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 attending: chief complaint: chest pain major surgical or invasive procedure: intubation s/p extubation central line placement picc arterial line history of present illness: mr. is a 66yo m with history of copd on 2l home o2 and hypertension who presented to his pcp's office with 12 days of non-radiating substernal chest pain and worsening shortness of breath. he felt this pain may have been his gerd but did not improve with tums. at (his pcp's office), he was noted to be look weak and an ekg was concerning for ? new anterior-lateral changes. in the ed, initial vs were: 98, 84, 136/88, 18, 96% 2l. on arrival to er, ekg was nsr without st changes, and labs were significant for trop of 0.31, platelets of 9, leukocytosis to 35 with 88% "other" cell types and hematocrit of 21. repeat ekg was still non-ischemic and cardiology felt his troponins were not due to active ischemia. given his platelets, there were no plans for intervention. heme/onc was consulted to review his smear given concern for acute leukemia. patient was given one sublingual nitro and started on morphine for pain control. he was moving very little air on exam and felt to be having a copd exacerbation. he was given solumedrol, ceftriaxone, azithromyin, cefepime and albuterol/ipratropium nebs. patient was transferred to the icu for further management. at time of transfer, vitals were 98.7, 93, 150/68, 20, 94% 3l nc. in the icu, he endorses having had chest pain for the past couple weeks that he felt was heartburn and epigrastric pain. over this time period, he has also had some generalized weakness and cough productive of blood tinged sputum. he feels his scattered arm bruises are related to tripping and falling a few days ago. past medical history: # pneumonia that was slow to resolve, requiring 2-3 months of abx # copd with 2l home o2 # history of asbestos exposure # psoriasis # hyperlipidemia # arthritis # hypertension # depression # venous insufficiency social history: he is married and has a daughter who is his hcp. previously smoked but quit a number of years ago. he occasionally drinks alcohol but denies iv drug use. family history: mother had unspecified mental illness and had a coronary artery bypass. his father with unknown cancer died at the age of 83. physical exam: icu exam on admission - vitals: t: 97.6 bp: 130/71 p: 102 r: 14 o2: 92% 4l nc general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: very limited air movement bilaterally but clear to auscultation without wheezes, rales, or rhonchi cv: regular rate and rhythm, distant s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly appreciated gu: no foley ext: scattered upper extremity ecchymoses, r>l mild, 1+ pitting edema, warm, well perfused, 2+ pulses, no clubbing or cyanosis icu exam on transfer - general: very somnolent but arousable (rn & daughter state not a change from baseline), a+o x 2 (name, hospital) heent: sclerae anicteric, perrl, eomi neck: supple lungs: scattered bibasilar crackles cv: regular rate and rhythm, distant s1 + s2, no murmurs, rubs, gallops abdomen: obese, soft, non-tender, distended, normal bowel sounds no hsm. right sided abd ecchymosis which is stable from prior exam gu: foley in place ext: l>r upper extremity edema, scattered upper extremity ecchymoses, trace pitting edema, warm, well perfused, 2+ pulses neuro: l sided hemiparesis from known iph pertinent results: admission labs: wbc-38.9* rbc-2.49* hgb-7.5* hct-20.3* mcv-82 mch-30.3 mchc-37.1* rdw-15.8* glucose-214* urea n-22* creat-0.6 sodium-131* potassium-3.8 chloride-91* total co2-28 anion gap-16 alt(sgpt)-52* ast(sgot)-70* ld(ldh)-661* alk phos-85 tot bili-0.9 lactate-1.3 ck(cpk)-739* ck-mb-70* mb indx-9.5* ctropnt-0.55* fibrinoge-158 d-dimer-8889* lipase-25 discharge labs: 12:00am blood wbc-3.2* rbc-3.65* hgb-10.9* hct-30.8* mcv-84 mch-29.9 mchc-35.5* rdw-15.9* plt ct-79* 12:00am blood neuts-25* bands-0 lymphs-40 monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 other-29* 06:00am blood pt-14.3* ptt-31.2 inr(pt)-1.2* 06:00am blood plt ct-105* 12:00am blood gran ct-810* 12:00am blood glucose-138* urean-19 creat-0.5 na-134 k-3.7 cl-99 hco3-23 angap-16 12:00am blood alt-29 ast-24 ld(ldh)-353* alkphos-82 totbili-1.4 12:00am blood albumin-3.6 calcium-8.7 phos-3.6 mg-1.8 uricacd-3.3* studies: neoplastic blood date of karyotype: 47,xy,+8,t(15;17)(q22;q21.1) only two metaphase cells were obtained and analyzed from this specimen. this limited/ incomplete study may not rule out mosaicism at a level that is standard for such an analysis. two cells contained an extra copy of chromosome 8 (trisomy 8) and a translocation of chromosomes 15 and 17. this translocation is associated with pml-rara fusion and is a characteristic finding in acute promyelocytic (m3) leukemia. ----------------interphase fish analysis, 100-300 cells------------------- nuc ish(pml,rara)x3(pml con rarax2) fish evaluation for a pml-rara rearrangement was performed on