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: ruq pain, breathlessness, nausea and vomiting major surgical or invasive procedure: - cta w/ contrast - right ij central venous line placement by icu team - left picc line placement by icu team - right heart catheterization by dr. - transjugular liver biopsy by dr. - right heart catheterization by dr. history of present illness: ms. symptoms began 2 weeks ago when she experienced sudden, severe pain in the right upper quadrant of her abdomen; the pain did not radiate to any other part of her body, was not precipitated by the intake of food, and became worse on deep inspiration. she immediately called her rheumatologist, who, after discussion over the phone, advised her to increase the dose of her prednisolone (her lupus was controlled with methotrexate, low-dose prednisolone, and planquenil). after following these instructions, she felt healthy for 2-3 days, after which the pain returned with a new onset of breathlessness. the pain was similar in nature to the first episode, and she felt like she could not take deep breaths because of it. the breathlessness was not associated with any chest pain or cough; it did not increased upon lying down, but, rather, was directly associated with the inability to fully inspire due to the abdominal pain. this episode was also associated with profuse sweating, but she reported no fever. . upon further follow-up with her rheumatologist, her prednisolone dosage was increased and she did not have a full-blown attack of her previously-stated symptoms. . during the night of , her symptoms re-appeared, prompting a visit to hospital emergency room. she was put on a face mask and oxygen, and a chest x-ray and ct-angio of the chest were performed, both of which were negative. she was told that she was suffering from a lupus flare-up and could leave, but within 10 minutes developed nausea and vomitting; the vomitus was yellow in color and contained food. after resting in the ed for two hours, she went home. during a visit to the bathroom, she lost consciousness while urinating; her husband told her she was shaking and her eyes were rolled upwards. she was not biting her tongue or frothing at the mouth. she refused going to a hospital. ms. was then healthy until , when she visited her rheumatologist. upon examination, she was found to have bilateral lower limb edema and so was taken to for further evaluation and management. . of note, she claims to have had hematuria with no dysuria, in addition to arthalgia in the large and small joints of her upper limbs. she did not have any history of chest pain, palpitations or productive cough. furthermore, she had no changes in weight, no loss of appetite, or diarrhea. . her workup in the ed, where she had vital signs of temp: 96.8 hr: 85 bp: 115/70 resp: 18 o(2)sat: 99, and on the medical floor included a ruq u/s that showed gallstones but no cholecystitis, as well as a hida scan that was similarly negative for cholecystitis. ct of her abdomen/pelvis showed possible hepatitis, ascites, colitis, and pelvic fluid. she had leni's that were negative for dvt, and cta that showed no pulmonary embolism. surgery was consulted in the ed for potential cholecystitis. gi was consulted for her abdominal pain, which was attributed to intermittent vasospasm from scleroderma. rheumatology was consulted, and recommended continuing with increased dose steroids and hydroxychloroquine. . on , the floor staff was unable to measure an oxygen saturation, and a blood gas (likely venous) was obtained, showing mixed respiratory and metabolic acidosis, with an elevated lactate. cxr was unchanged from prior. she was transferred to the icu on a non-rebreather mask, and shortly thereafter, she was able to maintain stable oxygen saturations with moderate-flow nasal cannula (3-4 l/min). her vital signs upon arrival at the icu were on the floor her vitals were: hr: 106, o2sat: 95%, rr: 30, bp: 110/93. lab results were wbc: 15.1, rbc: 4.12, hgb: 14.0, hct: 42.8, mcv: 104, plt: 358. repeat labs demonstrated new leukocytosis, a widening anion gap, and modest elevations in her transaminases. repeat blood gases (primarily venous) revealed varying levels of metabolic acidosis. a sodium bicarbonate infusion was started, and a cvl was