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: patient is a 79 year old female with multiple medical problems including coronary artery disease, type-2 diabetes, hypertension, a remote history of breast cancer 28 years ago, atrial fibrillation who transferred from an outside hospital ( hospital) to for management of her recurrent pleural effusion. patient reported that she began being diagnosed with effusions about one year ago, however, did not develop shortness of breath until . she noted that she had dyspnea on exertion, that has been gradually worsening. she denied any cough or chest pain. she denied any orthopnea. she had undergone paracentesis three or four times prior to presentation at , and reports relief after the procedures. recently, the patient was at hospital with a gastrointestinal bleed and hematocrit down to 16. during that admission, she had a thoracentesis which drained 1800 cc of fluid. she was discharged on and returned on because her shortness of breath had not resolved, however, it was not any worse than it was on the discharge. per the note, patient had oxygen saturation of 80 percent in the ambulance on the way to . in the outside hospital she had oxygen saturations of 96 to 99 percent on one liter. she was then transferred to for possible pleurax catheter placement and management of this recurrent effusion. past medical history: 1. sick sinus syndrome, status post pacer placement in . 2. hypothyroidism. 3. hypertension. 4. diabetes mellitus type-2. 5. cerebrovascular accident in . 6. atrial fibrillation. 7. coronary artery disease, status post myocardial infarction . 8. congestive heart failure. 9. gastrointestinal bleed with a hematocrit down to 16 at the hospital. 10. breast cancer, status post a right mastectomy 28 years ago and radiation therapy. 11. bilateral pleural effusions. 12. hypercholesterolemia. 13. osteoporosis. 14. chronic right arm lymphedema. 15. anxiety. 16. chronic obstructive pulmonary disease. 17. multiple thoracenteses including one on (1500 cc), (1500 cc), and (1800 cc), all of which were transudative. 18. left ankle fracture. admission medications: 1. protonix 40 mg p.o. once daily. 2. xanax 5 mg p.o. twice a day, 1 mg p.o. q. h.s. 3. potassium chloride 20 meq once daily. 4. lasix 20 mg once daily. 5. synthroid 0.088 mg p.o. once daily. 6. multivitamin once daily. 7. atenolol 25 mg p.o. once daily. 8. diovan 160 mg p.o. once daily. 9. aspirin 81 mg p.o. once daily. 10. iron sulfate 325 mg p.o. once daily. 11. ambien 5 mg p.o. q. h.s. 12. glyburide 10 mg p.o. q. a.m. and 5 mg p.o. q noon. allergies: no known drug allergies. social history: patient quit smoking one pack per day 35 years ago, denies any alcohol use, and lives with her husband. family history: noncontributory. physical examination: vital signs: on admission, temperature 97.5, heart rate 66, blood pressure 151/45, respiratory rate 26, oxygen saturation 96 percent on two liters of oxygen by nasal cannula. general: patient is a pleasant female in no acute distress, alert and oriented times three. heent: patient had pupils equal, round, and reactive to light, extraocular muscles were intact, mucus membranes moist. neck: no jugular venous distention, no lymphadenopathy, supple. lungs: decreased breath sounds two-thirds of the way on the right, at the left base, positive dullness to percussion. cardiac: irregularly irregular rhythm, no murmurs, rubs, or gallops. abdomen: soft, nontender, obese, nondistended, positive bowel sounds. extremities: trace left ankle edema, 2+ pedal pulses. neurological: alert and oriented times three, cranial nerves ii-xii intact. rectal: guaiac negative. laboratory values on admission: cbc - white blood cell count 11.9, hematocrit 30.5, platelets 347 with 77 percent neutrophils and 10 percent lymphocytes. electrolytes and renals are as follows: sodium 141, potassium 4.9, chloride 107, bicarbonate 25, bun 33, creatinine 1.4, glucose 156, calcium 8.6, phosphorus 3.6, magnesium 2.3. liver function tests as follows: alt 35, ast 38, ldl 299, albumin 3.2, alkaline phosphatase 85, total bilirubin 0.1, inr 1.1. chest x-ray on admission: large right-sided pleural effusion, no left-sided effusion, shifted trachea. ekg patient is paced. impression: patient is a 79 year old female with a history of coronary artery disease, atrial fibrillation, hypertension, cerebrovascular accident, gastrointestinal bleed, recurrent pleural