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: no known allergies / adverse drug reactions attending: chief complaint: supratherapeutic inr, rigors, delirium major surgical or invasive procedure: ercp history of present illness: mr. is a 78 year old man with h/o cad s/p mi , afib on coumadin, cmp ef 45%, s/p aaa repair, pvd s/p fem- bypass, cognitive impairment, htn, hld, biliary obstruction s/p biliary stent placement and revision in , who was admitted to with supratherapeutic inr, rigors, and confusion. the patient was seen in clinic and noted to have a supratherapeutic inr to 7. also noted to have altered mental status and rigors, so was transferred to the ed. wife has noted increased confusion from baseline (typically mild cognitive impairment and confusion when he moves from to ) x 1 week. at , the patient was admitted to the icu for further workup of ams, rigors, and low grade fevers (100.8). initial concern for uti given recent instrumentation of the bladder (bladder tear s/p repair in recently) and dirty ua, but ucx was negative. patient noted to have elevated ap, as well as biliary sludge on abd u/s and ?obstruction on ct abdomen, concerning for cholangitis, started on zosyn for empiric coverage. patient had a biliary stent placed in the past for obstruction that migrated and was replaced in . according to records, this was supposed to be removed in , but that was not done. ercp team at was notified and will evaluate his stent further. hospital course at was complicated by hypotension (sbp 90s), for which the patient was given some gentle ivf with improvement of pressures. he developed flash pulmonary edema and responded well to lasix 20mg iv x1. patient was also delirious/agitated, given ativan and haldol prn. on arrival to the micu, patient's vs: t 97.4 p 96 bp 145/84 rr 33 o2sat 96%. patient is confused, but denies pain, sob, or any other complaints. past medical history: cad, s/p mi cardiomyopathy, ef 45% afib on coumadin htn hld mild cognitive impairment tia - in the setting of low inr biliary obstruction - s/p biliary stent in the past with migration, replaced by metal stent in , supposed to be re-evaluated/possibly removed but was not done pvd s/p l fem- bypass s/p bladder repair for tear s/p aaa repair prostate ca - s/p radiation gout utis social history: lives with his wife, also has a home in . history of tobacco use, but quit in . does not drink alcohol. family history: father with prostate problems. mother died at age 89 after hip fracture, ?clot. physical exam: admission exam: vitals: t 97.4 p 96 bp 145/84 rr 33 o2sat 96% general: lethargic, arousable to voice, oriented x1, no acute distress, cheynes- breathing pattern heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: irregular, tachycardic, s1 + s2, no murmurs, rubs, gallops lungs: decreased breath sounds at bases, otherwise clear abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: orientedx1, moving all extremities. discharge exam: general: lethargic, arousable to voice, oriented x1, will have episodes of apnea altered with tachypnea heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp 8cm, no lad cv: irregular, tachycardic, s1 + s2, no murmurs, rubs, gallops lungs: decreased breath sounds at bases particularly r, otherwise clear abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: foley ext: cold and clammy, pulses in le dopplerable. no edema neuro: orientedx1, moving all extremities. eomi, perrla, will no participate in most of the exam pertinent results: admission labs: 04:25pm blood wbc-12.8* rbc-4.25* hgb-11.4* hct-36.1* mcv-85 mch-26.8* mchc-31.6 rdw-16.0* plt ct-310 04:25pm blood pt-16.7* ptt-29.9 inr(pt)-1.6* 04:25pm blood glucose-97 urean-34* creat-1.4* na-142 k-4.4 cl-109* hco3-18* angap-19 04:25pm blood alt-35 ast-40 alkphos-666* totbili-2.9* 04:25pm blood albumin-2.6* calcium-8.6 phos-4.1 mg-2.0 04:29pm blood type-art temp-36.3 po2-69* pco2-23* ph-7.51* caltco2-19* base xs--2 intubat-not intuba 04:29pm blood lactate-1.5 urine: 05:32am urine color-yellow appear-hazy sp -1.020 05:32am urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-mod 05:32am urine rbc->182* wbc-15* bacteri-few yeast-none epi-0 05:32am urine hours-random urean-720 creat-78 na-50 k-69 cl-10 05:32am urine osmolal-542 micro: mrsa screen: negative ucx: yeast ucx: yeast studies: ercp: - a previously placed metal stent in the biliary duct that migrated distally was found in the major papilla. - given the malposition of the stent decision was made to remove the stent using a snare. - pus, sludge, and debris was seen coming out of the bile duct after stent removal. - cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. - contrast medium was injected resulting in partial opacification. - further contrast injection was not done given cholangitis. - there were possible filling defects suggestive of sludge and debris in the bile duct. however, this could not be fully delineated given limited contrast injection. - a previously placed plastic stent was noted that had migrated well into the right hepatic duct/bilary tree - removal was not attempted given concurrent cholangitis. - a 5cm by 10fr double pig tail biliary stent was placed successfully for decompression with the proximal end terminating in the left hepatic duct. good bile flow was seen after stent deployment. - repeat ercp in 4 weeks to attempt removal of previously placed migrated stent from the right hepatic system and repeat biliary evaluation. . ct head technically limited study. no acute hemorrhage or mass effect . ct abdomen pelvis 1. bilateral pleural effusions with adjacent compressive atelectasis. 