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: morphine sulfate / penicillins attending: chief complaint: mental status changes major surgical or invasive procedure: xrt to brain history of present illness: -metastatic breast cancer- originally diagnosed in her early 30s when she palpated a left-sided lump. she underwent mastectomy, chemotherapy, and was disease free for approximately 8-10 years. she then re-presented with pain in her sternum and a bone scan at that time showed spread to the sternal bones. she then took tamoxifen for 8-10 years with good response. chemotherapy exposure has included zoladex, navelbine with avastin, gemzar with avastin, and then doxil during the past two years, and most recently xeloda. currently she is believed to have mets involving subcutaneous tissue, thyroid, lymph nodes, skin, pleura, bone, liver, and possibly the central nervous system. she is followed by dr. . -hypertension- diagnosed in treated with atenolol and hctz. -gerd -history of endometrial hyperplasia status post biopsy in for postmenopausal bleeding -status post cholecystectomy . past medical history: htn gerd onc history: per omr history of metastatic breast cancer originally diagnosed in her early 30s when she palpated a left-sided lump. she underwent mastectomy, chemotherapy and was disease free for approximately 8-10 years. she then represented with pain in her sternum and a bone scan at that time showed spread to the sternal bones. she then took tamoxifen for 8-10 years with good response. this was followed by arimidex for three year, and for the last year she reports she has been on several different trials. per her recent scans, ct of her head has been negative as recently as . ct of chest and abdomen show pleural thickening on the left, stable left pleural effusion, bilateral lung nodules, as well as several liver lesions and involvement of many vertebral bones and the right si joint with metastatic foci. she had a bone scan on that showed uptake in her sternum, bilateral ribs, c-spine and iliac bone. . ct scan : ct chest with contrast: the appearance of the chest is not significantly different from . no new pulmonary nodules are identified. there is stable pleural thickening of the left lung. moderate amount of pleural effusion. the multiple subcentimeter nodules are unchanged. ct abdomen with contrast: innumerable liver metastases are not significantly different . the patient is status post cholecystectomy. the pancreas, spleen, adrenals, kidneys are unchanged, with multiple likely simple cysts in both kidneys. small bowel loops are normal caliber. there is no free air or free fluid in the abdomen. ct pelvis with contrast: the rectum, sigmoid, and remainder of the colon is mostly collapsed, but normal-appearing. no free fluid present in the pelvis. there is no evidence for obstruction. the uterus and adnexa are unremarkable. the bladder is decompressed. bone windows: the osseous structures are grossly unchanged with innumerable bony metastases throughout the skeleton. social history: per omr: she lives in with her husband and 15-year-old son. she has a 23-year-old son who is a recent college graduate, and a 28-year-old daughter who is a nurse practitioner at hospital. she has one 8-month-old granddaughter. she denies tobacco use, reports occasional alcohol use. she works as a special ed teacher at system. her healthcare proxy is her husband, . family history: per omr: mother is alive with acid reflux and hypertension at 80. father died in his 70s of complications of end-stage liver disease from hepatitis c. she had one brother who died at age 24 of complications of kidney transplant. her three children are all alive and well. physical exam: vitals: t: 97.7 bp: 148/56 hr: 77 rr: 22 o2sat: 98% ra gen: fatigued-appearing cachectic middle-aged female, no acute distress heent: eomi, perrl, sclera anicteric, dry mm, op clear neck: no jvd, no cervical lymphadenopathy, trachea midline cor: rrr, no m/g/r, normal s1 s2, radial pulses +2 pulm: mild r basilar rales, decreased breath sounds at l base, no w/r abd: soft, distended, nontender, decreased bs, no hsm, no masses, dullness at the flanks, no fluid wave ext: 2+ le edema to thighs bilaterally neuro: alert, oriented to person, place, and time. cn ii ?????? xii grossly intact. moves all 4 extremities. strength 5/5 in upper extremities, 4+- in lle and in rle. did not assess gait. skin: no jaundice, cyanosis, or gross dermatitis. no ecchymoses. pertinent results: unilat lower ext veins right study date of : impression: no evidence of dvt in the right lower extremity. chest (pa & lat) study date of : impression: relatively stable x-ray again demonstrating left pleural effusion with left base opacity, likely atelectasis. an underlying consolidation from pneumonia is difficult to entirely exclude but is less likely. the remainder of the lungs are clear. ct head w/o contrast study date of : impression: single focus of hypoattenuation in the left superior frontal cortex of the superior frontal lobe as described above corresponds to the metastatic lesion noted on the mr . direction comparison size is not possible due to technique related differences. no other metastatic lesions are evident on ct. please note limit sensitivity of ct in detecting metastatic foci for which gadolinium-enhanced mr is more sensitive. no other intracranial pathology to explain patient's dizziness. renal u.s. study date of : impression: limited study due to suboptimal visualization of the renal parenchyma most significantly affecting the right side. within limitation, no hydronephrosis or obstructive renal calculi evident. abdomen u.s. (complete study) study date of : impression: 1. diffusely infiltrated liver, with innumerable hepatic metastases, causing architectural distortion. 