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: cool and painful right foot major surgical or invasive procedure: - rle cfa/ thrombectomy, fasciotomy and aortic stent placement - pericardiocentesis (apical approach) - left vats and pericardial window creation history of present illness: ms. is a 49y/o lady with recurrent breast cancer metastatic to liver/bone/stomach/likely lung, complicated by recurrent left pleural effusions s/p pleurex catheter placement , and also right-sided pe 1 month ago now on lovenox, who was transferred from an osh due to arterial thrombus, is now s/p thrombectomy, and is transferred to the ccu s/p pericardiocentesis after being incidentally found to have pericardial effusion with tte evidence of tamponade. the patient originally presented to hospital on with about 10 hrs of coolness and pain in her r foot that started about 10 pm the night before. the pain originated in her thigh but then travelled down to the dorsum of her right foot where it persisted prior to admission. the pain is not worsened by walking but is alleviated by pain medication and rest and she denies symptoms of claudication, leg swelling, or rest pain in the past. osh arterial duplex was performed at lgh that by report demonstrated no flow in the right dp, with a monophasic pt. she was started on a heparin drip (with bolus) and transferred here for further management. of note the patient reports baseline doe since and denies chest pain, palpitation, fevers, or chills. while here, she was evaluated by vascular surgery and taken to the or for rle cfa/ thrombectomy, fasciotomy and aortic stent placement. imaging revealed a pericardial effusion so cardiology was consulted. pulsus was 6 but tte showed evidence of tamponade physiology so she was taken to the cath lab for pericardiocentesis (apical approach). removed 475cc bloody fluid, mean pericardial pressure was 17. drain is in place. tte showed residual fluid, no tamponade. on arrival to the icu, patient is in pain from the groin site where the procedure took place earlier. feels tired but no other major complaints. review of systems (+): mild doe recently, after walking a few blocks. ongoing poor appetite and fatigue. (-): no prior history of stroke, tia, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: past medical history: breast cancer metastatic to bone, liver, stomach, and likely lung -recurrent l sided pleural effusions -s/p repeated drainage and l pleural catheter placement -treated with xeloda and tykerb, but recently stopped xeloda -oncologist (dr. at lgh) planned to institute new regimen next monday rt-sided pe one month ago, on lovenox past surgical history: r mastectomy b/l oophorectomy c-section social history: -home: she is recently widowed and lives at home with her daughter and son, who is autistic. -occupation: she has been unemployed since her cancer recurred. -tobacco: quit smoking about 15 yrs ago and smoked only 3 cigarettes/week before that. -etoh: none. -illicits: none. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: admission physical examination: vs: tcurrent: 37.7 ??????c (99.8 ??????f) hr: 79 (79 - 87) bpm bp: 111/59(79) {111/58(78) - 114/59(80)} mmhg rr: 19 (17 - 22) insp/min spo2: 94% general: tired-appearing lady in no respiratory distress. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. dry mm. neck: supple with no jvd. cardiac: s1 and s2, no murmur, no rub, no muffled heart sounds. chest: pericardial drain in placed draining small amount of bloody fluid lungs: cta anteriorly, no rhonchi/wheezing abdomen: soft, ntnd. no tenderness. no masses. extremities: rle is wrapped in ace bandage; lle with 1+ dp and pt pulses, rle warm with no palpable pulses but dopplerable dp pulse discharge vs: 98.1 92/54 72 18 98%ra general: tired-appearing lady in no respiratory distress. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. dry mm. neck: supple with no jvd. rt. ij site bandaged, no bleeeding, swelling, tenderness, erythema. cardiac: s1 and s2, no murmur, no rub, no muffled heart sounds. chest: cta anteriorly, no rhonchi/wheezing. left pleurex catheter in place. vats site bandaged with sutures, no leakage, heamtoma, tenderness. abdomen: soft, ntnd. no tenderness. no masses. extremities: rle is wrapped in ace bandage, fascotomy sites sutured, minimal pedal edema; lle with 1+ dp and pt pulses, rle warm with no palpable pulses but dopplerable dp pulse pertinent results: admission labs: 12:15am blood wbc-7.3 rbc-3.73* hgb-12.1 hct-37.9 mcv-102* mch-32.4* mchc-31.9 rdw-19.1* plt ct-223 12:15am blood neuts-66.9 lymphs-22.4 monos-7.3 eos-2.6 baso-0.8 12:15am blood pt-13.5* ptt-146.9* inr(pt)-1.3* 12:15am blood glucose-123* urean-6 creat-0.7 na-134 k-3.2* cl-103 hco3-25 angap-9 11:12am blood alt-21 ast-40 alkphos-98 11:12am blood ck-mb-2 