2. mild to moderate cardiomegaly with aortic and mitral valve, coronary artery calcifications, and calcification along the inferior myocardial wall of the left ventricle. 3. pneumobilia with double pigtail biliary stent with one end of the stent appearing to open within the duodenum and the other appears to end in the common bile duct. 4. dilated pancreatic duct up to the ampulla with ill-defined soft tissue around the pancreatic head, unclear if this is secondary to technique or due to recent procedure; however, recommend dedicated imaging to rule out presence of pancreatic mass such as multiphasic mr if the patient is able to optimally breath-hold versus consideration of dedicated multiphasic ct. 5. aortobifemoral stent with occlusion of the native aorta and common iliac arteries. 6. area of infarct along the upper pole of the right kidney. . cxr 1. worsening vascular congestion, with possible mild edema. 2. moderate right pleural effusion with right basal atelectasis. brief hospital course: mr. is a 78 year old man with h/o cad s/p mi , afib on coumadin, cmp ef 45%, s/p aaa repair, pvd s/p fem- bypass, cognitive impairment, htn, hld, biliary obstruction s/p biliary stent placement and revision in , who was admitted to with altered mental status and fevers. he was transferred to for ercp given concern for ascending cholangitis; he underwent ercp (see below), and was stabilized. active issues: #. ascending cholangitis: this was the most likely cause of his sepsis, altered mental status, and fevers. patient had a prior h/o obstruction, s/p instrumentation with 2 stents currently in place. he had elevated ap and e/o biliary sludge and possible obstruction on abdominal imaging. he was originally supposed to get a stent removed in summer , but as the pt spends part of the year in fl, this was lost to f/u. during ercp, a previously placed metal stent was removed; pus, sludge, and debris was seen coming out of the bile duct after stent removal. a previously placed plastic stent had migrated into the right hepatic duct/bilary tree - removal was not attempted given concurrent cholangitis; a 5cm by 10fr double pig tail biliary stent was placed successfully for decompression with the proximal end terminating in the left hepatic duct. good bile flow was seen after stent deployment. we continued antibiotics d1= for a 14 day course, initially with zosyn and then with augmentin (stop date ). as below he was transitioned back to zosyn when his mental status worsened, concerning for active infection. before discharge, he was transitioned back to augmentin. # intubation: intubated for airway protection and ercp, and was extubated without event. #. acute renal failure: cr 1.6 upon admission, up from baseline 1.0. likely prerenal in etiology, but possible atn from recent hypotension as well. fena was <0.7%. after callout to the floor, his creatinine was 1.4. he received 250 cc of normal saline and his creatinine improved slightly to 1.3. patient given another 250 cc of normal saline and his creatinine improved to 1.2. patient only given small boluses of iv fluids given report that he developed flash pulmonary edema with gentle hydration at . at time of discharge, his creatinine had bumped again to 1.5 but had remained stable. #. altered mental status: patient with waxing and mental status, with agitation at osh requiring ativan and haldol. likely multifactorial etiology in an elderly patient with mild cognitive impairment at baseline - infection, icu delirium. per family report, he has had delirium at home, with falling asleep mid-sentence, etc. this has been a gradual decline in the recent year or two and they are thinking about housing options. physical therapy evaluated patient and determined he would benefit from short term rehab. patients mental status became acutely worse on . patient was noted to be confused, lethargic and minimally responsive. the patient was also noted to have a new leukocytosis concerning for infection. head ct was unremarkable. ct abdomen was without sign of abscess. cxr was negative for pneumonia. ua was concerning for uti which was the presumed source of his confusion. he was transferred to the icu where he was started on broad spectrum antibiotics (vanc and zosyn). mental status improved and leukocytosis resolved. cultures were noteable only for yeast in his urine