atrial fibrillation and amiodarone was initiated at loading doses with caution, given her history of contrast allergy and thyroid issues. no recurrence was noted by and telemetry was discontinued on . the patient had no further events. the amiodarone is scheduled to go to 200 mg q.d. on , although the patient has been discharged on 200 mg b.i.d. 3. infectious disease: the patient was treated with levofloxacin and flagyl for 14 days for community-acquired pneumonia starting on . this was changed to vancomycin on for methicillin resistant staphylococcus aureus positive sputum and positive blood cultures with gram positive cocci, originally to complete a ten day course. the infectious disease service followed the patient on the consultant service starting on and felt that the pneumonia diagnosis was not entirely secure. a subclavian central line was pulled for positive cultures on after a triple lumen catheter was placed to replace it. the infectious disease service's recommendations included tapering the steroids, checking the clostridium difficile, giving vancomycin for at least ten to 14 days given the areas that she might seed with bacteria, including her neck and hip hardware, and checking fungal cultures for any spikes. on , they added obtaining an herpes simplex virus culture of a forearm lesion, which they felt was vesicular and possibly consistent with herpes simplex virus; this was negative. on , the patient had levofloxacin and flagyl reinitiated for a new infiltrate on chest x-ray, which was originally only done for nasogastric tube placement. however, the patient was afebrile and had an uninterpretable white blood cell count, given that she had a history of polycythemia . vancomycin was stopped on and the patient was afebrile thereafter. no changes were made to her antibiotics after this time with her antibiotic course of levofloxacin and flagyl completed on . after a positive urinalysis, the foley catheter was discontinued on . it was then reinserted for failure to void and was removed as of . the patient was originally thought to be having low grade temperatures, but it was later found out that these were rectal temperatures and were therefore one degree higher than the actual body temperature. 4. heme: the patient was initially treated with hydroxyurea and anagrelide for her polycythemia . she was also transfused with three units of packed red blood cells early in her course to obtain a goal hematocrit of 30. anagrelide was changed to b.i.d. on . a hypercoagulability panel was sent for her pulmonary embolus history and heparin was started on . on , the hydroxyurea and anagrelide were stopped. coumadin was begun on for her pulmonary embolus. this was increased on for failure of her inr to increase. the patient then required another unit of packed red blood cells and the hematology service was reconsulted and felt that she might be in the spent phase of polycythemia with myelofibrosis. however, hemolysis laboratory studies were sent on in an effort to explain her low increase in hematocrit after transfusion and stool was guaiac tested repeatedly. on , her ldh was noted to be elevated, but was not significant given her history of polycythemia . however, her haptoglobin was less than 20 and a delayed transfusion reaction workup was sent. this was discussed with her hematologist, dr. , who thought that the patient might have myelofibrosis and was therefore having a difficult time recovering from the marrow-suppressive effects of her polycythemia medications. he felt that there was no need to act regarding hemolysis and said that the schistocytes on peripheral smear probably represented the effects of her myelofibrosis. the hematocrit remained stable thereafter. further contact with the blood bank indicated that no transfusion reaction occurred and her schistocytes and her anemia were attributed solely to polycythemia . on , we considered getting a right upper quadrant ultrasound to explain asymmetric edema of the right upper extremity, but this was thought to be due mediastinal hematoma per the medical intensive care unit team and was improving and, further, would not have changed her management because she was already anticoagulated. therefore, this was deferred. the patient's coumadin was increased to 7.5 and then decreased to 5 after a good inr was obtained. heparin was discontinued. on , a decision was made to hold the polycythemia medications despite her increasing platelet count to 500,000 or greater because of her low hematocrit. coumadin was discontinued for peg placement and she was given vitamin k to decrease her inr. she was covered with heparin in the meantime. after peg tube placement, heparin was restarted with coumadin. on the day of discharge, her inr was 1.5. she will need to be covered with lovenox until her coumadin is therapeutic. 5. fluid, electrolytes and nutrition: tube feeds were started and titrated up. intravenous fluids were stopped on because the patient had a large positive balance. electrolytes were repleted p.r.n. a subclavian central line was placed on and discontinued, as per the infectious disease section above, after she had positive blood cultures. a picc line was placed on . the patient was bolused for several liters on because she had a low urine output. this increased in response and increased free water flushes were given thereafter. tube feeds were restarted after her peg tube was placed and, at the time of discharge, are being tolerated well by the patient. 