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: vancomycin attending: chief complaint: rib pain major surgical or invasive procedure: intubation stress mibi history of present illness: 71 y/o f w/ metastatic breast ca, w/ bone involvement, on tamoxifen, who presents with worsening right rib pain. . she reports that rib pain has been a chronic problem, but has been worse over past one week. the right side is worse, but she also reports left sided rib pain and chest wall pain. she does not report any trauma or heavy lifting or turning that seemed to precipitate the pains. she was recently started on percocet for pain which did help, but she has had to take it around the clock without full relief. . ros: denies n/v/f/c. no chest pain. + shortness of breath- secondary to not able to take in full breaths from pain in right side; no associated rash; + constipation. . in er, given oxycodone 10mg, flexerill 10mg, and 10mg oxycontin. however continued pain, therefore admitted for pain control past medical history: 1. hypertension 2. glaucoma 3. breast cancer 4. rib pain 5. atrial fibrillation . oncologic history: initially diagnosed in spring of with a dimpling in her right breast and a positive mammogram. excisional biopsy demonstrated infiltrating and intraductal carcinoma which was greater than 2 cm and she subsequently went for a right modified mastectomy and axillary dissection. she had negative margins and 1 positive lymph node. the tumor was er positive and she was subsequently stage 2, n1 disease. subseqeuently received adjuvant cmf chemotherapy, followed by 5 years tamoxifen. had long disease free interval, with subsequent recurrent disease w/ bony involvement in . started on femara at that point with good response. on progression from this she was placed on aromasin in but did not do well with this, with increased bone pain. most recently placed back on tamoxifen since . social history: lives at home in w/ husband, functional of adls. former smoker for approximately 50 pack years, quit 10 years ago. rare social alcohol. family history: sister died of breast ca, 56 physical exam: vitals- 98.3, 162/94,76, 18, 97% ra gen- nad heent- eomi. mmm pulm- cta b/l cv- rrr. no m/r/g abd- soft,non-tender, mild distension, nabs ext- 1+ ankle edema b/l les, no calf swelling, tenderness neuro- alert and oreinted x 3, cnii-xii intact. back/flank- no focal spinal tenderness; + tenderness to palpation diffusely along right posterior and anterior rib cage, also w/ tenderness on l side (r>l). + tenderness over sternum and anterior chest wall to palpation. no associated dermatomal rash pertinent results: cxr : pa and lateral chest radiograph: there is an opacity within the left lung base with associated volume loss consistent with atelectasis/consolidation. small left pleural effusion is present. the cardiomediastinal contour is stable. the pulmonary vessels demonstrate mild cephalization, however there is no frank edema. mild loss of height is seen in mid-thoracic spine vertebral body as well as mottled appearance and fractures involving multiple ribs. . tte : 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. overall left ventricular systolic function is normal (lvef>55%). transmitral doppler and tissue velocity imaging are consistent with grade ii (moderate) lv diastolic dysfunction. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated athe sinus level. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. the aortic valve leaflets are mildly thickened. the aortic valve is not well seen. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the mitral valve is not well seen. mild to moderate (+) mitral regurgitation is seen. there is no pericardial effusion. . rib films : multiple healed bilateral rib fractures and osseous metastatic disease involving the ribs. possible acute fracture of lateral left sixth rib. . ct t-spine : ct scan of the thoracic spine which was obtained on , and employed contrast administration intravenously. the study was reported by myself and dr. as revealing "diffusely abnormal appearing vertebral bodies in the thoracic spine as seen on the prior mri scan consistent with metastatic disease. a focal lytic lesion in t5 vertebral body has progressed since . anterior wedging of t12 with an associated central lucency extending to the superior endplate suggests pathological fracture. heterogeneously enlarged thyroid gland. correlate son." comparison with the prior study of reveals likely progression of diffuse metastatic disease of the thoracic spine. while the present study appears to be of higher spatial resolution than the prior examination, there has been some progression of compression fractures, including nearly all thoracic vertebral bodies, most notably at t7, t8 and t12. however, there does not appear to be retropulsion of pathologic fractures into the central spinal canal. the t5 lytic lesion is not as clearly discernible at this time, suggesting there may have been some interval reactive sclerosis. there are probable small bilateral pleural effusions, slightly more evident on the left side, as well as multiple small wedge-shaped areas of soft tissue density within the posterior lung fields. these pulmonary lesions were not present on the prior spinal ct scan but were seen, at least in part, on a recent torso ct scan. it is suggested that these pulmonary issues be reviewed with the chest ct service, and if deemed necessary, a followup chest ct scan be obtained. finally, there is no overt sign or an epidural mass on this study, although in this regard, mr scanning is more efficacious at detecting such an abnormality. conclusion: apparent progression of what is likely diffuse osseous metastatic disease, with the appearance of multiple compression fractures as noted above. . tte the left atrium is mildly dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the tricuspid valve leaflets are mildly thickened. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a fat pad. compared with the prior study (images reviewed) of , the mitral deceleration time is now shorter suggestive of more severe diastolic dysfunction/elevated left atrial pressures. significant tricuspid regurgitation is now detected (suboptimal visualized in prior study). significant pulmonary artery systolic hypertension in now detected (unable to assess in prior study). brief hospital course: 71 y/o f w/ metastatic breast ca, w/ bone involvement, on tamoxifen, who was admitted with worsening chest wall pain. . the patient was intially admitted to the oncology service for pain control. she was intially managed on the floor with oral narcotic pain regimens. rib films revealed multiple chronic and acute rib fractures. given persistently poorly controlled pain despite uptitration of narcotics, ct of her t-spine was obtained; this study revealed multiple vertebral compression fractures. patient was fitted with an abdominal binder for support with ambulation. on the patient developed an episode of atrial fibrillation with rapid ventricular resonse, and developed pulmonary edema requiring intubation and transferred to the . . 