ctropnt-<0.01 11:12am blood calcium-7.9* phos-2.9 mg-1.8 discharge labs: 07:00am blood wbc-4.9 rbc-3.18* hgb-9.7* hct-30.8* mcv-97 mch-30.5 mchc-31.6 rdw-18.0* plt ct-206 09:05am blood neuts-94* bands-0 lymphs-6* monos-0 eos-0 baso-0 atyps-0 metas-0 myelos-0 09:05am blood hypochr-3+ anisocy-1+ poiklo-1+ macrocy-2+ microcy-normal polychr-normal ovalocy-2+ tear dr1+ 07:00am blood plt ct-206 07:00am blood pt-13.5* ptt-35.8 inr(pt)-1.3* 07:00am blood lmwh-0.86 06:15am blood aca igg-1.5 aca igm-10.8 07:00am blood glucose-89 urean-8 creat-0.4 na-139 k-3.8 cl-107 hco3-24 angap-12 07:00am blood alt-16 ast-40 ld(ldh)-239 alkphos-285* totbili-0.4 07:00am blood albumin-1.9* calcium-7.7* phos-2.1* mg-1.9 pericardial fluid: 06:10pm other body fluid wbc-4125* hct,fl-8.5* polys-28* lymphs-25* monos-23* mesothe-10* macro-12* other-2* 06:10pm other body fluid totprot-3.9 glucose-82 ld(ldh)-299 amylase-17 albumin-2.5 studies: echo (): due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is unusually small and does not fully expand in diastole. there is a large pericardial effusion. there is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. impression: large pericardial effusion with evidence tamponade physiology. echo (): pre-pericardiocentesis (images ): large circumferential pericardial effusion. there is rv diastolic collapse consistent with tamponade physiology. saline bubble injection during pericardiocentesis (images 11,13) indicate catheter appropriately in pericardial space. post-pericardiocentesis (images 32-38): overall left ventricular systolic function is normal (lvef>55%). there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. normal global biventricular cavity size and systolic function. cta aorta/bifem/iliac runoff w impression: 1. thrombus within the distal aorta just above the bifurcation extending into the right common iliac artery with approximately 50% occlusion of the lumen. thrombus in the right anterior tibial and right posterior tibial arteries, with no opacification beyond the distal third of the leg. the posterior tibial artery is attenuated throughout its course. 2. the left pelvic and left lower extremity vasculature beyond the aortic bifurcation is widely patent. 3. large left partially loculated pleural effusion with a pleurx catheter in place and little aeration of the visualized left lobe. moderate pericardial effusion. 4. numerous hyperenhancing hepatic lesions and sclerotic bony foci, likely metastatic disease in the setting of known breast cancer. echo (): left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal and appear underfilled. there is a small circumferential pericardial effusion. no right ventricular diastolic collapse is seen. impression: suboptimal image quality. small circumferential pericardial effusion w/o echocardiographic signs of tamponade physiology. normal biventricular cavity sizes with preserved global biventricular systolic function. if clinicallly indicated, serial evaluation is suggested. echo (): left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. there is a small pericardial effusion. no right ventricular diastolic collapse is seen. impression: suboptimal image quality. small anterior pericardial effusion w/o echocardiographic signs of tamponade physiology. there is a septal bounce seen, consistent with effusive-constrictive physiology - commonly seen in the first week post pericardiocentesis. normal biventricular cavity sizes with preserved global biventricular systolic function compared with the findings of the prior study (images reviewed) of , the pericardial effusion is smaller with less fluid accumulation posteriorly. echo (): overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. there is a small pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. impression: limited study. small anterior pericardial effusion with likely cellular debris overlying the free wall of the right ventricle. no evidence of tamponade. septal bounce, consistent with effusive-constrictive physiology post pericardiocentesis. normal biventricular systolic function. compared with the prior study (images reviewed) of , the findings are similar. pericardial biopsy : pericardium (a): poorly differentiated carcinoma consistent with breast origin, (see note). note: the carcinoma is positive for ck7, mammoglobin, and very focally for progesterone receptor and negative for ck20, ttf-1, gcdfp and estrogen receptor. cxr indings: in comparison with the study of , there is no evidence of pneumothorax. subcutaneous gas is seen along the left lower chest and upper abdomen wall. the apparent engorgement of pulmonary vessels on the previous study has substantially decreased. retrocardiac opacification is consistent with volume loss in the lower lobe. brief hospital course: brief patient summary: ms. is