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: iodine attending: chief complaint: right hand weakness, facial droop major surgical or invasive procedure: 1. percutanrous biopsy of lung pleura 2. whole brain radiation therapy 3. fine needle aspiration of abdominal wall mass history of present illness: 68 yo woman recently s/p complicated hospital course (see below), also hx rcc s/p left nephrectomy in past, thyroid ca s/p surgery and radiation, adrenal mass with no w/u yet, known pulm nodules, known c7-t1 spine infiltrative process (ca vs abscess) s/p lami with negative path for malignancy, paraspinous abscess in recent past, among other medical problems who presents with l facial droop, r hand weakness x 3 days. she says that she had been doing well until 3 d pta when she noticed over 30 min to 1 hr gradual weakening of right hand described as "fingers closing up" which worsened more later in day. speaking with her daughter on the phone, the daughter thought she sounded different and wasn't articulating her words. she was also noticed to have a left facial droop that day (opposite side from hand). she did not want to come to the ed because she was afraid she would be admitted to the hospital. pt came to visit on third day and recommended she come to ed. she had no improvement or worsening of sx over past few days, and no ha/visual changes/ hearing/language/memory/ swallowing/dizziness/ltheaded/vertigo/unsteady gait (although she did have trouble holding onto her walker with the right hand) and no parasthesias/sensory loss/falls/weakness elsewhere. no f/cp/palp/n/v/d/abd pain/sob/wheeze but chronic cough and episodes hemoptysis. other ros + chills, depression related to acute illness. pt had been hospitalized after presenting with fever after recently having been discharged from hospital for paraspinous abscess s/p tx with abx with vanco and levaquin. had also c/o neck pain, found to have pseudomonal uti but no other source of fever; imaging showed fluid collection at l3-4 and stable cervical spine dz; cervical lesion through to be either neoplastic vs abscess. tx'ed with vanco, zosyn. she persistently spiked, extensive id, rheum and malig w/u with the following results: weakly positive; crp elev 298; pleural-based nodules s/p vats neg for malignancy or infection including afb/fungal; bal neg x some ; numerous neg bcx; stool neg c-diff; lp neg cytology and other studies nl (prot 55, gluc 34, no cells); bone scan pos. for mult areas abnl uptake spine, humerus, tibia, sternoclav joint, 2nd rib suspicious for malig. eventually underwent lami for tissue dx epidural mass - was negative for malig, afb or fungus. hosp course also sig for pseudogout (crystals on tap); neck pain with fluid collection at site of ind prev admission for paraspinous abscess, improved by end of hosp on vanco; tremor->mri brain rec by neuro, found 2.5 cm meningioma r parietal, no mets, no explanation for tremor x possible metabolic derangement; hemoptysis and chronic cough (vats neg for malig), arf thought some prerenal; anemia requiring several transfusions; yeast infection; elev tsh thought related to time of dosing per endocrine. improved and was sent to rehab. stable on coumadin, and dm and htn were under control at time. improved at rehab and was sent home on ; returned to rehab for anemia sx, transfused and sent home the following wednesday. did well over next week, with no c/o until 3 days pta. past medical history: per above; also sig for: 1. papillary thyroid ca. diagnosed by biopsy , resected , s/p radiation; on synthroid for replacement now 2. renal cell ca, s/p left nephrectomy at , , cri 3. adrenal mass, 2.8 cm, no w/u. 4. diffuse pulmonary ground glass opacities, followed in pulmonary clinic by dr. . also had numerous tiny well-circumscribed nodules, of unclr etiology, but with one that on last ct was enlarging (in lul), was supposed to go for bronch vs transthoracic bx but did not f/u. 5. hx of positive ppd, (exposure to pt w/tuberculosis when working as nurse's aide), s/p rx w/inh. 6. dm x 30 years with peripheral neuropathy 7. htn 8. pvd- fem-ant/tib bypass on l in on coumadin since then presumably for low flow state; no hx dvt's or pe's, no hx afib 10. cri (arf as inpt recently) social history: pt lives with her husband, has 6 children. previous 40 pack year smoking history, quit 10 years ago. no etoh, no illict drug use family history: children healthy, aunt with lung cancer, no other known fam hx physical exam: physical exam when seen initially in ed: vitals: t: 98.3 p: 76 bp: 140/80 to 193/56 at admission rr: 18 sao2: 95% general: awake, alert, and cooperative with exam in no acute distress. heent: normocephalic, no scleral icterus noted, clear oropharynx with moist mucus membranes neck: supple, with no ttp post neck pulmonary: lungs clear anteriorly cardiac: regular rate and rhythm abdomen: soft, nontender, with normoactive bowel sounds extremities: warm with no edema; feet slt cool skin: no rashes or lesions noted, but birthmark