placed. . review of symptoms: (+) per hpi (-) denies headache, sinus tenderness, rhinorrhea or congestion. denies any history of wheezing. denies history of frequency, urgency or flank pain. denies history of photosensitivity or rash. denies alopecia, photosensitivity, mucosal ulcerations, and raynaud's symptoms. furthermore, no history of seizures or blood clots in lungs or legs, miscarriages. rest of ros per hpi. past medical history: - sle: diagnosed 6 years ago, originally presented with inflammatory polyarthritis and raynaud's phenomenon; positive for , rheumatoid factor, , rnp, ssa, ssb, had high esr and mild leukopenia. she was initially on prednisone and plaquenil, then plaquenil and imuran. she moved to for 8 months, ran out of medications and her symptoms worsened. she was then started on methotrexate. last >1:1280 speckled. crp was 23. dsdna on 1:20. - mixed connective tissue disease: diagnosed 3 years ago; overlap of symptoms with sle, with some sclerodactyly. - polyclonal hypergammaglobulinemia - history of nasal septal operation social history: she is originally from . in she was a cook. she emigrated to the us 10 years ago. she lives with her husband and two children. she is not currently working. cigarettes: never ex-smoker current pack-yrs: quit: ______ etoh: no yes drinks/day: _____ drugs: none marital status: married single received influenza vaccination in the past 12 months y n received pneumococcal vaccinationin the past 12 months y n family history: father died of complications from dm at age 68. her mother is in good health. mother has breast cancer but now is in remission. no family history of gi disorders. she has two children who were visiting her mother at the beginning of her hospitalization. physical exam: admission to exam: vs t 97.8 p 65 bp 126/69 rr 24 o2sat 100% on ra general: slightly tired but well appearing young female who appears her stated age. nourishment:good. grooming: good mentation: alert, she eyes:nc/at, perrl, eomi without nystagmus, no scleral icterus noted ears/nose/mouth/throat: , no lesions noted in op neck: supple respiratory: , lll crackles cardiovascular: rrr, nl. s1s2, 3/6 sem at lusb. gastrointestinal: nabs, soft, lower mid quadrant tenderness and pronounced ruq tenderness. pelvic exam: limited by lack of speculum but there appears to be blood in the vaginal vault. no cmt. skin: no rashes or lesions noted. extremities: + pitting edema b/l dp and pt pulses b/l could not be appreciated. i was able to doppler dpps b/l. lymphatics/heme/immun: no cervical lymphadenopathy noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact -motor: normal bulk, strength and tone throughout. no abnormal movements noted. -dtrs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. plantar response was flexor bilaterally. no foley catheter/tracheostomy/peg/ventilator support/chest tube/colostomy psychiatric: tired but wnl. access: piv cvl site ______ foley: present none trach: present none peg:present none site c/d/i colostomy: :present none site c/d/i discharge exam from : vs t 97.6 p 95 bp 115/78 rr 21 o2sat 100% on 5 l nasal cannula general: patient was sitting up in bed speaking comfortably, complained of tiredness which has been gradually improving mentation: alert, sometimes tired eyes: nc/at, perrl, eomi without nystagmus, no scleral icterus noted ent: , no lesions noted in op neck: supple, elevated jvp respiratory: bilateral air entry with scattered wheezes and subtle bibasilar crackles; otherwise no added sounds such as ronchi or coarse crackles. chest expansion is adequate cardiovascular: rrr, nl. s1s2, 3/6 sem at lusb, also heart at llsb. gastrointestinal: soft and lax, non-tender with no obvious distension skin: no rashes or lesions noted. extremities: 2+ pitting edema b/l, peripheral pulses felt in all extremities. there was no evidence of clubbing or peripheral cyanosis lymphatics: no cervical lymphadenopathy noted neurologic: - mental status: alert, oriented x 3 - cranial nerves: ii-xii intact - motor: normal bulk, strength and tone throughout. no abnormal movements noted. - dtrs: not assessed access: picc line foley: present none trach: present none peg:present none site c/d/i colostomy: :present none site c/d/i admission to 3 ( service) exam: vs: 97.9 107/77 91 20 