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: latex / lisinopril attending: chief complaint: dyspnea major surgical or invasive procedure: lumbar puncture thoracentesis left breast wound drainage history of present illness: 55 yo f with breast cancer, htn, dm2, presents with dyspnea on exertion, orthpnea, and lower extremity edema. she says her symptoms started 2 weeks ago, even before her breast surgery, which was on . at that time, she underwent left needle-localized lumpectomy, sentinel node biopsy, and low axillary dissection. during the last couple of weeks, her dyspnea has worsened. it is worse with exertion and with lying flat. she has also noticed lightheadedness and has needed to steady herself when walking. she has had a cough, productive of yellow sputum. no hemoptysis. +bilateral ankle swelling. due to wheezing, she was treated with albuterol as an outpatient, but that did not seem to help. the symptoms became worse over the past couple of days, leading the patient to present to the ed. in the ed, initial vs were: t 98.0 bp 103/73 hr 112 rr 16 sat 97%/ra. bedside ultrasound showed significant bilateral pleural effusion without pericardial effusion. the patient was given levofloxacin and vancomycin due to concern for infection. subsequently cta showed pe. she was guaiac negative, but head ct showed an abnormality for which the differential included subarachnoid hemorrhage, so heparin was not started. the patient was given 500 cc of normal saline. on transfer to the , vital signs were 97.5 120 24 128/75 100%/2l. on arrival to the micu, the patient stated that her breathing was improved. past medical history: diabetes mellitus, type 2 breast cancer (see below) vitamin d deficiency htn hyperlipidemia obesity low vision congenital syphilis oncologic history: -breast cancer, stage iib - mammogram/ultrasound: mass in left upper outer quadrant. hypoechoic solid, irreg., spiculated 2.5x2.1x2.4cm. left axilla with multiple hypoechoic nodules consistent with lymph nodes, largest 1.7cm and 3.4cm. -pathology: poorly differentiated invasive ductal carcinoma without definite in situ or lymphatic vascular invasion. immunohistochemistry showed a negative estrogen and progesterone receptor her2/neu was 2+. -: ct chest/abd/pelvis neg for malignancy - - : 4 cycles of adriamycin and cytoxan -, and taxol 80mg/m2 and herceptin - taxol 175/m2, herceptin (cycle #3) - taxol/175/m2, herceptin c4 social history: has 8 children. tobacco: quit etoh: quit 22 year ago. drugs: quit 22 years ago. family history: daughter with breast cancer. no family history of venous thromboembolism. physical exam: admission exam: vitals: hr 115 bp 117/66 sat 96% general: alert, oriented, no acute distress heent: left eye cloudy, with chronic visual loss, mmm, oropharynx clear, eomi neck: supple cv: tachycardic. regular rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: decreased breath sounds at bilateral bases abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: no foley ext: warm, well perfused, trace bilateral le edema neuro: right pupil round and reactive. left eye opacified (chronic). eomi, with end-gaze nystagmus in all directions of gaze. facial movement full, 5/5 strength upper extremities, lower extremity movement symmetric but did not stress calves due to possibility of dvt. discharge exam: vitals: 97.4, 98/68 (90-100/60-80s), 100, 20, 97% on ra general: alert, oriented, no acute distress heent: left eye with congenital lid lag, mmm, eomi neck: supple axilla: left axilla with area of swelling at surgical site, surrounding erythema and induration cv: tachycardic, no m/r/g lungs: decreased breath sounds at bases b/l, otherwise clear without wheezes abdomen: +bs, soft, non-distended, no tenderness ext: warm, well perfused, no pedal edema neuro: right pupil round and reactive. left eye opacified (chronic). pertinent results: admission labs: 03:30pm wbc-5.1 rbc-3.88* hgb-11.3* hct-35.8* mcv-92 mch-29.0 mchc-31.5 rdw-16.3* 03:30pm neuts-68.6 lymphs-22.1 monos-5.5 eos-3.1 basos-0.6 03:30pm plt count-305 06:00pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 03:53pm lactate-1.5 03:30pm glucose-97 urea n-10 creat-0.9 sodium-139 potassium-3.8 chloride-107 total co2-21* anion gap-15 cardiac labs: 03:30pm ck(cpk)-72 03:30pm ctropnt-0.04* 03:30pm ck-mb-2 12:06am blood ck-mb-2 ctropnt-0.04* 05:22am