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: penicillins / erythromycin estolate / xylocaine attending: chief complaint: dyspnea major surgical or invasive procedure: none history of present illness: 71 yo woman with metastatic breast cancer to spine, femur p/w acute dyspnea. pt was in usoh until this afternoon, when she developed sudden dyspnea @ 3pm. she was not exerting herself during this period. she reports sitting in a chair at the time of onset. pt's caregiver her daughters. the pt was hesitant to go to the hospital without her daughters. however, she became progressively more dyspneic over the next hour and ems was called. of note she had recent admit for dyspnea, thought to be pna (and a possible aspiration event), treated with cefpodoxime/flagyl. . on arrival to the , pt was initially afebrile (though eventually spiked to 101.6), bp 180s/110s, hr 120s-140s, rhonchi on exam, given ntg slx1, started on nitro gtt and given lasix 40 mg iv x1 (uop 750cc). pt initially placed on bipap, but was weaned off to a nrb. however, while getting ct, as below, pt transiently required bipap, which was again taken off before being transferred to . otherwise w/u in the ed included: ekg st @128 bpm, lad, twi i, avl, std v4-6. cxr: perihilar vascular congestion, cephalization of the pulmonary vasculature. cta negative for pe or consolidation, though evidence of pulmonary edema and large bilateral pleural effusions as well as increased right hilar lymphadenopathy. ct abd showed multiple liver metastases (new since ), increasing bilateral adrenal thickening - mets vs hypertrophy, small amount of ascites, mild anasarca. ct head checked in case of the need for anti-coagulation, showed mass at r cranial vertex. labs sig for wbc 15.5, hct 32.2, plt 492, na 126, cl 87, ck 155, ck-mb 4, tpn 0.02. bnp 4491. other than nitro and lasix, pt given asa 325 mgx1, levoflox 750 mg x1, vanc 1 gm x1, tylenol 650 pr, dilaudid 1 mg x1, oxycontin 280 mg x1. past medical history: onc history: left breast cancer diagnosed in with three positive nodes and underwent lumpectomy followed by cytoxan and adriamycin. in she was diagnosed with a vetebral metastatic lesion and at the same time was also diagnosed with colorectal cancer for which she underwent excision. has also been on gemtricitabine. right pathologic proximal femur fracture s/p orif , s/p xrt -goiter with hypothyroidism -hypertension -anxiety disorder -lymphedema left arm -rectal cancer social history: lives alone with caregiver during day, former tob and etoh, 2 daughters family history: father died at 73 of coronary artery disease and mother died at 97. physical exam: temp 95.3 oral bp 122/66 pulse 82 resp 16 o2 sat 99% 6 l nc gen - anxious, but no acute distress heent - extraocular motions intact, anicteric, mucous membranes moist neck - no jvd, no cervical lymphadenopathy chest - rales throughout cv - normal s1/s2, rrr, no murmurs, rubs, or gallops abd - soft, nontender, nondistended, with normoactive bowel sounds extr - trace edema b/l. 2+ dp pulses bilaterally neuro - alert and oriented x 3 skin - no rash pertinent results: ekg st @128 bpm, lad, twi i, avl, std v4-6. . 05:30pm blood wbc-15.5*# rbc-3.42* hgb-10.3* hct-32.7* mcv-96 mch-30.1 mchc-31.4 rdw-21.4* plt ct-492*# 12:02am blood wbc-9.6 rbc-3.24* hgb-10.3* hct-30.6* mcv-94 mch-31.7 mchc-33.7 rdw-20.0* plt ct-370 05:30pm blood neuts-63 bands-4 lymphs-13* monos-18* eos-0 baso-0 atyps-1* metas-0 myelos-1* 04:25am blood pt-14.0* ptt-26.0 inr(pt)-1.2* 05:30pm blood glucose-252* urean-9 creat-0.8 na-126* k-4.4 cl-87* hco3-24 angap-19 12:02am blood glucose-137* urean-16 creat-0.7 na-127* k-4.4 cl-89* hco3-26 angap-16 12:02am blood glucose-137* urean-16 creat-0.7 na-127* k-4.4 cl-89* hco3-26 angap-16 05:30pm blood ck(cpk)-155* 12:03am blood alt-13 ast-81* ck(cpk)-215* alkphos-348* amylase-30 totbili-0.3 04:25am blood ck(cpk)-178* 12:03am blood lipase-9 05:30pm blood ck-mb-4 probnp-4491* 05:30pm blood ctropnt-0.02* 12:03am blood ck-mb-8 ctropnt-0.18* 04:25am blood ck-mb-8 ctropnt-0.16* 02:28am blood calcium-9.3 phos-3.9 mg-2.4 12:04am blood calcium-8.7 phos-3.7 mg-2.4 cholest-190 12:02am blood calcium-9.3 phos-3.5 mg-2.3 12:04am blood triglyc-132 hdl-60 chol/hd-3.2 ldlcalc-104 05:41am blood osmolal-259* 04:25am blood cea-29* 12:03am blood ca27.29-77* 05:42pm blood lactate-2.5* 01:10am blood lactate-1.3 . ct head w/o contrast: non-contrast head ct: there is a hyperdense ill-defined 3.2 x 1.9 