93% on 3l general: pleasant middle aged woman, sitting up in bed with nc, breathing heavily, very tired looking, in and out of sleep during interview : ncat. sclera anicteric neck: supple cardiac: split s2, regular rate lungs: dry crackles to 3/4 up back abdomen: tenderness to palpation of lower abdomen, r>l, soft, nondistended, +bs extremities: +purpulish discoloration of fingertips b/l cold toes b/l, poor perfusion, slight discoloration of toes could not appreciated le pulses edema, 2+ pitting edema up leg to upper thigh. discharge from 3 ( service) exam: vs: t 97.5 bp 96/66 hr 78 rr 18 sao2 95% on 3l i/o: wt: 81.5 (from 81.7) general: nad, lying in bed in private room, mother present : , minimal scleral icterus neck: supple, jvp elevated to 5 cm cardiac: rrr, nl s1/s2, soft rumbling systolic murmur loudest at llsb lungs: ctab, good air movement, no crackles abdomen: soft, nondistended, nontender, +bs. bruising on lower abdomen persists. no bruising in ruq. extremities: 2+ pitting edema up to knees bilaterally. bruising on arms. picc dressing changed, no drainage or erythema. pertinent results: admission labs and studies: . 01:42pm blood glucose-100 urean-14 creat-0.6 na-134 k-3.9 cl-102 hco3-22 angap-14 01:42pm blood wbc-11.2*# rbc-4.10* hgb-13.6 hct-40.1 mcv-98 mch-33.1* mchc-33.9 rdw-18.4* plt ct-313 01:42pm blood alt-61* ast-48* ld(ldh)-312* alkphos-65 totbili-0.4 01:42pm blood lipase-18 01:42pm blood plt smr-normal plt ct-313 04:18pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-mod 04:18pm urine rbc-11* wbc-8* bacteri-few yeast-none epi-4 01:30am blood hcg-<5 07:30pm blood dsdna-negative 07:30pm blood c3-110 c4-30 08:48am blood calcium-8.2* phos-3.4 mg-2.0 07:20am blood hbsag-negative hbsab-negative igm hav-negative 07:20am blood hcv ab-negative . . relevant labs: . cultures: : blood culture negative x3 : blood culture negative & : urine culture negative : mrsa screen negative : urine culture negative : catheter tip culture negative : catheter tip culture pending . pathology: transjugular liver biopsy: 1. prominent centrilobular hepatocyte necrosis and parenchymal collapse involving 25-30% of the parenchyma with minimal associated inflammation (confirmed with reticulin stain). 2. mild to moderate canalicular cholestasis without neutrophils or ductular proliferation. 3. no pathologic abnormalities or significant inflammation seen in portal areas. 4. trichrome stain demonstrates focal perivenular fibrosis surrounding residual central veins; no increase in portal fibrosis is recognized. 5. iron stain shows no stainable iron. . . discharge labs: : complement c3 50, c4 20 : ceruloplasmin negative : d-dimer 1887, haptoglobin 12 : wbc , hgb 9.4, hct 29.1, plt 80 : na 126, k 3.8, cl 91, hco3 27, bun 29, cr 0.8, glucose 79, calc 6.7, mag 2.9, phos 2.6 : pt 19.3, ptt 35.4, inr 1.8 : alt 113, ast 161, ldh 773, alk 149, tbili 4.3 : fibrinogen 72, esr 1 . . relevant imaging: . outside imaging: from medical center on ct chest with contrast: no evidence of pe. central airways are patent. small geographic regions of gorund glass opacities are seen within both lower lungs which could represent air trapping. . ct abdomen and pelvis : thickened r colonic wall w/ moderate-to-large amt of free fluid, but normal appendix and no free air; most c/w colitis. . ruq us : impression: 1. gallstones with sub-cm gallbladder polyp. mild gallbladder wall thickening and trace pericholecystic fluid, but no specific signs for acute cholecystitis. 2. small amount of ascites, with largest pocket in the right lower quadrant. 3. normal kidneys without evidence of hydronephrosis or renal calculi. . + - lenis negative . - echo: impression: severe right ventricular cavity enlargement with free wall hypokinesis. moderate to severe pulmonary artery systolic hypertension. moderate to severe tricuspid regurgitation. patent foramen ovale with small right-to-left shunt. significant pulmonary regurgitation. these findings are suggestive of a primary pulmonary process (e.g., pulmonary embolism, primary pulmonary hypertension, etc.). . right heart cath: resting hemodynamics revealed elevated left- and right-sided pressures. the ra pressure was 26 mmhg, pa pressure was 39 mmhg, and wedge pressure was 21 mmhg. there was no step-up in oxygen saturation to indicate a left-to-right shunt. the patient's cardiac output was on the low side of normal. final diagnosis: 1. elevated left and right pressures. 