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: levofloxacin / metronidazole attending: chief complaint: fever and jaundice major surgical or invasive procedure: ercp (endoscopic retrograde cholangiopancreatography) with sphincterotomy and stent placement . history of present illness: mr. is a 60m with history of advanced als, chronic trach/mechanical ventilation/peg, dvt/pe on warfarin who is transferred to now with concern for acute cholecystitis and need for ercp. patient initially admitted to after presenting with fevers and jaundice. the pt is nonverbal so hx is per wife. over past 10 days has noticed him to becoming increasingly more jaundice associated with darker colored urine and colored stools. went to pcp who referred him to the hospital. on arrival to pt was febrile to 101.5 w/ tachycardia. his initial labs were notable for wbc 20,000 w/ 16% bands, bili of 8.3, alk phos of 559 and inr supratherapeutic at 6.1. ct scan and ruq at osh revealed dilated intrahepatic biliary ducts. patient was started on empiric antibiotics with vanc/zosyn. he remained hemodynamically stable with good uop. he received ffp and vitamin k prior to transfer. . with regard to his als, he has been bed-ridden for 2 years. currently communicates by raising his eye brows, up indicating "yes," and no movement indicating "no." he has a chronic trach and is on mechanical ventilation, and also has a peg through which he receives nutrition and meds. his care is provided by his wife at home. . on arrival to the icu,he was not in appearant distress although difficult to assess in this pt. he was notably jaundice on exam and was complaining of some abominal pain with palpation but difficult to assess exactly where in his abdomen. . review of systems: per hpi past medical history: als, chronic trach/mechanical ventilation/peg dvt/pe hypothryoidism social history: lives w/ his wife - : denies - alcohol: denies - illicits: denies family history: father had unknown type of cancer physical exam: on admission vitals: t:98 bp:162/70 p:110 r:12 o2: 100% general: jaundice, alert, no acute distress, non verbal, communicates with eye brow raising, rising eye brows indicates yes, no response is no movement of eyes. heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not able to assess, trach in place lungs: clear to auscultation bilaterally on ant exam, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, hypoactive bs, no rebound tenderness or guarding, no organomegaly gu:foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: on admission: 09:42pm blood wbc-14.7* rbc-3.65* hgb-9.5* hct-30.5* mcv-84 mch-26.2* mchc-31.3 rdw-17.8* plt ct-397 09:42pm blood pt-25.6* ptt-42.8* inr(pt)-2.5* 09:42pm blood glucose-59* urean-6 creat-0.1* na-136 k-3.5 cl-104 hco3-19* angap-17 09:42pm blood alt-85* ast-48* ld(ldh)-135 alkphos-368* totbili-8.6* 09:42pm blood albumin-2.8* calcium-8.1* phos-2.3* mg-2.0 09:42pm blood tsh-5.1* . prior to discharge: 04:31am blood wbc-6.5 rbc-3.63* hgb-9.2* hct-30.6* mcv-84 mch-25.3* mchc-30.0* rdw-17.9* plt ct-416 03:56am blood pt-12.7* ptt-29.6 inr(pt)-1.2* 04:31am blood glucose-170* urean-7 creat-0.1* na-135 k-3.9 cl-101 hco3-26 angap-12 04:31am blood alt-45* ast-33 alkphos-316* totbili-3.0* 04:31am blood calcium-7.8* phos-2.1* mg-2.1 . imaging ruq u/s (prelim read) cholelithiasis and mild gallbladder wall edema in a minimally distended gallbladder. additionally, there is mild prominence of the intrahepatic ducts with a top-normal cbd. these findings are more suggestive of a chronic cholecystitis as opposed to an acute cholecystitis. furthermore, the liver demonstrates areas of increased echogenicity and hepatitis must be excluded clinically. multiple hepatic cysts and granulomas incidentally noted. correlation with outside imaging recommended. . ercp : procedures: multiple balloon sweeps were performed and no sludge or stone were extracted.a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. cytology samples were obtained for histology using a brush in the narrowing at the bifurcation of the bile duct. a 10cm by 10fr cotton biliary stent was placed successfully. impression: the tip of a g tube was noted to be in place in the stomach major papilla had a lacerated appearance suggestive of recent passage of stone. cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. the bile duct had a thin calibur. a small area of narrowing was noted at the level of the bifurcation of the cbd. rest of the biliary tree appeared unremarkable with no filling defects. a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. cytology samples were obtained for histology using a brush in the narrowing at the bifurcation of the bile duct. a 10cm by 10fr cotton biliary stent was placed successfully. otherwise normal ercp to third part of the duodenum. recommendations: return to icu npo overnight. if patient's condition appears clinically stable, would advance diet as tolerated tomorrow to clears iv hydration with lr as tolerated hemodynamically continue antibiotics await brush cytology results. if the cytology is positive for malignancy, patient will need surgical consult. otherwise will need repeat ercp in 3 months for stent pull and evaluation of stricture labs pending at time of discharge: - cytology from ercp brief hospital course: primary reason for hospitalization: 60ym with pmh significant for als who is vent and peg tube dependent who initially presented to osh w/ fever, jaundice, abdominal discomfort consistent with ascending cholangitis. . # ascending cholangitis - on admission patient w/ wbc 20,000, fever, tachycardia with elevated cholestatic lft concerning for cholangitis. he was started on antibiotics and underwent ercp and was found to have evidence of recent cbd stone passage as well as a stricture at bifurcation. a sphincterotomy was performed and stent placed. cytology samples were obtained for histology using a brush in the narrowing at the bifurcation of the bile duct. after ercp the patient improved rapidly with wbc and lfts downtrending. all