effusions, and a remote history of breast cancer presenting for symptomatic treatment of her recurrent right-sided pleural effusion. hospitalization course by system: 1. pulmonary: patient underwent a therapeutic thoracentesis on which was consistent with a transudate and revealed 222 white blood cells, 2,000 red blood cells, 11 percent polys, 72 percent lymphocytes, total protein of 2.0, glucose 152, ld 114, amylase 56, albumin 1.2, triglycerides 18. serum albumin was 3.3 and ld was 338. cultures were collected but not evaluated due to laboratory error. patient underwent serial evaluations of her effusion via chest x-ray and repeat x-rays on and revealed increasing in the size of the right-sided effusion. patient initially required oxygen of about four liters, and decreased her oxygen requirements down to one liter with oxygen saturations of 99 percent by the time of discharge. patient was evaluated by interventional pulmonology who planned to insert a permanent pleurax catheter for self draining to prevent future recurrence of the effusion. however, this procedure was deferred to the day of discharge as the patient developed chest pain and underwent a cardiac workup as listed below. the cause of the effusion remained unknown. it was unlikely due to recurrence of malignancy as the patient has had no other signs or symptoms or laboratory evidence of malignancy. an ultrasound of the liver and gallbladder was performed to see if the changes were consistent with cirrhosis which could be a contributing etiology. however, this study was negative for any such change. an infectious etiology was also considered and therefore the patient was placed on prophylactic antibiotics for perhaps an underlying pneumonia. congestive heart failure was also a possible etiology and therefore an echocardiogram was repeated which was consistent with right ventricular dysfunction, pulmonary hypertension, and mild mitral regurgitation, mild left atrial dilatation with an ejection fraction of 50 percent, but not consistent with florid congestive heart failure. lymphatic syndrome was also unlikely given the patient's albumin. lymphedema was also entertained as a possibility, however, this would be an unusual cause of the effusion given the remote history of cancer nearly 30 years ago. patient continued to improve symptomatically, particularly after the pleurax catheter was placed and she was instructed on how to use this catheter as an outpatient. 2. cardiovascular: the patient has history of atrial fibrillation. however, coumadin was held for an inr of 5.0 and a recent history of gastrointestinal bleed. the coumadin will need to be restarted as an outpatient, and one might want to consider rhythm control with digoxin. the patient was also maintained on aspirin and later plavix was started for anticoagulation. on , the patient was evaluated multiple times for chest pain and shortness of breath. she had a troponin of 0.5, 0.46, 0.56 with ck values of 86, 72, 98. at the outside hospital, the patient has had a troponin level of 0.1 to 0.23. ekg changes were very nonspecific. the patient was treated for her symptoms with an aspirin, beta blocker, nitroglycerin, oxygen. however, due to her recent gastrointestinal bleed, iv heparin could not be started. it was thought that the patient underwent a non-st elevation myocardial infarction at that point. an echocardiogram on showed right ventricular dysfunction, pulmonary hypertension, mild mitral regurgitation, and mild left atrial dilatation with an ejection fraction of 50 percent. on the patient underwent serial cardiac enzymes one more time, again for development of chest pain symptoms. since that point, the troponin levels are 0.47, 0.48, 0.50, 0.51 with ck values of 79, 72, 70, 60. again, the ekg remained stable. due to these continual symptoms and is suspected non-st elevation myocardial infarction, the patient underwent a persantine stress test on . during this test, the patient had no anginal symptoms, and no st segment changes. the patient had an ejection fraction of 51 percent with hypokinesis of the inferior wall, a fixed lateral inferior wall defect, a defect to the inferior portion of the lateral wall with slight reversibility, moderate left ventricular cavity defect with lateral inferior wall defect. patient was also begun on aldactone and lasix during her stay for possible congestive heart failure. she diuresed well with stabilization of her electrolytes and relief of her symptoms of shortness of breath. patient's blood pressure was well controlled with metoprolol which has been increased to 75 mg p.o. twice a day at the time of this dictation. 