for which the foley was replaced. vancomycin was discontinued and the patient remained afebrile. # pancreatic mass: ct of the patient's abdomen and pelvis was concerning for a possible pancreatic mass vs changes consistent with his previous ercp. pt has a planned repeat ercp to be done in 4 weeks. chronic issues: #. acute on chronic chf: pt flashed after small fluid bolus at osh. we continued metoprolol, held his ace i. his ace-i was restarted prior to discharge from the icu. given htn, his dose was increased to 10mg po qday. after receiving ivf, pt was found to have some intravascular cogenstion on cxr. he was diuresed with 20iv lasix. at time of discharge he was euvolemic and was not started on lasix. #. afib: hr mostly 100-110s, although occasionally up to the 130-140s. continued metoprolol tid. he was noted to have a large amount of ectopy and his dose was increased to 37.5 mg tid. coumadin was held for procedure, was restarted thereafter at a decreased dose of 1mg by mouth daily given history of supratherapeutic inr and concominant treatment with augmentin. his dose of coumadin will likely need to be adjusted as an outpt. #. anemia: at baseline throughout hospitalization. #. cad/pvd: patient was off asa since for hematuria and bladder tear. however, given his severe vascular disease, benefits of asa likely outweigh the risks. we continued bb and restarted baby asa after ercp. #. htn: sbp 140-160s, improved from hypotension in the 90s at . continued bb and held lisinopril initially given recent low bps and . he was then restarted on lisinopril 10mg by mouth daily. transitions of care: -pt's code status this admission was full code -patient will be contact by the ercp team for repeat ercp in 4 weeks for stent removal -inr will need to be trended every other day given unstable inr and concurrent use of augmentin. - continue augmentin until medications on admission: medications at home: metoprolol 25mg po bid lisinopril 5mg po daily coumadin 2.5mg po daily x 6 days, 5mg po daily mondays, currently held for supratherapeutic inr mvi 1tab po daily protonix 40mg po daily flomax 0.4mg po qhs asa - d/c'd in recently medications on transfer: zosyn 3.375mg iv q8h metoprolol 25mg po tid / 5mg iv q6h prn protonix 40mg iv daily xopenex 1inh q6h prn colace 100mg po bid prn senna 2tabs po daily bisacodyl 10mg daily lasix 20mg iv x1 tylenol 650mg po q6h prn ativan 1mg iv x1 morphine 0.5mg ivx1 discharge medications: 1. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 2. amoxicillin-pot clavulanate 875-125 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 13 doses: last day of antibiotics is . 3. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day). 4. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 7. tamsulosin 0.4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po hs (at bedtime). 8. docusate sodium 50 mg/5 ml liquid sig: one (1) tab po bid (2 times a day). 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. discharge disposition: extended care facility: of foxhill discharge diagnosis: cholangitis discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted with an cholangitis, which is an infection in your bile duct. you had your stent removed by ercp. you will need to stay on antibiotics through (14 days total), and will need to have another ercp to remove your other stent in 4 weeks. medication changes: 1) added augmentin 875mg by mouth every 12hrs through 2) change warfarin to 1mg by mouth daily. 3) increase metoprolol to 37.5mg by mouth three times daily 4) increase lisinopril to 10mg by mouth daily. followup instructions: department: healthcare of when: wednesday at 2:00 pm with: , md, mph building: (, ma) ground campus: off campus best parking: parking on site you will need follow up with our gi department for a repeat ercp in 4 weeks. when this is scheduled, someone from the gi department will call you with an appointment. procedure: endoscopic retrograde cholangiopancreatography [ercp] replacement of stent (tube) in biliary or pancreatic duct central venous catheter placement with guidance diagnoses: other primary cardiomyopathies abnormal coagulation profile anemia, unspecified coronary atherosclerosis of native coronary artery acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified unspecified essential hypertension unspecified septicemia severe sepsis atrial fibrillation personal history of malignant neoplasm of prostate peripheral vascular disease, unspecified other and unspecified hyperlipidemia old myocardial infarction long-term (current) use of anticoagulants mechanical complication due to other implant and internal device, not elsewhere classified anticoagulants causing adverse effects in therapeutic use metabolic encephalopathy acute on chronic systolic heart failure cholangitis infection and inflammatory reaction due to other internal prosthetic device, implant, and graft mixed acid-base balance disorder microscopic hematuria 

Answer: The patient is high likely exposed to