nuclei with the lsi pml/rara dual color, dual fusion translocation probe ( molecular) for pml at 15q22 and rara at 17q21.1 and is interpreted as abnormal. rearrangement was observed in 89/100 nuclei, which exceeds the normal range (up to 1% dual rearrangement) for this probe in our laboratory. a pml-rara rearrangement is found in most acute promyelocytic leukemias (fab m3). this test was developed and its performance determined by the cytogenetics laboratory as required by the clia ' regulations. it has not been cleared or approved by the u.s. food and drug administration. this test is used for clinical purposes. flow cytometry: results: three color gating is performed (light scatter vs. cd45) to optimize blast yield. abnormal cells comprise 82% of total gated events. b-cells comprise 6% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. t-cells comprise 57% of lymphoid-gated events, express mature lineage antigens, and have a normal helper-cytotoxic ratio of 1.04 (usual range in blood 0.7-3.0). cell marker analysis demonstrates that the majority of the cells isolated from this peripheral blood express myeloid associated antigens (cd13, cd33 (bright), cd15 (bright, subset), express cd64, cd71, lack b and t cell associated antigens, are cd10 (callaa) negative, and are negative for cd34, hla-dr, cd14, cd41, cd11c, cd56 and glycophorin a. immunophenotypic findings consistent with involvement by acute myeloid leukemia. lack of cd34 and hla-dr promyelocytic differentiation. however, correlation with concurrent cytogenetic findings is recommended for further characterization. . imaging: echocardiogram conclusions the left atrium is elongated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is moderate to severe global left ventricular hypokinesis, with some regional variation (the anterior septum, anterior free wall, and apex appearing more hypokinetic than the other walls) (lvef = 30 %). right ventricular chamber size is normal. with severe global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the ascending aorta is moderately dilated. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , contractile function of both ventricles is now significantly reduced. ct head w/o contrast 6:31 pm impression: large intraparenchymal hemorrhage in the right frontal lobe, with surrounding vasogenic edema and local mass effect. a hypodense lesion with smaller hemorrhagic component is also seen in the right occipital lobe, with two additional non-hemorrhagic hypodense lesions seen in the left cerebellar hemisphere and the right parieto-occipital cortex. given the multifocality of these lesions, and history of malignancy, these may represent metastases with associated hemorrhage. an alternate consideration is multiple infarctions, some hemorrhagic, likely embolic. mri with and without contrast would be helpful for further evaluation. mri brain 3:27 pm conclusion: multiple acute areas of infarction, many with hemorrhage. the distribution suggests emboli from a proximal source, most likely cardiac. 5-6 mm anterior communicating artery aneurysm. the location of the hemorrhages does not imply prior bleeding from this aneurysm. within the limits of an adequate but not optimal mra examination, no other intracranial vascular abnormalities are detected. echocardiogram at 1:30:32 pm conclusions: no spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. no mass/thrombus is seen in the left atrium or left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with anterior hypokinesis. no masses or thrombi are seen in the left ventricle. rv hypokinesis is seen. there are complex (>4mm) atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is small vegetation (4mm) on the mitral valve attached to the posterior leaflet on the . mild to moderate (+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. impression: small vegetation of the mitral valve. complex, non-mobile atheroma of the aortic arch. mild regional lv systolic dysfunction. ct head 8:28 pm impression: 1. no interval change since , with unchanged appearance of right frontal parenchymal hematoma with associated edema, local mass effect and stable degree of leftward shift of normally-midline structures. 2. hypodense lesions in the right occipital and parietal occipital cortex appear grossly unchanged but are not further characterized on this motion- degraded study. left upper extremity ultrasound: 1:45 pm findings: grayscale and doppler son of right subclavian vein was performed and shows normal compressibility, flow, and augmentation. grayscale and doppler son of left subclavian, left internal jugular, left axillary, left brachial, left basilic, and left cephalic veins were performed. the left internal jugular vein shows normal flow and augmentation. there is abnormal flow in the left subclavian vein, left axillary vein, and left basilic vein. hypoechoic foci consistent with clots are also clearly visualized in the left basilic and left axillary veins. these findings are consistent