3. fluid, electrolytes, nutrition/gastroenterology: patient was status post a gastrointestinal bleed recorded on . an esophagogastroduodenoscopy at the outside hospital was consistent with a hiatal hernia, gastritis, an inflamed duodenal bulb, but no active bleeding. patient underwent an ultrasound of the gallbladder and liver on which showed a normal liver, gallbladder, pancreas, and kidneys and a large right-sided pleural effusion. patient also developed nausea on which was relieved with zofran. electrolytes remained stable throughout the stay and were repleted accordingly. an elevated potassium on was treated with kayexalate. the patient initially had guaiac positive stools, however, these went into negative a few days prior to discharge. protonix was continued, 40 mg p.o. twice a day, for the patient's recent gastrointestinal bleed and gastritis. she also developed diarrhea on , and c-difficile was negative. h. pylori was also checked and was negative. 4. genitourinary: the patient had a urinary tract infection on admission, and this was treated with levofloxacin for a total of seven days. this was discontinued on day seven, . 5. hypothyroidism: patient had an elevated tsh of 5.5, but a normal free t4. the synthroid dose was not increased or changed during this admission as it was believed the abnormal tsh could be due to euthyroid sick syndrome. 6. diabetes mellitus: the patient was maintained on sliding scale insulin throughout her stay. she had several episodes of hypoglycemia which were treated with juice and an amp of dextrose as needed. her glyburide was decreased to 2.5 mg p.o. twice a day due to increasing renal dysfunction and rising creatinine. the patient had a hemoglobin-a1c of 5.4 on this admission. 7. renal: patient was found to have a baseline creatinine of about 1.5. the cause of her chronic renal insufficiency was not known. her creatinine had decreased to 1.4 or essentially remained stable throughout admission. 8. anemia: patient was initially anemic with an hematocrit of 28 with the outside hospital and 30.5 at our hospital. she did not undergo a transfusion. however, she was started on epogen 40,000 units subq times one, and responded nicely with an increased hematocrit to 34. the patient should continue on 20,000 units of epogen q week q friday after this admission. patient was also started on feso4 on . patient also had hemolysis laboratory, vitamin b-12, ferritin levels drawn, all of which were within normal limits. 9. psychiatric: patient had symptoms of anxiety. these were eventually controlled using lorazepam p.o. q. h.s. p.r.n. and the patient's home dose of xanax p.o. q. h.s. 10. hypercholesterolemia: the patient had a triglyceride of 120, hdl 51, ldl 81. she was started on lipitor 20 mg p.o. once daily given her history of hypercholesterolemia. condition on discharge: good. discharge status: rehabilitation facility at , in . discharge diagnoses: 1. recurrent pleural effusions. 2. non-st elevation myocardial infarction. 3. anemia. 4. hypothyroidism. 5. anxiety. 6. urinary tract infection. discharge medications: 1. multivitamin p.o. once daily. 2, valsartan 160 mg p.o. once daily. 3. levothyroxine sodium 88 mcg p.o. once daily. 4. protonix 40 mg p.o. twice a day. 5. spironolactone 25 mg p.o. once daily. 6. plavix 75 mg p.o. once daily. 7. atorvastatin 20 mg p.o. once daily. 8. lorazepam 0.5 mg p.o. q. h.s. p.r.n. 9. ferrous sulfate 325 mg p.o. once daily. 10. folic acid 1 mg p.o. once daily. 11. aspirin 325 mg p.o. once daily. 12. furosemide 30 mg p.o. twice a day. 13. alprazolam 1 mg p.o. q. h.s. 14. glyburide 2.5 mg p.o. twice a day. 15. metoprolol 75 mg p.o. twice a day. 16. epoetin alfa 20,000 units subq once a week q friday. 17. insulin sliding scale. follow-up plans: patient discharged to the facility for physical therapy as well as training in the use of her pleurax catheter. , m.d. dictated by: medquist36 d: 19:45 t: 03:19 job#: procedure: insertion of intercostal catheter for drainage thoracentesis diagnoses: coronary atherosclerosis of native coronary artery unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified atrial fibrillation cardiac pacemaker in situ 

Answer: The patient is high likely exposed to