cm mass at the right frontovertex that appears to be extra-axial in location with slight mass effect on the subjacent cortex and minimal subfalcine herniation (approximately 5 mm of midline shift). no other intracranial mass is identified. - matter differentiation is preserved and there is no evidence of acute hemorrhage or major vascular territorial infarct. no hydrocephalus. a 1 cm destructive osseous lesion at the right frontal calvarium is seen (2:11), likely a metastasis. there is also a well-defined lytic lesion of the left parietal calvarium, at the vertex (2:26) which may represent a prominent arachnoid granulation, or could represent metastasis in this patient with extensive metastatic breast cancer. the visualized paranasal sinuses and mastoid air cells are clear. impression: 1. hyperdense extra-axial mass at the right cranial vertex may represent dural metastasis or meningioma. there is minimal mass effect and 5 mm of subfalcine herniation. no evidence of intracranial hemorrhage or major vascular territorial infarct. 2. destructive osseous lesion at the right frontal calvarium is likely a metastatic lesion. 3. possible metastasis versus prominent arachnoid granulation at the left parietal vertex. findings were conveyed to the ed dashboard at the time of the exam, and discussed with the micu team. note added in attending review: unusual constellation of findings, as above. given the known extensive metastatic disease, including epidural involvement in the lumbar spine, the right craniovertex extra-axial lesion, which crosses the midline and may breach the superior sagittal sinus, likely represents a dural metastasis. however, incidental meningioma remains a possibility as these may occur with increased frequency in patients with breast cancer. the well-defined, scalloped left parietovertex lesion is most suggestive of an incidental "giant" pacchionian (arachnoid) granulation. the lytic "punched out" lesion, in the region of the right pterion, has a most unusual appearance. this includes peripheral low-attenuation (measuring negative , suggestive of fat) as well as central stippled calcification or ossification, with no associated soft tissue component. this could represent an unrelated hemangioma or, less likely (given the calcification), epidermoid. however, lytic breast metastasis with residual bone fragments, remains a concern. if further evaluation is necessary (unclear, given current clinical scenario), comparison with any previous cross-sectional study, as well as mri (including post-contrast, fat-suppressed sequences) may be of help. . cta and ct torso technique: multidetector helical scanning of the chest, abdomen and pelvis was performed prior to and following the administration of iv contrast (130 cc iv optiray). coronal, sagittal and multiple oblique reformats were performed of the chest as well as coronal and sagittal reformats of the abdomen and pelvis. cta of the chest: there is no evidence of pulmonary embolism. the heart is moderately enlarged with no evidence of pericardial effusion. there is no evidence of aortic dissection. large mediastinal and hilar lymph nodes are noted including a 2 x 2.7 cm pretracheal lymph node (3a:29), and two right hilar lymph nodes measuring up to 1.5 cm each. the bronchi are patent to the subsegmental level. diffuse perivascular ground-glass opacification of the lungs is consistent with pulmonary edema. there are moderate bilateral pleural effusions, measuring simple fluid density, with associated atelectasis. no definite consolidations are seen. geographic airspace opacity along the left upper lobe is relatively unchanged since and consistent with post-radiation changes. no pathologically enlarged axillary lymph nodes are seen. ct of the abdomen: multiple enhancing masses are seen within the liver, new since and consistent with metastases from patient's known metastatic breast cancer. the largest lesions include a 3 x 2.5 cm lesion in the right lobe (3b:107). a 2.7 x 2.5 cm lesion of the inferior and posterior aspect of the right lobe (3b:123) and an ill-defined 3 x 3 cm lesion in the inferior aspect of the left lobe (3b:116). the adrenal glands are thickened bilaterally, increased since , also concerning for metastases. the spleen, pancreas and gallbladder are unremarkable. a non-enhancing exophytic cyst of the left kidney is again noted. the kidneys enhance and excrete contrast normally. the aorta is of normal caliber