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: tetracycline / tape / metal can/brush top applicat attending: chief complaint: sob major surgical or invasive procedure: bronchoscopy picc line placement history of present illness: the patient is a 64 year-old female with a pmh significant for asd repair with patch in complicated by sternal wound infection, post-op afib, and c. diff colitis; tobacco use, copd, and htn presenting with intermittent back pain and worsening sob from baseline. the back pain has been present for several weeks-it was initially intermittent and then became constant. for the last several days she has complained of increasing shortness of breath. she denies having chest pain, fever/ chills or cough. she has constant nausea, which is her baseline for several weeks. she denied any infectious contacts. she usually takes lasix for lower extremity edema but has not had worsening edema recently; however, stopped taking her lasix several days ago because of aggravation with the frequent urination. she was referred to an osh er where cxrs were obtained. on her way home from the osh er she was contact by her primary care physician who told her to go to er because her cxr was concerning for a mass in her chest. . in the ed, she was afebrile. ct chest demonstrated diffuse lad (+/- mass) and postobstructive pneumonia. this is a new finding, although there are no other ct scans in our system. her sternal wound has continued nonunion. she was seen by the ct pa who thought there was no active csurg issues. she was seen by the plastics team who also thought there were no active wound issues. she came in with a hr 170 in atrial fibrillation with st depressions in the lateral leads. cardiology was consulted who thought the paf was related to the pneumonia. she was initially rate controlled with iv diltiazem, but her home po metoprolol was not started. she received iv vancomycin and iv levofloxacin for her postobstructive pneumonia. she refused flagyl given previous history of gi side effects, but is willing to reconsider if her clinical status worsens. . on initial merit evaluation, she was in nsr with rates in the 90s. she had not received po vancomycin since ed arrival. she was restarted on home medications including nebs. per discussion with id, the antibiotics she received were acceptable. she has c.difficle infection, and she was restarted on po vancomycin. she continues to complain of mild shortness of breath, although is overall improved. she has continued nausea. she spits up white sputum. past medical history: asd now s/p gortex patch closure copd (not on home o2) sternal wound infection s/p surgery (completed course nafcillin ) hyperlipidemia c. diff colitis (current ) htn s/p appendectomy r femoral artery damage and repair (operative complication) atrial fibrillation, rate controlled, never been on coumadin (use to be on digoxin, temporarily on amiodarone in for post op af) histoplasmosis of eyes social history: retired 45 pack year smoking history, quit . no etoh or other illicits family history: nc physical exam: general: she is a chronically ill-appearing female in no acute distress. heent: unremarkable. lymphatics: she has no cervical, axillary, or supraclavicular adenopathy. heart: she has a regular rate and rhythm with no murmurs, rubs, or gallops. lungs: clear with decreased breath sounds anteriorly. she has a midline sternal scar, which is healing by secondary intention. abdomen: she has no hepatosplenomegaly, no ascites. extremities: no peripheral edema. pertinent results: studies: ecg study date of 2:40:38 am sinus rhythm with frequent atrial premature beats. compared to tracing #1 frequency of atrial premature beats has significantly increased. intervals axes rate pr qrs qt/qtc p qrs t 97 0 82 398/462 0 42 60 . cxr: impression: large region of post-obstructive consolidation in the left lung with left hilar mass. mild pulmonary edema and a small right-sided pleural effusion are seen, without overt congestive heart failure. . cta of the chest: impression: 1. no central or segmental pulmonary embolism. 2. newly apparent marked lymphadenopathy in the mediastinum with mass and/or lymphadenopathy in the left hilum, highly concerning for a left hilar neoplasm with metastatic lymph nodes. endobronchial biopsy could be performed for further evaluation. the infiltrate in the left lower lobe could represent post- obstructive consolidation, given that the bronchial obstruction of segmental lower lobe branches. small amount of loculated left pleural fluid. 3. sternal non-, with unchanged appearance of multiple sternotomy wires, and pectoralis flap. no adjacent fluid collections. . head ct: impression: normal head ct without and with contrast without evidence of hemorrhage, or masses. . tte: the left atrium and right atrium are moderately dilated. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%) right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , the severity of tricuspid regurgitation and the estimated pulmonary artery systolic pressure are reduced. no residual atrial septal defect flow identified. . ct abdomen/ pelvis with contrast: impression: 1. indeterminate 1.4 cm lesion in segment of the liver. differential includes a benign entity such as a hemangioma, though hypervascular metastasis is an important consideration. further imaging with mr recommended. 2. multiple scattered hypodense lesions in the liver, measuring smaller than 9 mm. these are also indeterminate, though it could potentially represent cysts or metastases. further imaging recommended. 3. indeterminate 14 mm left adrenal nodule. further evaluation with mr recommended. differential includes metastasis versus benign adenoma. further imaging with mr recommended. 4. further partial collapse of the left lower lobe with partially enhancing left pleural effusion. 5. 2 cm fluid collection at surgical site in right groin, likely seroma, though infection (abscess) should be considered in proper clinical setting. 5. rectal distention with stool. 6. multiple hypodense lesions in both kidneys, likely cysts. ultrasound (or mr) could evaluate this finding, though these likely represent cysts. . cxr findings: in comparison with study of , there is now almost complete opacification of the left hemithorax. although some of this may reflect pleural fluid, the shift of the mediastinum to the left indicates that most of the opacification relates to volume loss. the expanded right hemithorax shows no evidence of acute pneumonia. . mri abdomen: impression: 1. 16-mm enhancing lesion in segment iv-a of the liver along the anterior liver margin. this lesion does not have characteristics of a benign lesion. additional small 7-mm segment iv-b lesion along the anterior liver margin of similar enhancement characteristics which could also represent metastases. there are several additional foci which are too small to be characterized, for which metastases cannot be excluded. hepatic ultrasound could be performed to assess as to whether the dominant lesion is amenable to ultrasound-guided biopsy, and whether further characterization of any of the smaller lesions is possible. 2. nodular left adrenal gland, consistent with hyperplasia, without discrete lesion identified. 3. consolidation of visualized left lung with associated effusion. . cxr: impression: 1. significant improvement in aeration of the left upper lung as well as the lingular region, most likely secondary to resolution of an intrabronchial mucous plug. 2. persistent mediastinal and hilar masses encasing and narrowing the left main bronchus. 3. bilateral small pleural effusion with persistent left lower lobe collapse. . pathology: flow cytometry: interpretation: non-diagnostic study. cell marker analysis was attempted, but was non-diagnostic in this case due to insufficient numbers of cells for analysis. correlation with clinical findings and morphology (see separate cytology report c08-6163g) is recommended. if clinically indicated, we recommend a repeat specimen be submitted to the flow cytometry laboratory. . micro: bcx: neg x 2 ucx: neg urinary legionella ag neg cryptococcal ag neg . laboratory data: admission labs, : cbc: white blood cells 8.9 k/ul red blood cells 3.74*# m/ul hemoglobin 11.3*# g/dl hematocrit 33.4* % mcv 89 fl mch 30.3 pg mchc 33.9 % rdw 17.1* % differential neutrophils 75.5* % lymphocytes 15.5* % monocytes 6.7 % eosinophils 1.8 % basophils 0.4 % platelet count 428 k/ul . electrolytes: glucose 133* mg/dl urea nitrogen 13 mg/dl creatinine 1.2* mg/dl sodium 135 meq/l potassium 3.9 meq/l chloride 97 meq/l bicarbonate 26 meq/l anion gap 16 meq/l calcium, total 11.0* phosphate 3.6 mg/dl magnesium 1.8 mg/dl . discharge labs, : cbc: white blood cells 3.6* k/ul red blood cells 2.88* m/ul hemoglobin 9.0* g/dl hematocrit 25.9* % mcv 90 fl mch 31.1 pg mchc 34.7 % rdw 19.3* % platelet count 251 k/ul . electrolytes: glucose 87 mg/dl urea nitrogen 9 mg/dl creatinine 0.9 mg/dl sodium 138 meq/l potassium 4.1 meq/l chloride 104 meq/l bicarbonate 26 meq/l anion gap 12 meq/l . other labs: gran count: 12:00am 2470 12:00am 2140* 12:01am 2840 12:00am 5170 . brief hospital course: the patient is a 64 year-old female with a pmhx sx for open asd repair c/b sternal wound infection and post-operative af who was initially admitted through the ed with sob and back pain, with cta in the ed demonstrating diffuse lad and post-obstructive pna concerning for malignancy. . #) post obstructive pna - the patient was treated with a 2 week course of vancomycin and zosyn to cover for hospital acquired organisms, which ended on . she remained afebrile with no recurrence of symptoms for the remainder of her hospital course. the patient showed improved aeration on pulmonary exam for remainder of hospital course. . # large cell lung ca - as below, the pulmonary service performed a bronchoscopy which showed external compression of her left mainstem bronchus. the patient underwent biopsy/fna, which showed large cell carcinoma. oncology was consulted for further recommendations on workup/ management. of note, the patient also has a liver lesion suspicious for metastasis. the patient underwent palliative xrt for an 11-session course. she also initiated /taxol therapy on . the patient became neutropenic on to nadir anc of approx. 