a 49 y/o lady with metastatic breast cancer who presented with cold right foot, now s/p intervention for arterial thrombus who was found to have pericardial effusion with tamponade for which she is s/p pericardiocentesis. active issues: #. pericardial effusion: the patient presented with evidence of a pericardial effusion with evidence of tamponade physiology on echo. patient is s/p pericardiocentesis with no current evidence of tamponade. the patient had pericardial drain removed on . pericardial fluid analysis revealed no bacteria on gram stain and no growth on culture. repeat tte after removal of drain, performed on , demonstrated no significant increase in pericardial fluid. however, effusion then re-accumulated. patient had pericardial window in the or by thoracic surgery team on . a pericardial drain was placed, and subsequently removed once drainage had decreased and patient was stable on anticoagulation. the site was sutured. #. left pleural effusion: s/p pleurx (also drained 1l on ). we appreciated thoracic surgery recs. pleurx was intermittently drained throughout hospitalization. #. right arterial thrombus: she is now s/p r groin/ cutdown, aortic stent, rle thrombectomy, and 4 compartment fasciotomies. her malignancy makes her hypercoagulable, but the fact that she developed an arterial thrombus while on lovenox is difficult. vascular surgery is following very closely. vascular surgery will decide upon outpatient anticoagulation regimen. we continued patient on heparin gtt (goal ptt 60-80 per vascular) while on the ccu service. fasciotomy sites wtd/ with ace-wrap. nylon suture close in a few days s/p procedure. pain control was achieved with tylenol, dilaudid iv. we appreciated vascular surgery recommendations while the patient was on the ccu service. the patient's extremity is currently warm with dopplerable pulses. she was initially anticoagulated with a heparin drip, but eventually discharged on 80mg lovenox , and a factor xa level was checked after the second dose to ensure that she was therapeutic. #. hypotension: hypotension periodically to sbp 70s-80s, fluid responsive. likely volume depleted (poor po intake, might be 3rd spacing into pleural effusion). pain meds might have a very minimal contribution as well. it is very reassuring that she was mentating fine with no lab evidence of end-organ malperfusion. pt received multiple boluses of ivf on night of , for a total of approximately 4l fluid. in setting of hct decreasing, repleted with 2u prbcs on . # anemia: pt??????s hct on admission 37.9 --> 31.8, likely secondary to hemoconcentration on admission. pt??????s hct further dropped from 27.8 --> 24.4 night of , in the setting of receiving 3-4l ivf, and also other cell lines decreased, so now may have a component of hemodilution. no e/o bleeding (no bloody or melenic bowel movements, no overt bleeding from surgical wound) aside from small amount of bloody drainage from pericardial drain. pt w/ actively cross-matched units. received 2 units of prbcs on . hemolysis and dic labs unremarkable. #. recent pulmonary embolism: was on a heparin drip throughout ccu stay. she was on lovenox (100mg daily) as an outpatient, but she had a le arterial thrombus on lovenox (daily dosing). following discussion between hem/onc and vascular surgery, it was decided to start her on 80mg lovenox for anticoagulation, given the proven efficacy of lovenox over warfarin in cancer-associated thrombosis. factor xa level was checked and was therapeutic prior to discharge. #. breast cancer: stage iv. metastatic to bone, liver, stomach, and likely lung - recurrent left sided pleural effusions s/p repeated drainage and left pleural catheter placement . right sided pe one month ago. continued tykerb 1250mg daily initially. she was eventually transferred to the omed service and following discussion with outpatient oncologist khitrik-palchuk, she was started on a new regimen on navelbine + trastuzumab. she started the treatment inhouse and will followup with dr. to complete the cycle as an outpatient. #. depression: stable. continued home wellbutrin, celexa. had social work see patient. transitional issues: -complete cycle of navelbine+trastuzumab as an outpatient. -continue 80mg lovenox for anticoagulation. -f/u with vascular surgery for removal of rle sutures. medications on admission: home medications: lovenox 100mg sc daily tykerb 1250mg daily wellbutrin 80mg qam celexa 80mg daily oxycontin 15mg prn prilosec 20mg daily transfer medications: heparin iv sliding scale (goal ptt 60-80) tykerb *nf* (lapatinib) 1250 mg oral daily bupropion (sustained release) 100 mg po qam citalopram 80 mg po/ng daily morphine sulfate 2-4 mg iv q4h:prn pain omeprazole 20 mg po daily ondansetron 4 mg iv q8h:prn nausea vancomycin 1000 mg iv once duration: 1 doses administer 10 hrs after entering pacu. give with cefazolin unless serious beta-lactam allergy. cefazolin 2 g iv q8h duration: 2 doses administer first post-op dose hrs after entering pacu, and second (final) dose administered 10h after entering pacu discharge medications: 1. enoxaparin 80 mg/0.8 ml syringe sig: eighty (80) mg subcutaneous q12h (every 12 hours): please inject only to 70mg (or 0.7ml) subcutaneous every 12 hours. disp:*60 syringes* refills:*0* 2. bupropion hcl 100 mg tablet extended release sig: one (1) tablet extended release po qam (once a day (in the morning)). 