blood ck-mb-2 ctropnt-0.03* probnp-684* 04:16pm blood ck-mb-2 ctropnt-0.02* bodily fluids: 01:14pm pleural wbc-450* rbc-3550* polys-5* lymphs-68* monos-15* eos-1* atyps-2* meso-2* other-7* 01:14pm pleural totprot-1.8 glucose-94 ld(ldh)-74 cholest-17 triglyc-8 05:28pm cerebrospinal fluid (csf) wbc-0 rbc-0 polys-1 lymphs-77 monos-22 05:28pm cerebrospinal fluid (csf) totprot-19 glucose-65 ld(ldh)-16 herpes simplex pcr: negative discharge labs: 04:48am blood wbc-4.1 rbc-3.68* hgb-10.3* hct-33.3* mcv-91 mch-28.1 mchc-31.1 rdw-15.7* plt ct-287 04:48am blood glucose-88 urean-8 creat-0.8 na-138 k-3.8 cl-100 hco3-30 angap-12 04:48am blood calcium-9.2 phos-4.1 mg-2.0 microbiology: blood culture -no growth csf gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. fungal culture (final ): no fungus isolated. acid fast culture (preliminary): the sensitivity of an afb smear on csf is very low.. if present, afb may take 3-8 weeks to grow.. no mycobacteria isolated. viral culture (preliminary): no virus isolated. pleural fluid gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. blood culture - no growth. imaging: # cxray: impression: bilateral moderate pleural effusions with adjacent bibasilar atelectasis and mild pulmonary congestion. pneumonia cannot be entirely excluded in the right clinical setting. # cta chest: impression: 1. left lower lobe segmental pulmonary embolism without evidence of right heart strain or pulmonary infarction. 2. interlobular septal thickening is concerning for fluid overload. given the lack of nodularity, carcinomatosis seems much less likely, but is hard to completely excluded. 3. moderate bilateral pleural effusions, larger on the right than the left. in conjunction with the septal thickening, these are most likely secondary to fluid overload from chf, although malignant effusions cannot be completely excluded. 4. bibasilar consolidations are likely atelectasis, although in the proper clinical setting, infection cannot be excluded. 5. subcutaneous air in the left breast, possibly extending to the skin. these are likely postoperative changes. recommend clinical correlation, however, with direct inspection of the operative site. 6. left axillary seroma. 7. trace pericardial effusion. # ct head: abnormal gyriform hyperdensity in the left frontal lobe of uncertain etiology in the setting of prior intravenous contrast administration, but the differential diagnosis includes abnormal enhancement associated with leptomeningeal carcinomatosis, possibly with a parenchymal mass or edema; although unlikely, it is not possible to exclude hemorrhage. recommend an mri for further evaluation. # echo: left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is severe global left ventricular hypokinesis (lvef = 25-30 %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. the right ventricular cavity is mildly dilated with borderline mild global free wall hypokinesis. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a small to moderate sized pericardial effusion. there are no echocardiographic signs of tamponade. impression: cardiomyopathy. pericardial effusion. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. # mri w and w/o contrast: conclusion: left frontal and right parietal enhancing lesions appear most likely to be subacute infarction, with the right parietal lesion more recentthan the left frontal. # cta head: no vascular abnormalities detected on the head cta. left frontal enhancement and left mastoid opacification appear unchanged. # cxr impression: moderate left and trace right pleural effusion with likely mild pulmonary edema. # left axillary u/s: findings: a focused left axilla ultrasound was performed in the in the region of concern. two heterogeneous complex collections, which appear to communicate, are identified in the anterior left axilla. the 1st more superior and superficial collection in subdermal location, measures 5 cm in transverse and 2 cm deep. this collection demonstrates several persistent foci of low-level back and forth flow. a 2nd more inferior collection measures 7 x 6.5 cm. no doppler flow is seen in this 2nd collection. the collections are far removed from the left axillary artery. impression: two, apparently communicating, 5 and 7 cm complex fluid collections in the left axilla may represent hematomas although infection cannot be