300 and was started on neupogen 300 sc daily until . gran ct > 5000 by time of discharge with no recurrence of neutropenia. the patient will follow-up in clinic for restaging and further discussion of chemotherapy regimen in 2 weeks. . # atrial fibrillation - etiology was thought to be multifactorial, in setting of a post-obstructive pneumonia and atrial irritation from invasive and expansive pulmonary masses. this was controlled initially in the , and the patient was then transferred to the floor on metoprolol 50 mg tid. while on the floor, she had a bronchoscopy performed which showed external compression of her left mainstem bronchus, and she had a biopsy/fna performed, which showed large cell carcinoma. she was then readmitted to the with atrial fibrillation with hr 130s, and was started on a diltiazem gtt. in the , she was started on po diltiazem, which was rapidly uptitrated to 60 mg qid with good effect. she was briefly called out, but developed hr 160s, w/ekg c/w af with rvr, for which she received metoprolol 5 mg iv x2, followed by diltiazem 10 mg iv x2 without conversion. she denied chest pain, sob, tachypnea. she was put back on a dilt gtt, and shortly thereafter an amiodarone gtt was begun with plan to continue with po load. cardiology was consulted and recommended against amiodarone. she was put on po metoprolol and po diltiazem which was aggressively uptitrated with good effect. however, she experienced an acute respiratory decompensation which precluded her from taking her po medications, and in that setting experienced rvr to the 140-150s again. the patient was again transferred to the floor on regimen of diltiazem 120mg q8h and metoprolol 100mg po tid, where she remained somewhat tachycardic. her blood pressure was low-normal on this regimen (90s-100s/ 50s-60s), so she was started on digoxin 0.0625mg for additional hr control with good effect (hr ~ 100 by time of discharge). anticoagulation was not pursued as the patient has a high risk of bleeding given large tumor burden and a chads score of 0. . # hypoxia - the patient began to suffer worsening oxygenation with desaturations on . she also became agitated and delirious. cxr was consistent with worsening edema in the remaining lung (known l lung collapse). the patient was diuresed with marginal effect. she required bipap for an abg which showed hypercarbia to 60. cardiogenic etiology for edema was felt to be unlikely given nl echo on this admission, and ekgs without ischemic changes. central etiology for decreased respiratory drive was also felt to be unlikely. low suspicion for pe given that she was on a heparin gtt for afib at that time. she was also treated for a copd exacerbation, including nebs and incidental administration of high dose steroids (from chemotherapy for nausea ppx) without much success. her code status was briefly changed from dnr/dni to focus on comfort measures, but this was reversed as the patient spontaneously had a return in mental status towards baseline and an improvement in o2 saturations. by the time the patient was discharged to rehab, she was saturating in the mid-90%s on 0.5-1l nc. . # c diff colitis - the patient was continued on po vanc for an additional 2 weeks after resolution of broad spectrum treatment for post-obstructive pna. this course was completed while inhouse with no further diarrhea. . # anemia: the patient has a stable hct ~25. the patient was transfused a total of 2u prbc per oncology recommendations to keep hct > 22. this was well-tolerated with appropriate increase in hct. hct on discharge was 25.9. . # dyspepsia: the patient began experiencing symptoms of dyspepsia, likely secondary to xrt. she treated with a ppi and h2 blocker with magic mouthwash before meals. . # nausea: this was also felt to be secondary to xrt. the patient was continued on a ppi, h2 blocker, and reglan. low dose dexamethasone may be started if symptoms persist. . # dysphagia: also likely secondary to xrt. the aptient was continued on magic mouthwash and liquid oxycodone prior to meals. po meds were changed to liquid when possible. . # the patient was discharged to rehab on in good condition, vss, ambulating well and tolerating po. follow-up in heme/onc clinic was arranged for 2 weeks. medications on admission: advair (unknown dose) spiriva (unknown dose) albuterol prn zantac 150 mg po qam aspirin 81 mg po qam promethazine 25 mg po q6h prn metoprolol 50 mg po tid zocor 40 mg po qpm oxazepam 15 mg po qhs vancomycin 250 mg po q6h discharge medications: 1. morphine concentrate 20 mg/ml solution : ml po q2h (every 2 hours) as needed for sob, pain. 2. albuterol sulfate 2.5 mg/3 ml solution for nebulization : one (1) treatment inhalation q4h (every 4 hours) as needed for sob, wheezing. 