1. respiratory failure: due to pulmonary edema secondary to hypertension and atrial fibrillation with underlying diastolic heart failure. she was diuresed on a lasix gtt with improvement. she was extubated on . she did well, and was transferred to omed on , however, became quite anxious, hypertensive and developed recurrent pulmonary edema requiring transfer back to the icu on ; her respiratory status quickly normalized with diuresis as well as control of her anxiety and blood pressure. she continued to improve o nthe floor, with iv lasix 20mg . 2 hypertension, diastolic heart failure: patient was on regimen of diovan and toprol at time of admission. these were discontinued on the floor as her narcotics were uptitrated. after extubation, she developed another episode of hypertension in the setting of anxiety and was noted to have persistantly elevated sbp, therefore her diovan was restarted on . she was transferred to cardiology for optimization of her cardiac regimen. beta blocker was discontinued and her diovan was uptitrated. . 3 paf: the patient has a history of paroxysmal atrial fibrillation. her inr was supratherapeutic at 3.5 at time of admission on home dose of 4.5 mg qhs. on the patient developed afib with rvr, developed pulmonary edema requiring intubation. while in the icu, her coumadin was discontinued due to anticipated procedures. several regimens for rate control were trialed including diltiazem gtt, digoxin; the patient flipped in and out of nsr and afib for several days, frequently dropping her bp and requiring neo while in afib. ep was consulted. she was loaded on amio; she converted to nsr and remained there for the remainder of her hospitalization with intermittant brief periods of asymptomatic paf, . coumadin was restarted on and she reached therapeutic levels prior to d/c. . 4 pain control: the pain team was consulted. the patient was controlled with dexamethasone, tylenol, lyrica, tizanidine, lidocaine patch, and prn dilaudid. . 5 anxiety: the patient has significant anxiety which exacerbate her htn and atrial fibrillation. she was given ativan prn with good relief. . 6 metastatic breast cancer: the patient was continued on tamoxifen. she will follow up with her primary oncologist for further management. . 7 diarrhea: the patient developed diarrhea on . she was started empirically on po flagyl with improvement of her symptoms. c diff was negative x2. she will complete a 7 day course of flagyl. on the day of discharge, patient is feeling improved. she has had good success with physical therapy, and her breathing feels improved. her blood pressure is well controlled and she is in nsr. medications on admission: diovan 40mg toprol 50mg coumadin 4.5 mg qhs timolol eye drops od alphagan ou citrocal percocet 5-10mg q 4-6prn discharge medications: 1. tamoxifen 20 mg tablet sig: one (1) tablet po once a day. 2. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day) as needed. 3. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q4h (every 4 hours). 4. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 5. pregabalin 75 mg capsule sig: one (1) capsule po bid (2 times a day). 6. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical qday (). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 8. nystatin 100,000 unit tablet sig: one (1) tablet vaginal hs (at bedtime). 9. brimonidine 0.15 % drops sig: one (1) drop ophthalmic (2 times a day). 10. hydromorphone 2 mg tablet sig: one (1) tablet po q3-4h (every 3 to 4 hours) as needed for pain. 11. insulin lispro (human) 100 unit/ml solution sig: 1-10 units subcutaneous asdir (as directed). disp:*500 units* refills:*0* 12. tizanidine 2 mg tablet sig: 0.5 tablet po tid (3 times a day). 13. timolol maleate 0.25 % drops sig: one (1) drop ophthalmic daily (daily). 14. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day). 15. warfarin 1 mg tablet sig: three (3) tablet po hs (at bedtime). 16. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day). 17. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. 18. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day). 19. dexamethasone 4 mg tablet sig: one (1) tablet po q6h (every 6 hours). 20. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 21. valsartan 160 mg tablet sig: one (1) tablet po bid (2 times a day). 22. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 23. lorazepam 1 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 24. heparin flush picc (100 units/ml) 2 ml iv daily:prn 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. 25. outpatient lab work inr check every thursday discharge disposition: extended care discharge diagnosis: rib fractures vertebral compression fractures metastatic breast cancer atrial fibrillation discharge condition: afebrile, vital signs stable, tolerating pos. discharge instructions: you were admitted for pain control. you were found to have several rib fractures, as well as multiple vertebral compression fractures in your thoracic spine. . additionally, you experienced 2 episodes of pulmonary edema (fluid on the lungs). these may have been due to your atrial fibrillation and hypertension. a stress mibi test showed normal myocardial perfusion. some of your medicines have been adjusted. please take them exactly as prescribed on the attached list. please take amiodarone 200mg daily please take valsartan 160mg twice a day. please continue to take the flagyl for 3 more days to complete a 7 day course. . you should call dr. office if you are experiencing fevers, shortness of breath, chest pain, confusion, or other concerning symptoms. followup instructions: you should call dr. office to schedule a follow-up appointment in days: (. please call dr. office at to make a follow up appointment in 2 weeks. please follow up with dr. in weeks. please call his office for an appointment. md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances transfusion of packed cells diagnoses: hyposmolality and/or hyponatremia atrial fibrillation personal history of malignant neoplasm of breast constipation, unspecified anxiety state, unspecified acute respiratory failure long-term (current) use of anticoagulants dermatitis due to drugs and medicines taken internally diarrhea acute diastolic heart failure secondary malignant neoplasm of bone and bone marrow neoplasm related pain (acute) (chronic) pathologic fracture of other specified site pathologic fracture of vertebrae family history of malignant neoplasm of breast unspecified hypertensive heart disease with heart failure unspecified drug or medicinal substance causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to