with an upper extremity thrombus in the left subclavian vein, left axillary vein, and left basilic vein. brief hospital course: 66 yo man h/o severe emphysema who presented with a new diagnosis of apml and nstemi with ef 30%, s/p intubation with extubation on , found to have large iph, multiple strokes, and endocarditis. # apml: mr. was diagnosed with apml by peripheral smear, flow cytometry, and pcr of the blood. he was treated with atra and hydroxyurea initially and when his wbc was <10k, his hydroxyurea was stopped. he also received steroids initially for prophylaxis of atra syndrome and this was gradually weaned. he was monitored for tumor lysis and dic and transfused blood products prn to keep his fibrinogen >100 and inr <1.5. his platelet goal was initially 20k but this was increased to 100k after his intraparenchymal hemorrhage. # nstemi with new heart failure (ef 35%): mr. initially presented to his pcp's office with chest pain. he had elevated troponins on admission with no st or t wave changes on ekg, c/w nstemi. we trended his troponins which plateaued at 3.50. his first echo showed moderate to severe global left ventricular hypokinesis, with some regional variation (the anterior septum, anterior free wall, and apex appearing more hypokinetic than the other walls) and lvef = 30 %. he was monitored on telemetry and had no significant arrhythmias. given his concurrent iph (see below), antiplatelet & anticoagulant agents are contraindicated and he was medically managed with nitrates, beta-blockers, low-dose ace-i and a statin. repeat echo on showed a persistent small vegetation of the mitral valve, complex, non-mobile atheroma of the aortic arch, and mild regional lv systolic dysfunction (ef 45%). # intraparenchymal hemorrhage: on the morning of , it was noted that mr. was not moving his l arm. ct head showed a large intraparenchymal hemorrhage in the right frontal lobe, with surrounding vasogenic edema and local mass effect. a hypodense lesion with smaller hemorrhagic component was also seen in the right occipital lobe, with two additional non-hemorrhagic hypodense lesions seen in the left cerebellar hemisphere and the right parieto-occipital cortex. mri/a on revealed multiple areas of acute infarction, many with hemorrhage, with a distribution that suggests emboli from a proximal source, likely cardiac. unclear etiology for embolism ?????? blood cultures are negative to date to assess for bacteremia. tee showed aortic plaque that could be potential embolic source. mra showed a 5-6mm communicating artery aneurysm as well. neurosurgery had no plans for intervention. neurology was consulted & recommended eeg which showed a diffuse encephalopathy pattern and a focal area with epileptogenic potential, but no electrographic seizures. all antiplatelet/anticoagulant agents were held. dic labs were stable, with a platelet count goal of >100k. he was able to be extubated on and pt/ot was consulted for help managing/recovering from his stroke. he continued to suffer from mood lability on the floor and intermittently refused his medications. neurology continued to follow him. eeg was repeated and did not show any seizure activity, just a diffuse encephalopathy. haldol 0.5mg iv was used prn for mood stabilization as he refused. # respiratory distress/hypoxia: on presentation, he was hypoxic and required oxygen support by nasal cannula (up to 6l). it was felt to be multifactorial, with his underlying emphysema, acute systolic heart failure, pulmonary edema, and pneumonia contributing. following his iph, he was intubated for airway protection on with successful extubation on . bronchoscopy on showed edematous airways with friability but no frank blood. bal grew yeast (it was initially reported as mold, concerning for aspergillus, but galactomannan/glucan were normal and it was re-read as yeast). he is s/p 8 day course of cefepime and levofloxacin for his pneumonia. following extubation, he was maintained on his home copd medications and was maintaining stable o2 sats on room air. # culture-negative endocarditis: echo on showed a small vegetation on mitral valve. unclear if this is infectious versus malignant. added vancomycin (d1=) for mrsa endocarditis coverage and started ceftriaxone (d1=). had abdominal ct which did not show any infectious source. per id, 6 week course of antibiotics recommended. # lue edema: lue>rue edema, of hand and arm. patient had picc placed in left arm and his edema was concerning for dvt. given his recent iph, anticoagulation was not an option. left upper extremity u/s done on to r/o dvt was negative. edema and pain persisted, so a repeat lue u/s was done on and showed extensive dvt of the l subclavian, axillary and basilic vein. the picc line was removed on and a peripheral iv was placed. on , the family expressed a desire to transfer his care to . dr. the inpatient hematologic malignancy team who accepted the patient in transfer. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs inhaled four times daily as needed for shortness of breath bupropion hcl 150 mg tablet sustained release - 1 tablet(s) by mouth twice a day clobetasol - 0.05 % ointment - apply to affected areas x up to 2 weeks per month: avoid face and folds ; may wrap with saran to areas as directed diazepam - 5 mg tablet - 1 tablet(s) by mouth twice a day as needed fluticasone-salmeterol - 250 mcg-50 mcg/dose disk with device - 1 puff inhaled every 12 hours; rinse mouth well after each use furosemide - 40 mg tablet - 1 tablet(s) by mouth daily hydrochlorothiazide - 25 mg tablet - 1 tablet(s) by mouth daily oxygen - - 2l by nasal cannula continuously during sleep and with any exertion room air sat 87% with minimal exertion documented potassium chloride - 10 meq capsule, sustained release - 1 capsule(s) by mouth daily sildenafil - (not taking as prescribed) - 100 mg tablet - 1 tablet(s) by mouth as needed simvastatin - 40 mg tablet - 1 tablet(s) by mouth daily tiotropium bromide - 18 mcg capsule, w/inhalation device - 1 puff inh daily verapamil - 240 mg cap,24 hr sust release pellets - 1 cap(s) by mouth daily acetaminophen - (otc) - 500 mg tablet - 2 tablet(s) by mouth twice a day as needed aspirin - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth daily discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 3. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 4. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 5. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day). 6. polyethylene glycol 3350 17 gram/dose powder sig: one (1) packet po daily (daily). packet 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. isosorbide mononitrate 20 mg tablet sig: one (1) tablet po bid (2 times a day). 9. fluticasone 110 mcg/actuation aerosol sig: four (4) puff inhalation (2 times a day). 10. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). 11. tretinoin (chemotherapy) 10 mg capsule sig: five (5) capsule po bid (2 times a day). 12. ipratropium bromide 0.02 % solution sig: one (1) inhalation inhalation q6h (every 6 hours). 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q2h (every 2 hours) as needed for shortness of breath or wheezing. 14. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours). 15. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush . 16. bupropion hcl 100 mg tablet sig: one (1) tablet po bid (2 times a day). 17. ceftriaxone 2 gm iv q24h start: in am start on morning of 18. vancomycin 1000 mg iv q 8h d1= 19. haloperidol 0.5 mg iv bid:prn agitation 20. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 21. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 22. lantus 100 unit/ml cartridge sig: eighteen (18) units subcutaneous at bedtime. 23. humalog 100 unit/ml cartridge sig: 2-10 units subcutaneous qachs: according to sliding scale. . discharge disposition: extended care discharge diagnosis: primary: acute promyelocytic leukemia stroke with intracranial hemorrhage non st elevation mi endocarditis, culture negative delerium chronic obstructive pulmonary disease discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , you were admitted with an nstemi, new diagnosis of apml, stroke with ich and endocarditis. you were treated with atra and antibiotics. you are being transferred to for further care per your request. dear mr. , you were admitted with an nstemi, new diagnosis of apml, stroke with ich and endocarditis. you were treated with atra and antibiotics. you are being transferred to for further care per your request. followup instructions: you will need to follow up with a hematologist on discharge. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances diagnostic ultrasound of heart insertion of endotracheal tube arterial catheterization closed [endoscopic] biopsy of bronchus removal of other device from thorax diagnoses: pneumonia, organism unspecified subendocardial infarction, initial episode of care unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension adrenal cortical steroids causing adverse effects in therapeutic use acute kidney failure, unspecified hyposmolality and/or hyponatremia obstructive chronic bronchitis with (acute) exacerbation depressive disorder, not elsewhere classified paroxysmal ventricular tachycardia acute respiratory failure defibrination syndrome cerebral aneurysm, nonruptured acute and subacute bacterial endocarditis hypoxemia diarrhea cerebral embolism with cerebral infarction acute systolic heart failure accidents occurring in residential institution drug-induced delirium other psoriasis unspecified intracranial hemorrhage anemia in neoplastic disease venous (peripheral) insufficiency, unspecified personal history of contact with and (suspected) exposure to asbestos arthropathy, unspecified, site unspecified acute myeloid leukemia, without mention of having achieved remission neoplasm of uncertain behavior of brain and spinal cord dysphagia, unspecified other secondary thrombocytopenia 

Answer: The patient is high likely exposed to