3. fluticasone-salmeterol 250-50 mcg/dose disk with device : one (1) puff inhalation (2 times a day). 4. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 5. heparin (porcine) 5,000 unit/ml solution : one (1) injection injection tid (3 times a day). 6. acetaminophen 325 mg tablet : 1-2 tablets po q6h (every 6 hours) as needed for pain, fever. 7. levalbuterol hcl 0.63 mg/3 ml solution for nebulization : one (1) treatment inhalation q6hrs prn (). 8. docusate sodium 100 mg capsule : one (1) capsule po bid (2 times a day). 9. senna 8.6 mg tablet : one (1) tablet po bid (2 times a day) as needed. 10. ipratropium bromide 0.02 % solution : one (1) treatment inhalation q6h (every 6 hours) as needed. 11. clotrimazole 10 mg troche : one (1) troche mucous membrane qid (4 times a day). 12. digoxin 125 mcg tablet : 0.5 tablet po daily (daily). 13. metoprolol tartrate 50 mg tablet : two (2) tablet po tid (3 times a day). 14. diltiazem hcl 60 mg tablet : two (2) tablet po q8h (every 8 hours). 15. ondansetron 8 mg tablet, rapid dissolve : one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed. 16. ranitidine hcl 150 mg tablet : one (1) tablet po bid (2 times a day). 17. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 18. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension : 15-30 mls po qid (4 times a day) as needed: please give prior to meals. 19. metoclopramide 10 mg tablet : one (1) tablet po tid (3 times a day). 20. oxycodone 5 mg/5 ml solution : ml po q6h (every 6 hours) as needed: please give 30min prior to meals. discharge disposition: extended care facility: guardian - discharge diagnosis: primary: - large cell lung cancer - atrial fibrillation - post-obstructive pneumonia - anemia - neutropenia . secondary: - copd/emphysema - hyperlipidemia - hypertension discharge condition: good, afebrile and vss, ambulating and tolerating po well discharge instructions: you were admitted with shortness of breath that ultimately lead to a diagnosis of lung cancer. you were treated with chemotherapy and radiation therapy for this. you are being set up with a new oncologist, dr. , for further treatment of your lung cancer. . you were also diagnosed with atrial fibrillation, or an irregular heart rhythm. you have been started on several new medications for this: metoprolol, diltiazem, and digoxin. you should take these as scheduled to prevent a rapid heart rate. . please take all of your medications as prescribed. several changes have been made, so you should take all medications as instructed on the updated list provided. please attend all of your follow-up appointments. . if you experience any fevers > 100.5, chills, chest pain, shortness of breath, palpitations, dizziness, abdominal pain, nausea/ vomiting/ diarrhea, or any other concerning symptoms please contact your pcp or go to the er for further evaluation. followup instructions: please follow-up with dr. (oncology) in 2 weeks from discharge. contact: , : . . you will need a ct scan of the torso before this appointment. this has been scheduled tentatively for , but you should reschedule this for the same day (just before your appointment) that you will follow-up with dr. . phone: . you will need a blood test to evaluate your renal function (bun, creatinine) before this test. . please follow-up with your primary care physician, . , within 1-2 weeks of discharge to discuss the events of your hospitalization. phone: procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified other bronchoscopy non-invasive mechanical ventilation closed [percutaneous] [needle] biopsy of lung injection or infusion of cancer chemotherapeutic substance other radiotherapeutic procedure diagnoses: pneumonia, organism unspecified anemia, unspecified esophageal reflux malignant neoplasm of liver, secondary unspecified essential hypertension acute kidney failure, unspecified atrial fibrillation obstructive chronic bronchitis with (acute) exacerbation other chronic pulmonary heart diseases personal history of tobacco use nausea with vomiting constipation, unspecified other and unspecified hyperlipidemia acute respiratory failure unspecified disorder of adrenal glands alkalosis intestinal infection due to clostridium difficile other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use hypoxemia other postprocedural status encounter for palliative care other specified complications of procedures not elsewhere classified drug induced neutropenia secondary and unspecified malignant neoplasm of intrathoracic lymph nodes hypercalcemia radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure cyst of kidney, acquired malignant neoplasm of main bronchus edema dysphagia, unspecified other alopecia histoplasmosis, unspecified, without mention of manifestation contact dermatitis and other eczema due to drugs and medicines in contact with skin 

Answer: The patient is high likely exposed to