excluded. flow into the more superior collection may be due to mobile fluid or slow continued bleeding (felt less likely). a contrast ct may be useful to evaluate for continued bleeding, if clinically warranted, but venous bleeding can be difficult to assess. brief hospital course: 55 yo female with hx breast cancer, htn, dm2, who presented with dyspnea on exertion, orthopnea, and lower extremity edema found to have a pe, bilateral pleural effusions, and pericardial effusion with new systolic chf. active issues: # pe: pt presented with doe, orthopnea and cough, likely due in part to new diagnosis of pulmonary embolism. in the , pt was guaiac negative, but head ct showed an abnormality for which the differential included subarachnoid hemorrhage, so initiation of heparin was deferred and pt was transferred to the . neurology was consulted and an lp was performed, which was unrevealing for any infectious etiologies. neurology felt it was safe to start anticoagulation so she was started on lovenox. pt was not interested in coumadin monitoring so she was continued on lovenox. she had a tte which was negative for any evidence of right heart strain. she was quickly weaned off oxygen and was satting in mid to high 90s on room air at time of discharge. # systolic chf: because of new pleural effusions noted on chest ct, tte was performed which showed severe global left ventricular hypokinesis with ef of 25% along with small pericardial effusion (no tamponade), which was new from prior echo at start of chemo therapy. the concern is that her new diagnosis of chf may have been secondary to chemotherapy she received for recent diagnosis of breast cancer. pt had a therapeutic/diagnosis paracentesis performed, which was transudative in nature. she was initially diuresed, but this was complicated by hypotensive episodes. at time of discharge, pt appeared euvolemic. she was started on valsartan and low dose aspirin and will follow up with cardiology as an outpatient. consider spironolactone and beta blocker once stable to medically optimize, although anticipate cardiomyopathy may reverse when adriamycin is complete and these medications may not be necessary. her pleural fluid cytology was negative for malignant cells. # axillary fluid collection: pt was noted to have increasing erythema, warmth and induration in left axilla at site of recent breast drainage. surgery was consulted and drained a small collection of serosanguinous fluid. she was initially started on keflex for presumed cellulitis, however the patient was afebrile and without leukocytosis so keflex was discontinued. her factor x level was checked given that patient was on lovenox and there was concern that if she was supratherapeutic, it may be contributing to bleeding within her recent surgical site. however, her lovenox dosing appeared adequate and her hct remained stable. she had a left axillary ultrasound that did show a communicating fluid collection so surgery drained more fluid. at time of discharge, pain and induration had improved, and pt will follow up with surgery as an outpatient. # brain mri c/w infarcts: because of abnormal head ct obtained in the , mri was obtained which showed several enhancing lesions consistent with subacute infarcts. neurology felt that these were most likely embolic in nature. she had a tte with negative bubble study. she was continued on her pravastatin and aspirin and will need a repeat mri as an outpatient in months. # neuropathy: pt complained of recent onset lower extremity tingling, concerning for chemotherapy induced neuropathy. she was started on low dose gabapentin during this admission and this can be increased as necessary as an outpatient. chronic issues" # breast cancer: staged as 2b s/p treatment with adriamycin and cyclophosphamide, taxol, and weekly herceptin, needle-localized lumpectomy, sentinel node biopsy, and low axillary dissection with pleural effusion negative for malignancy. her further chemotherapy options may be limited as pt appeared to develop chf in setting of active chemotherapy. she will follow up with oncology as an outpatient. # t2dm: pt was on metformin at home, though this was held while in house. her blood sugar was controlled with insulin 75/25 as well as sliding scale insulin. her insulin dose was decreased during this hospitalization given low blood sugars. her