2. low cardiac output. 3. no step-up in oxygen saturation to indicate a left-to-right shunt. . liver/gb u/s: 1. there has been interval filling of the gallbladder with sludge in comparison to prior study from . however, there is no evidence of intra- or extra-hepatic biliary duct dilatation with the common bile duct measuring 3 mm. gallbladder is not distended and there is no gallbladder wall edema. 2. trace perihepatic ascites. 3. biphasic morphology of the doppler and main portal vein is representative of congestive hepatopathy. . spleen u/s: no splenomegaly identified. . liver/gb u/s: 1) sludge-filled gallbladder without evidence of intra or extrahepatic biliary ductal dilatation. there is no gallbladder distention or gallbladder wall edema. 2) significant interval increase in ascites of unclear etiology. right heart cath: 1. resting hemodynamics on oxygen at 2 l/min nc revealed elevated right sided filling pressures with a baseline ra mean of 27 mmhg (with v wave up to 42 mm hg) . left sided filling pressures were normal with a pcwp of 12 mmhg. there was pulmonary arterial hypertension with a mean pa pressure of 38 mmhg. the pulmonary vascular resistance was 578 dynes-sec/cm5. the cardiac index was low at 1.8 l/min/m2. the ra waveform appeared ventricularized withv waves to 44 mm hg. 2. treatment wiht 100% fio2 demonstrated lowering of the pulmonary vascular resistance (to 411 dynes-sec/cm5) due to decrease of pa- difference with stable calculated cardiac output. 3. treatment with inhaled no at 40 ppm in addition to 100% fio2 did not change the pulmonary pressures significantly with a mean pa pressure of 35 mmhg. the pulmonary artery resistance increased due to a relative decrease in to 8 mmhg with a mild decrease in cardiac output to 3.3 l/min. 4. treatment with milrinone increased cardiac output to 4.25 l/min and pulmonary artery mean pressure to 40 mm hg with no significant change in pulmonary vascular resistance. tte (milrinone gtt): dilated and hypokinetic right ventricle with pressure/volume overload. small left ventricle with vigorous systolic function. moderate to severe tricuspid regurgitation. significant pulmonary hypertension, not further quantified on this study. brief hospital course: ms. is a 40 y/o f with h/o of lupus, mixed connective tissue disorder with scleroderma features who was initially admitted for ruq pain, worsening le edema, and vaginal bleeding, course c/b icu stay for hypoxemia with subsequent pulmonary htn and r heart failure on echo and subsequent congestive hepatopathy and acute renal failure. . summary of hospital course: . # pulmonary hypertension and right heart failure: as the patient presented wtih shortness of breath and hypoxia, she was admitted to the on a non-rebreather. initial differential for hypoxia included pe, despite recent negative cta, as patient was hypoxic and tachycardic, with signs of r heart strain on ecg (prominent p waves in ii, twi iii). extensive work-up for pe (v/q mismatch scan, lenis, repeat ct angio of the chest) was done; however, these tests were unequivocally negative. dvt prophylaxis was initiated. radiologic investigation showed evidence of significant right heart strain on ct scan, predisposing her to right->left shunt. further investigation with echocardiogram showed a patent foramen ovale with right to left shunt, now thought to be secondary to pulmonary hypertension (which, in turn, was due to her underlying mixed connective tissue disease with features of scleroderma). the reason for her acute decompensation is not completely clear; however, she had been in for an extended period of time (>8 months) during the past 1.5 years, during which she had ran out of her medications (methotrexate + prednisolone + planquenil) and not replaced them. it is thought that this allowed for a more chronic decompensation with extensive pulmonary vasculature damage, eventually causing right heart pressures so high that right-->left shunt ensued. . the patient had a large oxygen requirement since her arrival, starting with 2 l nasal cannula which was then increased to 5 l o2 on nasal cannula. she was treated with