over right side of face and forehead neurologic: mental status: the patient is awake, alert, and oriented x 3. able to relate history without difficulty. language is fluent with intact repetition and comprehension, and speech is normal rate, tone and volume. patient was able to register 3 objects and recall at 30 seconds and easily at 5 minutes. could recall phone number for pharmacy. there was no apraxia. cranial nerves: olfaction not tested. pupils equal, round and reactive to light bilaterally, and visual fields intact to confrontation bilaterally with no hemineglect. no ptosis is noted, and on fundoscopic exam discs were hard to visualize. extra-ocular muscles were intact without nystagmus. sensation was intact to light touch over face with no ext to dss. left umn facial droop was noted; hearing was intact to finger-rub bilaterally. palate and uvula elevate at midline. there is 5/5 strength in trapezii and sternocleidomastoids bilaterally. tongue protrudes in midline, with no fasciculations. motor: diffuse atrophy of limbs (arms and legs), nl tone throughout. no tremor, asterixis or drift. delt bic tri wre ffl fe io ip ham ta edb l 5 5 5 5 3 2 2 5 5- 5 5 4+ 4+ r 5 5- 5- 5- 5 5 5 5 4+ 5 5 4+ 4+ sensory: no deficits to light touch, pinprick, vibratory sense, proprioception throughout upper extremity. lower ext with decr pp to ankle. no extinction to dss. + agraphesthesia and astereognosis of right hand, nl on left hand. coordination: normal finger to nose on left; right could not perform but touched face with hand, no tremor or dysmetria; nl heel to shin bilat, with no dysmetria. nl finger tapping on left, could not perform on right; nl foot tapping. reflexes: 2+ biceps, triceps, brachioradialis, 1+ patellar and 0 ankle jerks bilaterally. the patient had mute toes on plantar response bilaterally. gait: could not assess due to pt's being taken for study. patient reexamined at 5:45pm for acute change in ms (last seen at 5:30pm): -pt now unresponsive to voice and sternal rub; finally awoke to deep sternal rub and could raise hand on command, open eyes but did not stay awake unless stimulated. mvmt of all four extremities noted, toes still mute, reflexes unchanged. for change in ms and intubated. bp in 200/80 range at the time. inr reversed with prolix. pertinent results: 03:20pm wbc-28.2* rbc-3.65* hgb-10.3* hct-32.4* mcv-89 mch-28.1 mchc-31.6 rdw-21.1* 03:20pm neuts-67 bands-4 lymphs-2* monos-7 eos-19* basos-0 atyps-1* metas-0 myelos-0 03:20pm plt count-337 03:20pm pt-18.2* ptt-28.2 inr(pt)-2.3 03:20pm ck(cpk)-51 03:20pm ck-mb-4 ctropnt-0.11* 03:20pm glucose-307* urea n-22* creat-1.3* sodium-133 potassium-4.8 chloride-100 total co2-24 anion gap-14 06:45pm urine blood-lg nitrite-neg protein-tr glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 06:45pm urine color-straw appear-clear sp -1.008 06:45pm phenytoin-15.7 09:25pm lactate-1.9 ekg: sinus rhythm. poor r wave progression, cannot rule out old anteroseptal myocardial infarction. loss of r waves in leads iii and avf, consider old inferior wall myocardial infarction. compared to the previous tracing of loss of r waves in lead avf is new. otherwise, no significant diagnostic change. mri with contrast findings: again seen are numerous intraparenchymal enhancing masses with associated hemorrhage. these are compatible with the clinical impression of metastatic disease. note that a large right frontal extra-axial lesion most likely represents a meningioma. the extra-axial lesion appears approximately stable since the mr . the intraparenchymal lesions are new since that time, but appeared stable since the study of . a preliminary report was issued that read "multiple hemorrhagic enhancing metastases are again seen, with variable amounts of surrounding edema. the largest lesion is in the right cranial vertex. the vasculature appears unremarkable." conclusion: numerous hemorrhagic enhancing intraparenchymal masses compatible with the clinical impression of metastatic disease. extra-axial lesion at the right vertex likely representing a meningioma. 1st ct : findings: again seen is a calcified meningioma measuring approximately 2.2 cm near the vertex in the right frontal region. since the prior examinations, there have been development of numerous well-circumscribed rounded lesions of increased attenuation seen scattered throughout both frontal and temporal lobes. the largest two lesions are in the left frontal lobe measuring approximately 10 x 12 mm and in the right temporal lobe measuring 12 x 9 mm. both these lesions have some surrounding hypodensity consistent with edema. there is no subdural or subarachnoid hemorrhage seen. there is no hydrocephalus or shift of normally midline structures. soft tissues and osseous structures are normal. the visualized paranasal sinuses and mastoid air cells are clear. impression: 1. interval development of numerous hyperdense lesions within both frontal and temporal lobes. the differential for this is hemorrhagic metastases or traumatic contusion. the appearances are suggestive of hemorrhagic metastasis. 