2. main portal vein and splenic vein immediately proximal to its junction with the smv appear grossly patent. parts of the splenic vein left of the midline are obscured by overlying bowel gas. 3. moderate amount of ascites. mr l spine w/o contrast study date of : impression: diffuse osseous metastatic disease, without pathologic compression or epidural disease. no cord compression or significant compromise of the thecal sac. mr head w/o contrast; mra brain w/o contrast study date of : impression: limited study due to lack of intravenous contrast, which was not administered due to patient's renal failure. interval development of multiple cerebral and cerebellar masses highly suspicious for worsening metastatic disease. unilat up ext veins us right study date of : impression: no evidence of dvt. chest (portable ap) study date of : findings: in comparison with the study of , there is little overall change. again there are low lung volumes with an area of increased opacification at the left base consistent with atelectasis and effusion. the possibility of supervening pneumonia cannot be excluded. eeg study date of : impression: markedly abnormal portable eeg due to the disorganization and slowing of the background and bursts of generalized slowing, along with bilateral independent sharp waves. the first two abnormalities signify a widespread encephalopathy affecting both cortical and subcortical structures. there were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. the sharp waves (more in the right central region than in the left temporal) indicate areas of cortical hypersynchrony and were occasionally rhythmic for a few seconds, but they did not include simple spike or sharp and slow wave complexes or definite electrographic seizures. overall, the encephalopathy dominated the tracing. the sharp features suggest a risk for seizures but not any ongoing seizures at the time of the recording. selected hematologies: 09:40am blood wbc-18.4*# rbc-3.43* hgb-9.6* hct-31.2* mcv-91 mch-28.1 mchc-30.9* rdw-24.2* plt ct-313 04:10am blood wbc-4.9 rbc-2.82* hgb-7.9* hct-24.6* mcv-87 mch-28.1 mchc-32.2 rdw-24.7* plt ct-102* 05:26am blood wbc-0.9*# rbc-2.86* hgb-8.0* hct-24.3* mcv-85 mch-28.2 mchc-33.1 rdw-24.7* plt ct-64* 12:00am blood wbc-0.3*# rbc-2.99* hgb-8.6* hct-25.5* mcv-86 mch-28.8 mchc-33.6 rdw-24.3* plt ct-69* 12:00am blood wbc-0.1*# rbc-3.04* hgb-8.7* hct-26.5* mcv-87 mch-28.5 mchc-32.7 rdw-24.1* plt ct-58* 12:45am blood wbc-1.7*# rbc-2.99* hgb-8.8* hct-26.1* mcv-87 mch-29.3 mchc-33.5 rdw-24.2* plt ct-97*# selected coagulopathies: 01:18pm blood pt-18.2* ptt-49.6* inr(pt)-1.7* 12:00am blood pt-15.8* ptt-25.2 inr(pt)-1.4* selected chemistries: 01:18pm blood glucose-94 urean-145* creat-7.2*# na-140 k-4.1 cl-107 hco3-8* angap-29* 09:40am blood alt-27 ast-56* ld(ldh)-361* alkphos-436* totbili-0.7 05:26am blood glucose-149* urean-126* creat-4.9* na-140 k-4.5 cl-106 hco3-18* angap-21* 05:26am blood alt-31 ast-96* alkphos-331* totbili-3.0* dirbili-2.3* indbili-0.7 12:45am blood glucose-190* urean-140* creat-4.3* na-142 k-4.9 cl-107 hco3-17* angap-23* 12:45am blood alt-30 ast-39 ld(ldh)-429* alkphos-275* totbili-2.6* 12:45am blood albumin-2.2* calcium-6.7* phos-5.6* mg-2.2 miscellaneous lab results: 05:26am blood ammonia-77* 02:18pm blood hbsag-negative hbsab-negative hbcab-negative 09:40am blood cea-86* ca27.29-568* 02:18pm blood hepatitis c - riba-negative microbiology: stool clostridium difficile toxin a & b test-final (negative) blood culture blood culture, routine-final { albicans}; aerobic bottle gram stain-final blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) mrsa screen mrsa screen-final (negative) blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) stool clostridium difficile toxin a & b test-final (negative) blood culture blood culture, routine-final (no growth) blood culture blood culture, routine-final (no growth) urine urine culture-final (no growth) blood culture blood culture, routine-final {beta streptococcus group b}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final brief hospital course: micu course: ## acute renal failure: pt presented with creatinine of 6.9. anion gap of 26 and lactate of 4.6. appeared intravscularly depleted on exam, but did not demonstrate robust improvement in creatinine with fluid boluses. intrinsic etiologies were of concern, including nsaid induced nephropathy. fe urea was 20.8% and fena was 0.5% with urine na of 14. there was no hydronephrosis on renal ultrasound. the renal service was consutled and recommended bicarb administration prn, calcium repletion, phosphate bidners. the patient started hd on ... # weakness/confusion: did not improve with