throughout. intra- abdominal small and large bowel loops are unremarkable. increased stranding within the mesentery and soft tissues consistent with anasarca. duodenal diverticulum is again noted. ct of the pelvis: the patient is status post sigmoid resection. post-surgical changes of the anastomotic site are stable with no extraluminal air identified. this area is not well distended to evaluate for recurrence. no free fluid or lymphadenopathy within the pelvis. foley catheter is seen within the bladder. bone windows: again seen are diffuse sclerotic metastases throughout the lumbar spine and pelvis with a stable l1 compression fracture status post vertebroplasty. multiplanar reformats confirm the above findings. impression: 1. no evidence of pulmonary embolism. 2. moderate pulmonary edema and bilateral pleural effusions. 3. increasing mediastinal and right hilar lymphadenopathy. 4. stable radiation changes in the left upper lobe. 5. progression of disease with new liver metastases and bilateral adrenal enlargement suggestive of metastasis. 6. diffuse osseous metastases with no evidence of new fractures. 7. anasarca. . cxr findings: the patient is in lordotic and slightly leftward rotated position. a right central venous catheter is identified with tip overlying the expected region of the distal svc. there is mild cephalization of the pulmonary vasculature which may be consistent with mild pulmonary edema. there is a stable appearing dextroscoliosis of the thoracolumbar spine. there is a right-sided pleural effusion which is unchanged in size. there is no evidence of a right pleural effusion. the sclerotic appearance of several lower thoracic vertebral body is stable corresponding to sclerotic metastasis on prior studies. impression: 1. perihilar congestion and cephalization of the pulmonary vasculature consistent with congestive heart failure. 2. blunting of the left costophrenic angle is consistent with either effusion or atelectasis and is stable. 3. again identified is sclerotic foci and vertebroplasty material from patient's known metastatic disease to the spine. . cxr moderately severe pulmonary edema and small-to-moderate pleural effusions, right greater than left, have increased since . mild cardiac enlargement has increased. tip of the right subclavian line projects over the superior cavoatrial junction. no pneumothorax. . mri brain head mri technique: multiplanar t1, t2, diffusion-weighted, and post-gadolinium sequences were obtained. findings: an 8 x 9 mm ring-enhancing lesion is present within the right occipital lobe with an adjacent 9 x 10 mm more homogeneously enhancing lesion within the left occipital lobe, both consistent with metastatic disease. additionally, a previously identified dural-based mass, predominantly located at the cranial right-sided vertex with midline extension to involve the left- sided vertex appears to have mild amount of homogeneous enhancement in association with thickening of the dura and dural enhancement, also suggestive of a dural metastatic lesion. two osseous lesions, one within the inner table of the right frontal bone with extension to an extradural location and the second within the posterior high vertex of the parietal bone with inner table erosion and adural extension are also likely consistent with osseous metastatic disease. increased t2 and flair signal abnormalities within the cerebral periventricular deep matter are compatible with chronic small vessel infarction. there is no evidence of hydrocephalus, shift of normally midline structures, or acute infarct. no abnormal areas of restricted diffusion are identified surrounding the parenchymal lesions. there is mild mucosal thickening of the maxillary sinuses bilaterally, likely inflammatory in origin. impression: findings most consistent with bilateral occipital, subdural, and osseous right frontal and left parietal metastatic lesions. coincident meningiomas accounting for the vertex dural lesions is an alternative diagnosis. . mri spine: findings: there are areas of low signal identified predominantly in c2, c4, c5, t1, t2, and t3 vertebral bodies indicative of sclerotic metastasis. there is no evidence of spinal cord compression or epidural mass identified. there is no evidence of intrinsic spinal cord signal abnormalities. multilevel degenerative changes are seen from c3-4 to c6-7 without spinal stenosis. impression: sclerotic metastatic disease in the visualized cervical