2. unchanged appearance of right calcified meningioma. 2nd ct brain : there has been no change in the appearance of innumerable bilateral hemorrhagic lesions, likely hemorrhagic metastases. the extent of surrounding vasogenic edema within the left frontoparietal and right temporal lobes is also unchanged. there is no new intracranial hemorrhage. the ventricles and sulci are stable in appearance. in the intervening time, the patient has been intubated. ct torso: findings: images of the lower thorax again demonstrate nodular thickening of the left pleura which is slightly increased since the prior exam of . interstitial thickening is present in the left base which was also seen previously and is slightly more prominent on the current exam. again visualized is a left subpulmonic fluid collection measuring 7.0 x 8.6 x 7.8 cm. it is predominantly low density with iso and hyperdense material present within it. no associated rib lesions are present. the size of this collection has not significantly changed since an mri from . in the context of a non-contrast enhanced ct, the liver, spleen, pancreas, and left adrenal gland are unremarkable. again noted is a 2.2 x 2.7 cm nodule in the right adrenal gland which was seen on the recent mri at which time it likely represented an adenoma. the patient is status post left nephrectomy. cysts are again identified in the right kidney. again identified is prominence of the right collecting system without hydronephrosis. there is no abdominal lymphadenopathy. there is no evidence of intra-abdominal hemorrhage. a nodule is present in the subcutaneous soft tissues of the anterior abdominal wall which measures 1.4 cm in diameter. there is atherosclerosis. there are no dilated bowel loops. the gallbladder is present. ct pelvis findings: there is free fluid in the dependent position of the pelvis. the urinary bladder is well distended and contains gas likely related to the patient's foley catheter. a nodule is present in the right hemipelvis measuring 2.8 x 2.3 cm best seen on series 2, image 62. there are no dilated bowel loops in the pelvis. graft material is seen in the left external iliac artery. bone windows demonstrate degenerative changes in the spine. no blastic or lytic lesions are present. impression: 1. stable appearance of a left subpulmonic fluid collection representing either an abscess or hematoma. it has not changed in size since the mr from . 2. no dense material present within the abdomen on the current examination to suggest hemorrhage. 2. nodular thickening involving the left pleura and interstitial thickening involving the left base likely representing metastatic disease slightly worse since the previous exam. the pericardium is slightly thickened on the current exam as well but not significantly changed since the prior exam. 3. a soft tissue nodule in the right hemipelvis likely represent an ovary. it was seen on a more remote exam from . 4. small amount of pelvic-free fluid. brief hospital course: 68 yo woman with dm, htn, past malignancies including rcc and thyroid ca, and recent w/u with negative path for malignancy but concerning bone scan, mult known pulm nodules, adrenal nodule, who p/w right weak hand and left facial droop, multiple areas of hemorrhage on ct with no substantial edema or effacement of the grey-white jxn, no midline shift, vents open. initial exam showed left facial droop and right arm weakness; however, several hours after being in the ed, (hours after being given 10 mg iv decadron and 1.5g iv dilantin) she became unresponsive. she was intubated and a stat head ct was repeated after acute change in ms, showing no change. given her hx, and location of hemorrhages, as well as the fact that they are multifocal, mets were considered to be primary concern in this pt. could have recurrence of rcc, which can met to brain and bleed, versus new lung cancer versus new malignancy of other source versus recurrence of her thyroid cancer. infection, autoimmune still possibilities, but less likely given pattern of lesions, and hemorrhagic component. acute change in ms, given no change on ct could have been sz. she was admitted to neuro icu, attending dr. . bp was monitored with goal 120-150. neurosurg was consuted for workup of ?brain mets. mri showed lesions to be enhancing. wbc was initially elevated with negative ua (except rbc's), cxr with no change. she was placed on dilantin 100 mg tid and decadron 4 mg iv q6hrs. she was managed on an insulin sliding scale, and given protonix and pneumoboots for prophylaxis. she was extubated within 24 hours with no recurrence of seizure activity and return to her pre-mental status change state, with some improvement of strength in the hand and facial droop. dr. (pcp) and dr. (pulm) were involved with her care. . : onc thinks lung>brain ca, . cea and rad-onc consult, bx pelvic lesion by surgery (not reachable per interv.rads); rad onc aware. pulm reluctant to re-bx