metformin was resumed on discharge. # depression: continued bupropion transitional issues: # pt's hypercoagulable work up was pending at time of discharge and should be followed as an outpatient. # pt will need a repeat outpt brain mri in months. # she will need to establish care with cardiology as an outpatient for continued adjustment of medications given her new diagnosis of heart failure. # pt will need to follow with surgery regarding her left axillary seroma. medications on admission: losaratan 50mg oral daily pravastatin 40mg daily metformin 1000mg daily clobetasol 0.05% topical prn (eczema) insulin lispro 75-25 kwikpen 18 units before breakfast and dinner (does not check her bg usually otherwise) buproprion 300mg xl daily herceptin - every 4 weeks infusion discharge medications: 1. lovenox 80 mg/0.8 ml syringe sig: eighty (80) mg subcutaneous every twelve (12) hours. disp:*60 syringes* refills:*0* 2. pravastatin 40 mg tablet sig: one (1) tablet po once a day. 3. valsartan 40 mg tablet sig: 0.5 tablet po once a day. disp:*15 tablet(s)* refills:*0* 4. bupropion hcl 300 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. 5. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*0* 6. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) puff inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*0* 7. metformin 1,000 mg tablet sig: one (1) tablet po twice a day. 8. gabapentin 100 mg capsule sig: one (1) capsule po q8h (every 8 hours). disp:*90 capsule(s)* refills:*0* 9. humalog mix 75-25 100 unit/ml (75-25) suspension sig: six (6) units subcutaneous twice a day. 10. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* discharge disposition: home with service facility: vna discharge diagnosis: primary: pulmonary embolism congestive heart failure secondary: breast cancer discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure taking care of you at . you were admitted for shortness of breath. you were found to have a pulmonary embolism (a blood clot in your lungs) as well as congestive heart failure. this means that your heart does not pump as effectively as it should. you were noticed to have some bleeding into your left breast where you had surgery. because of the blood clot, you will need to be on blood thinners. we also changed some of your other medications for your heart. please make the following changes to your medications: # start lovenox 80 mg injections twice a day # start valsartan 20 mg daily # start omeprazole 40 mg daily # start aspirin 81 mg daily # start gabapentin 100 mg three times a day # use albuterol inhaler every 4 hours as needed for shortness of breath # stop losartan # decrease insulin 75-25 to 6 units in the morning and before dinner. please check your blood sugars 4 times a day, as your insulin dose may need to be adjusted further. please continue all other medications as prescribed. followup instructions: cardiology appointment: thursday, at 1:30pm with: dr. location: , , phone: pcp :, at 10:40am with: ,md location: address: , , phone: hematology/oncology: , at 11am with: dr. location: , 4th fl , phone: surgery appointment:pending with: dr. phone: **we are working on a follow up appointment with dr. in the next week. you will be called at home with the appointment. if you have not heard within 2 business days or have questions, please call the number above. you should be seen this week. you will also need to have a repeat mri brain done as an outpatient. please discuss this with your primary care doctor. procedure: spinal tap incision of lung thoracentesis diagnoses: other primary cardiomyopathies pure hypercholesterolemia unspecified pleural effusion congestive heart failure, unspecified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled hematoma complicating a procedure constipation, unspecified long-term (current) use of insulin other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation hypoxemia primary hypercoagulable state obesity, unspecified cerebral embolism with cerebral infarction unspecified hereditary and idiopathic peripheral neuropathy acute on chronic systolic heart failure other pulmonary embolism and infarction profound impairment, both eyes, impairment level not further specified unspecified vitamin d deficiency malignant neoplasm of breast (female), unspecified 

Answer: The patient is high likely exposed to