vertebral bodies without epidural mass or spinal cord compression. no evidence of intrinsic spinal cord signal abnormalities. thoracic spine: technique: t1, t2 and inversion recovery sagittal and t2 axial images of the thoracic spine were obtained. comparison was made with the previous mri examination of . findings: again diffuse sclerotic metastasis is seen in the thoracic vertebral bodies. as seen on the previous lumbar spine mri of , there is a pathologic fracture of l1 vertebra visualized with retropulsion. there is mild spinal stenosis seen at that level. in the thoracic region at t9 and t10 level, mild epidural soft tissue changes are seen with mild-to-moderate spinal stenosis. there is no obvious spinal cord compression seen on the t2 axial images, however. there is no evidence of intrinsic spinal cord signal abnormalities seen. impression: bony metastatic disease with low signal intensities indicative of sclerosis. chronic pathologic fracture of l1 with retropulsion and mild spinal stenosis which appears to be secondary to epidural disease at t9 and t10 level which can be better evaluated with gadolinium-enhanced mri if clinically indicated. no spinal cord compression seen. . echo: conclusions: the left atrium is mildly dilated. the estimated right atrial pressure is 0-5mmhg. left ventricular wall thickness and cavity size are normal. there is focal hypokinesis of the distal half of the inferior wall. the remaining segments contract well. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , new regional left ventricular systolic dysfunction is now seen c/w cad and the severity of mitral regurgitation has increased. the estimated pulmonary artery systolic pressure is lower. a large left pleural effusion is similar (was present but not reported). clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. brief hospital course: a/p: 71 yo woman with metastatic breast cancer to spine, femur p/w acute dyspnea . dyspnea: pt with evidence of pulmonary edema on exam/imaging, responsive to nitro gtt in the ed. elevated bnp. no evidence of pe despite risk factors. no clear pna but underlying parenchymal changes, fever, bandemia. in regards to trigger for flash pulm edema, ces positive for nstemi with rate related changes on ecg. no baseline lv dysfunction or valvular disease on recent echo but new murmur concerning for mr. appeared to occur in setting of significant htn, ? related to medication effect (missed toprolxl, recently started on ritalin). - her dyspnea had resolved by discharge. it appeared to have been caused by ? flash pulmonary edema in the setting of hypertension and nstemi. unclear which precipitated which but her blood pressure was well-controlled on dishcarged and she had no further episodes while in-house. . nstemi: troponin elevated but trending down, at risk for cad given left chest wall xrt, h/o hypertension. not a candidate for heparin/iibiiia inhibitors given cns pathology. started on aspirin, continued on beta blockade, nitro gtt overnight. nitro gtt stopped prior to transfer from icu to omed. - she was continued on metoprolol and this was increased w/ goal hr < 70 - lisinopril was also started prior to d/c - dr. was emailed and she will follow-up with him as an outpatient . htn: have missed her toprol dose on the day of admission. bp initially controlled with nitro gtt but this was weaned before she was transferred to omed and her bp was well-controlled w/ toprol and the additional of lisinopril. . leukocytosis/fever: ? pulm source, no other localizing s/s. blood sent/urine sent and negative. cont levoflox for empiric 7 day course (day 1=). also given new mr murmur and indwelling portacath concern for endocarditis, she had a tte that was not concerning for endocarditis although it did show slightly worsened mr. . metastatic breast ca: recently began treatment with velban . now with evidence on imaging concerning for mets to head, new mets to liver and elsewhere in abd. she was given the news of the spread of her disease and an mri was performed of her brain and spine. she started whole brain radiation while inpatient () and will continue this as an outpatient per dr. . - prednisone taper per dr. . . s/p orif of right pathologic femur fracture: pt recently discharged home from rehab. has been ambulating with walker. plan for ortho f/u as out-pt. c/s pt/ot. . hypothyroidism: cont home synthroid . anxiety: cont home ativan . ppx: ppi, br, pneumoboots, holding heparin given brain mets . fen: hh diet, replete lytes . acccess: piv, port . comm: daughter /hcp, (work)/ (cell) . full code medications on admission: oxycontin 280 mg q8h. oxycodone 20 mg - 30 mg q3h. p.r.n. colace prn senna prn ativan 1 mg q4h prn ritalin 2.5 mg daily levothyroxine 25 mcg daily ibuprofen prn sertraline 50 mg daily toprol 12.5 mg daily omeprazole 20 mg daily discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. oxycodone 40 mg tablet sustained release 12 hr sig: seven (7) tablet sustained release 12 hr po q8h (every 8 hours). 