lung b/c of mult neg bx'es to date. . : got day of whole brain xrt. pelvic nodule is really an ovary, not a mass, so can't be bx'ed. pulm will touch base with ct ?look at lung bx option; tw neurosurg again- really not good bx options, is stereotactic brain (ie, frontal lobe lesion) feasible? cea mildly elevated- unhelpful in differentiating lung from renal cell. . : transferred to . avss. no complaints. continued rue weakness (). ct neck/chest today with increased pleural thickening and nodularity. . : avss w/ increased wbc to 32 likely secondary to steroids. foley replaced pvr 400 and polyuria. fna of abdominal wall mass. whole brain xrt qd continues. . : avss with increased wbc to 34. no complaints. percutaneous biopsy of pleura performed without complication. touch prep positive cytology. . : no xrt. patient's nph and metoprolol increased for improved blood sugar and blood pressure control. decadron decreasaed to 4mg iv q6 hours. patient experienced chest pain relieved with nitorglycerin. no ecg changes. cardiac enzymes not sent. . : afvss with sbp 170 transiently. increased metoprolol to 37.5 tid. patient npo for possible open biopsy today. fsg 383. nph and humalog given as well as mg 4 grams iv in 250cc d5w. pathology results: poorly differentiated malignancy. . : avss with bp controlled. patient "feeling great" and would like to return home for the holidays. social work discussed with patient the general plan and dr. discussed "next step" options with the family. physical therapy worked with patient with very good response. medications on admission: 1. atorvastatin 20 mg qd 2. levothyroxine sodium 200 mcg tablet sig: one (1) tablet po daily at 4pm to be taken 4 hrs separatedly with other medications. 3. gabapentin 300 mg tid 4. candesartan 32 mg qd 5. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 6. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 7. docusate sodium 100 mg 8. senna 8.6 mg 9. cepacol 2 mg lozenge prn 10. dextromethorphan-guaifenesin 10-100 mg/5 ml liquid sig: five (5) ml po q6h (every 6 hours) as needed. 11. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical qd (). 12. protonix 40 mg qd 13. labetalol 150 mg po bid 14. insulin nph human recomb 100 unit/ml suspension sig: (30) units subcutaneous daily at breakfast and (26) units subcutaneous at bedtime. 15. insulin regular human injection 16. warfarin 2 mg po hs 17. epoetin alfa 4,000 unit/ml solution sig: 8000 (8000) units injection qmowefr (monday -wednesday-friday). allergies: iv ct contrast->rash discharge medications: 1. levothyroxine 100 mcg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. gabapentin 300 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*30 capsule(s)* refills:*0* 4. oxycodone 10 mg tablet sustained release 12hr sig: one (1) tablet sustained release 12hr po q12h (every 12 hours). disp:*60 tablet sustained release 12hr(s)* refills:*2* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). disp:*30 * refills:*2* 7. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). disp:*30 * refills:*2* 8. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). disp:*135 tablet(s)* refills:*2* 9. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. phenytoin sodium extended 200 mg capsule sig: two (2) capsule po at bedtime. disp:*60 capsule(s)* refills:*2* 11. decadron 4 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 12. outpatient physical therapy bed bar discharge disposition: home with service facility: homecare discharge diagnosis: 1. metastatic non small cell carcinoma 2. anemia discharge condition: stable discharge instructions: 1. dressing changes to sacral decubitus ulcer per nursing (duoderm or equivalent) 2. regular diet/ pureed food as tolerated 3. continue checking blood glucose qid (four times a day) while on steroids. 4. return to the emergency department for fevers, chills, chest pain, shortness of breath, sensation changes, weakness, or other concerns. 5. do not restart coumadin 6. continue insulin dosing as before admission followup instructions: , m.d. phone: date/time: 3:00 , m.d. date/time: 3:00 vas non-invas lmob vascular lmob (nhb) date/time: 10:00 , m.d. phone: date/time: 1:00 , md date/time: 11:50 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube other pleural biopsy transfusion of packed cells open biopsy of soft tissue transfusion of other serum other radiotherapeutic procedure diagnoses: unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled secondary malignant neoplasm of pleura intracerebral hemorrhage constipation, unspecified secondary malignant neoplasm of brain and spinal cord malignant neoplasm of bronchus and lung, unspecified retention of urine, unspecified pressure ulcer, lower back personal history of malignant neoplasm of kidney secondary malignant neoplasm of bone and bone marrow anemia in neoplastic disease other late effects of cerebrovascular disease, facial weakness personal history of malignant neoplasm of thyroid 

Answer: The patient is high likely exposed to