blood cultures were negative. - patient was discharged on zosyn to complete a 7 day course (last dose on 4.18) - wife will schedule follow-up with dr. (gi) in weeks. - cytology from ercp to be followed up by gi (dr. as outpatient - if the cytology is positive for malignancy, patient will need surgical consult. otherwise will need repeat ercp in 3 months for stent pull and evaluation of stricture . # history of dvt/pe - pt on warfarin chronically for history of dvt/pe. ? ivc filter present. presented with inr of 6 from osh. have been related to acute illness or acute liver injury causing decreased synthetic function. patient given vit k / ffp for procedure to reverse. now subtherapeutic. - restarted warfarin with lovenox bridge until therapeutic - vna will check inr on with result faxed to pcp. /c lovenox when inr > 2.0 . chronic issues: # elevated tsh ?????? the patient has a history of hypothyroidism although he is not on levothyroxine (confirmed w/ pcp) also with history of elevated tsh (up to 20) in critical illness. he was found to have a tsh of 5.1 on admission. - pcp should recheck thyroid studies in 4 weeks following acute illness . # pt has tracheotomy tube and is ventilator dependent. he also has peg tube in place for nutrition. he has been bed bound for 2yrs now. received prior care from . - held rilutek in setting of acute liver injury, will restart after discharge. - cont scopolamine patch for secretion management . # chronic respiratory failure- a complication of als. pt is trached and is now vent dependent. currently comfortable in no acute respiratory distress on home vent settings. - continue home vent settings of fio2 of 25%, vt 700, rr 12, peep of 5 . transitional issues: - pcp should recheck thyroid studies in 4 weeks following acute illness - inr subtherapeutic at discharge therefore discharged on lovenox bridge. inr check on to be faxed to pcp. need further inr checks until subtherapeutic. . labs pending at time of discharge: - cytology from ercp medications on admission: 1. combivent 18-103 mcg/actuation aerosol sig: four (4) puffs inhalation q3h as needed for shortness of breath or wheezing. 2. omeprazole 2 mg/ml suspension for reconstitution sig: twenty (20) mg po once a day. 3. rilutek 50 mg tablet sig: one (1) tablet po twice a day. 4. scopolamine base 1.5 mg patch 72 hr sig: one (1) patch 72 hr transdermal every 3 days (). 5. glycopyrrolate 2 mg tablet sig: one (1) tablet po q6h (every 6 hours). 6. polyethylene glycol 3350 17 gram powder in packet sig: one (1) powder in packet po every other day (every other day) as needed for constipation. 7. warfarin 2 mg tablet sig: one (1) tablet po days (mo,fr). 8. warfarin 3 mg tablet sig: one (1) tablet po days (,tu,we,th,sa). discharge medications: 1. piperacillin-tazobactam-dextrs 4.5 gram/100 ml piggyback sig: 4.5 grams intravenous q8h (every 8 hours) for 2 days: last dose in evening on . disp:*15 doses* refills:*0* 2. combivent 18-103 mcg/actuation aerosol sig: four (4) puffs inhalation q3h as needed for shortness of breath or wheezing. 3. omeprazole 2 mg/ml suspension for reconstitution sig: twenty (20) mg po once a day. 4. rilutek 50 mg tablet sig: one (1) tablet po twice a day. 5. enoxaparin 80 mg/0.8 ml syringe sig: eighty (80) mg subcutaneous q12h (every 12 hours) for as directed days: until inr > 2.0 . disp:*qs ml* refills:*0* 6. scopolamine base 1.5 mg patch 72 hr sig: one (1) patch 72 hr transdermal every 3 days (). 7. glycopyrrolate 2 mg tablet sig: one (1) tablet po q6h (every 6 hours). 8. polyethylene glycol 3350 17 gram powder in packet sig: one (1) powder in packet po every other day (every other day) as needed for constipation. 9. warfarin 2 mg tablet sig: one (1) tablet po days (mo,fr). 10. warfarin 3 mg tablet sig: one (1) tablet po days (,tu,we,th,sa). discharge disposition: home with service facility: home therapies discharge diagnosis: primary: - ascending cholangitis secondary: - sepsis - amyotrophic lateral sclerosis - chronic respiratory failure discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: mr. , it was a pleasure taking care of you here at . you were transferred here because you had an infection in your bile ducts, which is called "ascending cholangitis". you were given antibiotics and also had a procedure called ercp where a stent was placed to open up your bile duct. after this you improved. you will need to have another ercp in about 3 months to remove the stent. you will need to see dr. in clinic to set this up. you will need 2 more days of antibiotics as detailed below. you also will need a blood thinner called lovenox until your inr goes back up. the following additions were made to your medications: - zosyn (antibiotic) 4.5 g iv every 8 hours last dose to be given in evening on - lovenox (blood thinner) 80mg subcutaneous injection twice daily: until your inr is above 2.0 no other changes were made to your medications. you should continue taking all other medications as you were previously. followup instructions: you will need to make a follow-up appointment with your gastroenterologist (dr. . ) in the next weeks. you should call to make the appointment. you should also make an appointment in the next 2-4 weeks with your primary care provider. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours enteral infusion of concentrated nutritional substances endoscopic sphincterotomy and papillotomy endoscopic insertion of stent (tube) into bile duct other closed [endoscopic] biopsy of biliary duct or sphincter of oddi central venous catheter placement with guidance diagnoses: unspecified pleural effusion unspecified septicemia unspecified acquired hypothyroidism sepsis amyotrophic lateral sclerosis personal history of venous thrombosis and embolism cholangitis other and unspecified coagulation defects gastrostomy status tracheostomy status dependence on respirator, status personal history of pulmonary embolism calculus of bile duct with other cholecystitis, with obstruction 

Answer: The patient is high likely exposed to