3. oxycodone 5 mg tablet sig: 20-30 mg po q3h (every 3 hours) as needed for pain. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. lorazepam 0.5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for anxiety or insomnia. disp:*30 tablet(s)* refills:*0* 7. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. disp:*90 tablet(s)* refills:*2* 8. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 9. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). disp:*30 tablet sustained release 24 hr(s)* refills:*2* 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 11. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 12. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 13. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 2 days. disp:*2 tablet(s)* refills:*0* 14. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for heartburn. 15. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*2* 16. dexamethasone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours): through , then 1 tab 3 times per day through , then 1 tab 2 times per day through then per dr. . disp:*100 tablet(s)* refills:*0* 17. albuterol-ipratropium 103-18 mcg/actuation aerosol sig: inhalation every six (6) hours as needed for shortness of breath or wheezing. disp:*1 inh* refills:*0* 18. lidoderm 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) patch topical once a day: place patch, remove after 12 hours. wait 12 hours before placing the next patch. disp:*30 patches* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: nstemi pulmonary edema htn urinary tract infection siadh metastatic breast cancer hypothyroidism anxiety discharge condition: hemodynamically stable. ambulatory with a walker. discharge instructions: you were admitted with shortness of breath from pulmonary edema. the pulmonary edema was likely caused by high blood pressure, a small heart attack and worsening of your mitral valve function. it is very important that you have good blood pressure control (goal <120/80). you should also follow a low-fat, low cholesterol, low-salt diet. . please seek medical attention immediately if you develop fever, chills, nausea, vomiting, shortness of breath, chest pain or any other concerning symptoms. . we made some changes to your medicines. we stopped your ritalin. we increased your toprol dose to 25 mg per day. we added a blood pressure medication call lisinopril to your regimen. you will take an antibiotic called levofloxacin for two more days. a steroid was added to your regimen for the lesions in your brain. please follow the schedule that we have written out for you on how to take the steroids. we added a lidoderm patch to your regimen for your pain. we gave you an inhaler to use when you have shortness of breath. followup instructions: 1) you are scheduled to have radiation therapy on and at 10:00 am. dr. . tel (. . 2) you have an appointment w/ dr. (neuro-oncology) on at 2:00 pm. tel (. . 3) you have an appointment with dr. (cardiology) on at 10:40 am. tel (. . then following appointments are already scheduled for you: provider: , : date/time: 10:00. this appointment will also be with oncologist dr. . provider: , rn phone: date/time: 10:30 procedure: transfusion of packed cells diagnoses: pneumonia, organism unspecified subendocardial infarction, initial episode of care malignant neoplasm of liver, secondary urinary tract infection, site not specified congestive heart failure, unspecified unspecified essential hypertension unspecified acquired hypothyroidism personal history of malignant neoplasm of breast anxiety state, unspecified secondary malignant neoplasm of brain and spinal cord pressure ulcer, lower back acute diastolic heart failure other disorders of neurohypophysis secondary malignant neoplasm of bone and bone marrow personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus 

Answer: The patient is high likely exposed to