aggressive diuresis, initially with lasix but then changed to turosemide due to thrombocytopenia (thought to be secondary to use of lasix) and inadequate diuretic response. in addition to diuretic therapy, sildenafil was started to promote vasodilatation of pulmonary vasculature. she was briefly transferred to the floor, and a right heart catheterization was performed on . however she continued to show e/o volume overload and had a high oxygen requirement despite aggressive diuresis. she was admitted to the ccu to begin treatment with milrinone. unfortunately she had no improvement in cardiac output to milrinone or nifedipine, and both were discontinued. she was restarted on sildenafil. the rheumatology service was consulted for management of her mctd. she was initially on her chronic daily daily oral prednisone doses of 5 mg but then started on high dose iv solumedrol in hopes of decreasing inflammation and improving her pulmonary hypertension. . on her hct acutely decreased from 28 to 23 within 24 hours, which raised concern for acute bleed given her coagulopathy and thrombocytopenia. her bp decreased to 70s/40s and her o2 requirement increased, requiring emergent intubation and pressor support. ct chest/abdomen/pelvis showed no acute bleed. she was transfused rbcs and ffp. ng tube drained coffee-ground colored fluid, c/f acute gastritis or ulcer. she was evaluated by gi service and started on iv ppi. her hct then stabilized. she had endoscopy which showed no active bleed. she was evaluated by the hematology service for further workup of her coagulopathy. her labs were not c/w dic or heparin-induced thrombocytopenia, and her coagulopathy was thought most likely due to her hepatic congestopathy and cirrhosis. . she was evaluated by the pulmonary service regarding possibility of starting flolan therapy. however this was not able to be pursued since the patient's insurance would not cover this therapy. she was started on cytoxan but her cardiac output continued to decline. on , a family meeting was held and the family chose to change her code status to dnr as chest compression would not likely be effective for her in the event of cardiac arrest. on the morning of she passed away with her family at bedside. family declined autopsy. medications on admission: reviewed with patient on admission amlodipine - 5 mg daily setraline 50 mg po qd folic acid - 2 mg daily hydroxychloroquine - 200 mg levothyroxine - 25 mcg daily methotrexate sodium - 25 mg q week omeprazole - 40 mg daily prednisone - 20 mg daily calcium and vitamin d discharge medications: n/a discharge disposition: expired discharge diagnosis: primary diagnoses: right heard failure pulmonary hypertension mixed connective tissue disorder discharge condition: deceased discharge instructions: n/a followup instructions: n/a procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more combined right and left heart cardiac catheterization coronary arteriography using two catheters other endoscopy of small intestine insertion of endotracheal tube hemodialysis closed (percutaneous) [needle] biopsy of liver closed [endoscopic] biopsy of bronchus pulmonary artery wedge monitoring pulmonary artery wedge monitoring pulmonary artery wedge monitoring right heart cardiac catheterization right heart cardiac catheterization central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified acidosis systemic lupus erythematosus hyperpotassemia acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified long-term (current) use of steroids unspecified septicemia hyposmolality and/or hyponatremia severe sepsis other chronic pulmonary heart diseases defibrination syndrome acute and chronic respiratory failure cellulitis and abscess of leg, except foot cardiogenic shock ostium secundum type atrial septal defect septic shock other ascites do not resuscitate status acute diastolic heart failure hemorrhage of gastrointestinal tract, unspecified other and unspecified coagulation defects diseases of tricuspid valve raynaud's syndrome chronic passive congestion of liver systemic sclerosis other disorders of menstruation and other abnormal bleeding from female genital tract other secondary thrombocytopenia lung involvement in systemic sclerosis 

Answer: The patient is high likely exposed to