3. citalopram 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 4. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. disp:*18 tablet(s)* refills:*0* 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 6. vinorelbine (navelbine) 35 mg iv days 1, 8 and 15. (, and ) (30 mg/m2 - dose reduced by 33% to 20 mg/m2) reason for dose reduction: recent procedure administer iv push through running iv over 6-10 minutes. use port closest to the iv bag not the patient. 7. trastuzumab 145 mg iv days 8, 15 and 22. (, and ) (2 mg/kg) maintenance dose. infuse over 30 minutes, if loading dose tolerated well. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*60 tablet(s)* refills:*0* 9. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 10. acetaminophen 500 mg tablet sig: two (2) tablet po three times a day. disp:*90 tablet(s)* refills:*0* discharge disposition: home with service facility: , discharge diagnosis: metastatic breast cancer recurrent pericardial effusion with pericardial window placement arterial thrombus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure taking care of you at the . you were transferred to hospital because you had a clot in your right lower extremity artery. the vascular surgery team removed the clot and decompressed the swelling in your leg with a fasciotomy. while you were here you were found to have fluid collected around your heart. a drain was placed to remove the fluid but it recurred so a pericardial window was cut into the lining of your heart to help the fluid drain. the fluid had cancer cells in it. you were then transferred to the oncology service for chemotherapy, and were started on navelbine and herceptin. you will need to followup with your oncologist to complete a course of this chemotherapy. your next sessions are , , and . your oncologist's office (dr ) will contact you regarding when to come in. please contact the office if you have not heard from them by the end of tomorrow. we increased your dose of lovenox to prevent you from getting further blood clots. please followup with your providers, see below. we made the following changes to your medications: started: -standing acetaminophen for pain -oxycodone for pain -senna and colace to help you move your bowels increased lovenox to 70mg twice daily. the syringes come in 80mg. you will inject 0.7ml instead of the full 0.8ml. decreased citalopram from 80mg to 40mg because there can be an interaction with your omeprazole. (the two medications combined can cause irregularities in your heart rhythm). stopped: tykerb followup instructions: name: , md specialty: primary care provider : tuesday at 1pm location: medical associates address: one parkway, , phone: name: ,md location: hematology/oncology when: at 11:45am phone: department: vascular surgery when: wednesday at 2:00 pm with: , md building: lm campus: west best parking: garage procedure: angioplasty of other non-coronary vessel(s) arteriography of femoral and other lower extremity arteries pericardiocentesis aortography incision of vessel, lower limb arteries pericardiotomy insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) closure of skin and subcutaneous tissue of other sites other endovascular procedures on other vessels injection or infusion of cancer chemotherapeutic substance incision of vessel, abdominal arteries other incision of soft tissue cranial or peripheral nerve graft insertion of one vascular stent procedure on single vessel diagnoses: anemia, unspecified malignant neoplasm of liver, secondary secondary malignant neoplasm of other specified sites personal history of malignant neoplasm of breast personal history of tobacco use depressive disorder, not elsewhere classified hypotension, unspecified do not resuscitate status secondary malignant neoplasm of lung other specified diseases of pericardium secondary malignant neoplasm of bone and bone marrow arterial embolism and thrombosis of lower extremity embolism and thrombosis of iliac artery secondary malignant neoplasm of other digestive organs and spleen cardiac tamponade personal history of pulmonary embolism malignant pleural effusion other arterial embolism and thrombosis of abdominal aorta 

Answer: The patient is high likely exposed to