6. gastrointestinal: after the endotracheal tube was removed, the patient had a swallowing study on , which she failed. therefore, her nasogastric tube was kept to give medications and nutrition. the patient was given reglan as well to prove gastric motility. the dysphagia team followed the patient until she was ready for repeat swallow with video study, which was done on and showed residual pharyngeal material which she later aspirated. plans were therefore to keep her nasogastric tube and to retry later. diarrhea developed and clostridium difficile was checked repeatedly and remained negative. the diarrhea resolved after her colace was discontinued. however, it might also have been because flagyl was coincidentally started for pneumonia at the same time. promote with fiber tube feeds were felt to be ideal for her because it contained fiber but not lactose. baseline liver function tests were checked, given her amiodarone loading. on , the patient had persistent dysphagia and gastrointestinal was consulted for a peg tube. however, because the patient had a nasogastric tube, the interventional radiology service was consulted on the peg tube so that the patient could avoid endoscopy. the peg tube was completed on by the interventional radiology service without complications. 7. endocrine: thyroid medications were given. on , the endocrine team saw her for a question of endocrine contribution to her paroxysmal supraventricular tachycardia. they did not think that her amiodarone would cause hypothyroidism. 8. renal: mild acute renal failure at admission with a creatinine of 1.2 resolved. she had decreased urine output noted on and she was bolused for a total of 500 cc of normal saline. on , the patient had decreased but acceptable urine output and a stable creatinine which had stayed stable since the foley catheter was discontinued. the patient was incontinent, so at discharge the plan was to restart ditropan and see if she could regain control. 9. musculoskeletal: the patient was seen by the physical therapy service. she was followed with variable interest in her physical therapy. chest physical therapy was added to help with secretion management. occupational therapy was added on . an improved neurological function was noticed by the time of discharge with increased mobility of the right lower extremity and good function of the right upper extremity. 10. neurology: the patient's old cerebrovascular accident, old aneurysm clipping and old polyneuropathy were stable. psychiatry saw the patient for depression and irritability and thought a frontal lobe syndrome might be active. this was hard to interpret, given the lack of records at the time of her cerebrovascular accident at . their recommendations were to use risperdal p.r.n. for agitation. a repeat ct scan on showed no changes to the left frontal encephalomalacia and right periventricular low attenuation areas. this was performed because the patient had a rather dense right hemiparesis which was out of proportion to her weakness before being sent to the medical intensive care unit. thereafter, the patient had improved right upper extremity activity. however, the neurology service was consulted for their opinion whether a silent cerebrovascular accident versus exacerbated old cerebrovascular accident might be responsible. they felt that problem was primarily neuropathic, as her hemiparesis was flaccid. electromyograms were performed on . the initial read showed no demyelinating. however, they could not do a myelogram and the procedure was terminated early because of patient discomfort and her right side was not checked. only the left upper extremity was done. a nerve biopsy was considered, however, because it was unlikely that we would find a treatable cause of neuropathy and wanted to avoid the risk to the patient of the wound. this was deferred. this may be pursued if she fails to improve at rehabilitation. at the time of discharge, the patient had improving function of her right sided weakness. 11. prophylaxis: prophylaxis was with prevacid and pneumoboots and then heparin after her peg was secured. coumadin was added for pulmonary embolus. prevacid was later changed to protonix, as this was less deliriogenic; however, it was changed back to prevacid because protonix could not be crushed. condition on discharge: stable. discharge status: full code. discharge medications: zantac 150 mg by peg b.i.d. captopril 50 mg by peg t.i.d. colace 100 mg by peg b.i.d. synthroid 150 mcg by peg q.d. lopressor 100 mg by peg t.i.d. vitamin c 500 mg by peg b.i.d. zinc sulfate 220 mg by peg q.d. reglan 10 mg by peg every six hours. miconazole cream to groin p.r.n. serzone 50 mg p.o. q.a.m. and 100 mg p.o. h.s. risperdal 0.5 mg by peg t.i.d. p.r.n. for agitation. ativan 0.5 to 1 mg by peg t.i.d. p.r.n. for anxiety. senna two tablets by peg q.d. p.r.n. tylenol 650 mg by peg every four to six hours p.r.n. hydralazine 10 mg intravenous every four to six hours p.r.n. for hypertension. milk of magnesia 15 to 30 cc by peg every six hours p.r.n. ditropan 5 mg p.o. b.i.d. promote with fiber 65 cc/hour. amiodarone 200 mg b.i.d. to change to 200 mg q.d. on . coumadin 5 mg p.o. h.s. with monitoring of inr and dose adjustment. lovenox 65 mg subcutaneous b.i.d. until inr is 2.3, then discontinued. dressing changes to left wrist: cleanse with normal saline, apply a thin layer of duoderm, a moist dressing with normal saline, a dry sterile dressing and then kling wrap without tape, as the patient had tape injuries in the past; perform dressing changes b.i.d. discharge diagnoses: 1. neck hematoma secondary to thyroid hemorrhage, requiring intubation. 2. resultant pneumonia, possibly with methicillin resistant staphylococcus aureus. 3. methicillin resistant staphylococcus aureus bacteremia while in the medical intensive care unit. . exacerbation of chronic neuropathy. 5. status post peg. 6. see also the past medical history. follow up: the patient is to follow up with dr. , who will see her at rehabilitation. , m.d. dictated by: medquist36 procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] transfusion of packed cells diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified other pulmonary insufficiency, not elsewhere classified hematoma complicating a procedure other specified conduction disorders pneumonitis due to inhalation of food or vomitus bacteremia other pulmonary embolism and infarction polycythemia vera 

Answer: The patient is high likely exposed to