hydration, hd. originally thought to be secondary to renal failure, but bowel and bladder incontinence were concerning for cord lesion. mr spine did not demonstrate compression. head ct showed no concerning changes. however, mri showed interval development of multiple cerebral and cerebellar masses highly suspicious for worsening metastatic disease. the patient began xrt on , and is rec'ing second dose on day of discharge to floor (). plan on total of 10 doses. # infection: beta streptococcus group b (pan sensitive) grew from port-a-cath culture. lactates were stable in the 4's. the patient was treated with vancomycin for ?port-a-cath infection; given penicillin allergy, vancomycin was chosen as the antibiotic of choice. repeat cultures from the port-a-cath were drawn. if become positive, will need tohave line removed... # leukocytosis: wbc increased after receiving decadron with the taxol and is likely steroid and infection induced. now trending down to less than 1. marrow supression is consistent side effect of taxol, however, and patinet rec'd taxol less than two weeks ago. anc was pending at time of d/c to floor... # hypertension: patient with systol pressures generaly in the 130's throughout icu course. home medications were not administered in the icu. floor course: 1) metastatic breast ca: patient with known metastatic disease to subcutaneous tissue, thyroid, lymph nodes, skin, pleura, bone, liver, and possibly the central nervous system. cycle 1, day 1 of taxol was . family with desire to pursue measures to assure comfort and patient was discharged to home with hospice. 2) acute renal failure: family made decision to pursue hospice, they desired no additional hd treatments. renal team was notified and dialysis catheter was removed. 3) weakness/confusion: originally thought to be secondary to renal failure, but did not improve with hydration and hd. mri showed interval development of multiple cerebral and cerebellar masses highly suspicious for worsening metastatic disease. the patient began xrt on with plan for competion of 10 doses, though she was made cmo and did not receive additional wbrt after . 4) bacteremia and fungemia: beta streptococcus group b (pan-sensitive) grew from port-a-cath culture performed in the ed. lactates were stable in the 4's. the patient was treated with vancomycin for ?port-a-cath infection, given penicillin allergy. this may also represent contaminant. blood culture with result of budding yeast in one of two bottles discovered early morning of . she received fluconazole 200 mg iv q24h while in hospital per family request but did not receive any fluconazole at discharge. 5) dry mouth and mouth pain: patient reporting very dry mouth and mouth pain during floor course. likely some component of thrush contributing. she received clotrimazole troches briefly, but was unable to tolerate them. she was then covered by iv fluconazole indicated for her fungemia. she received symptomatic relief with viscous lidocaine via swab to mouth. 6) neutropenia: likely due to marrow suppression from taxol. total wbc was 100 on morning of . she was on neutropenic precautions & diet. while she was eating. 7) anxiety: patient reported one episode of anxiety on morning following transfer to the floor. she was managed with olanzapine oral dissolving tab 2.5 prn anxiety. medications on admission: atenolol 50mg po daily dexamethasone 8mg po the night before and the morning of taxol hctz 12.5mg po daily ranitidine 150mg po daily tussionex 5ml po tid prn vitamin b12 pyridoxine lac-hydrin 12% lotion loperamide prn discharge medications: 1. oxycodone 20 mg/ml (1 ml) concentrate sig: 5-10 mg po q2 hours as needed for pain: sublingual. disp:*30 ml* refills:*0* 2. levsin 0.125 mg tablet sig: 1-2 tablets po every four (4) hours as needed. tablet(s) 3. olanzapine 5 mg tablet, rapid dissolve sig: 0.5-1 tablet, rapid dissolve po tid (3 times a day) as needed for anxiety. 4. ativan liquid sig: 1-2 mg q2 hours as needed. discharge disposition: home with service facility: discharge diagnosis: acute renal failure altered mental status hepatic encephalopathy multiple brain metastases metastatic breast cancer candidemia group b strep bacteremia neutropenia discharge condition: comfort measures only. dnr/dni. discharge instructions: please contact dr. office ( regarding any issues that arise. followup instructions: none scheduled. procedure: hemodialysis venous catheterization for renal dialysis other radiotherapeutic procedure diagnoses: acidosis malignant neoplasm of liver, secondary acute kidney failure with lesion of tubular necrosis secondary malignant neoplasm of other specified sites secondary malignant neoplasm of pleura personal history of malignant neoplasm of breast sepsis secondary malignant neoplasm of brain and spinal cord bacteremia cerebral edema antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use disseminated candidiasis secondary malignant neoplasm of skin hepatic encephalopathy dehydration other and unspecified infection due to central venous catheter secondary malignant neoplasm of bone and bone marrow streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group b other specified aplastic anemias 

Answer: The patient is high likely exposed to