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: codeine / lisinopril / skelaxin / adhesive / tomatoes attending: chief complaint: recurrent cholangitis major surgical or invasive procedure: ercp with stent, sphincterotomy history of present illness: 65 yo female with hx of chd stricture s/p multiple ercps with stents and subsequent retrievals presented to hospital with fevers and abdominal pain suspicious for recurrent cholangitis. she presented early this am with fever to 104 and ruq abdominal pain x1 day. she was admitted to the icu where she developed hypotension requiring levophed and phenylephrine. labs were notable for wbc 9, with 30% bands, ph of 7.3, and lactate of 3.0. concerning for recurrent cholangitis given prior recurrent cholangitis, with last episode in . ercp was attempted at but they were unable to place the wire in the stricture so she was sent to where her chd was stented. stent was removed in . she was given vancomycin/zosyn, but plan was to broaden to linezolid given vre that i discussed with them. course today has been complicated by ams, she is awake but not communicating. she developed altered mental status and required intubation with a 7.5 ett prior to transfer. kub did not reveal any current stents. cvp was measured at 19 so fluids were decreased to 75cc/hr. she received a total of 5l of ivf. currently on propofol 80% peep 5 450x15. was updated re: transfer. she received an additional 1.5l of ivf in flight and her hr was noted to decrease. on arrival to the micu, she intubated and sedated. review of systems: unable to complete. past medical history: - common hepatic duct stricture at bifurcation since s/p multiple ercp with stents, with subsequent stent retrievals - s/p lap cholecystectomy - bipolar disorder - ptsd - copd, o2 dependent 2.5-3l at baseline - hypertension - hypothyroidism - fibromyalgia - restless legs - s/p spinal fusion - s/p hysterectomy/bilateral salpingo-oopherectomy social history: lives alone, has homemaker. not currently working. former cook and waitress. walks with cane. less than 1 pack per day since age 8. denies etoh or illicit drug use. family history: both parents with history of heart disease. mother with history of gallstones. physical exam: admission physical: vitals: 102.1 131 98/64 15 100% on 450 x 15 80% and 5 peep general: intubated heent: sclera anicteric, mm dry, oropharynx clear, perrl neck: supple, jvp not elevated, no lad cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding gu: +foley ext: cool ext, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact. pertinent results: admission labs: 01:40pm blood wbc-5.7 rbc-3.14*# hgb-10.4* hct-31.7* mcv-101*# mch-33.1* mchc-32.8 rdw-16.2* plt ct-55*# 01:40pm blood neuts-65 bands-21* lymphs-9* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 01:40pm blood pt-15.6* ptt-43.4* inr(pt)-1.5* 01:40pm blood fibrino-457* 01:40pm blood glucose-110* urean-27* creat-1.3* na-141 k-3.7 cl-112* hco3-17* angap-16 01:40pm blood alt-70* ast-117* alkphos-146* totbili-2.5* 01:40pm blood albumin-2.4* calcium-6.3* phos-4.2# mg-2.2 02:05pm blood lactate-3.0* 02:05pm blood freeca-1.02* discharge labs: 2:17 pm stool consistency: not applicable source: stool. **final report ** c. difficile dna amplification assay (final ): negative for toxigenic c. difficile by the illumigene dna amplification assay. (reference range-negative). 2:42 pm blood culture source: line-right ij. **final report ** blood culture, routine (final ): escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . enterococcus faecium. final sensitivities. daptomycin = 3mcg/ml, sensitivity testing performed by etest. high level gentamicin screen: resistant to 500 mcg/ml of gentamicin. screen predicts no synergy with penicillins or vancomycin. consult id for treatment options. high level streptomycin screen: resistant to 1000mcg/ml of streptomycin. screen predicts no synergy with penicillins or vancomycin. consult id for treatment options. . escherichia coli. final sensitivities second colony morphology. piperacillin/tazobactam sensitivity testing performed by . cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | enterococcus faecium | | escherichia coli | | | ampicillin------------ =>32 r =>32 r =>32 r ampicillin/sulbactam-- =>32 r 16 i cefazolin------------- 8 r <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin--------- =>4 r =>4 r daptomycin------------ s gentamicin------------ <=1 s <=1 s linezolid------------- 2 s meropenem-------------<=0.25 s <=0.25 s penicillin g---------- =>64 r piperacillin/tazo----- s s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r vancomycin------------ =>32 r anaerobic bottle gram stain (final ): gram negative rod(s). reported to and read back by dr. 11:39am. aerobic bottle gram stain (final ): reported to and read back by , 19:09. gram negative rod(s). gram positive cocci in pairs and chains. 3:08 am blood culture source: line- a liner. **final report ** blood culture, routine (final ): no growth. imaging: cxr : findings: there is an et tube with the tip approximately 4 cm from the carina as well as a right ij catheter with tip in the region of the cavoatrial junction. there has been improvement in the right lung base atelectasis, but there has been mild increase in the left basilar atelectasis. there is no pneumothorax. cardiomediastinal silhouette is stable with mild cardiomegaly. right hilus is similar in appearance compared to previous film. impression: left basilar atelectasis worsening with right basilar atelectasis improvement. monitoring and support devices still in good position. cxr : findings: as compared to the previous radiograph, the patient has undergone intubation. the tip of the endotracheal tube projects 2.6 cm above the carina. the patient has also received a right-sided internal jugular vein catheter. the tip of the catheter projects over the cavoatrial junction. no other monitoring and support devices are seen. there is mild cardiomegaly with mild fluid overload and atelectasis in both the retrocardiac lung areas and the right lung bases. although the morphology of the right lung base suggests atelectasis, short-term radiographic followup can be performed to exclude early pneumonia. no pneumothorax or other complications. ercp report : evidence of a previous sphincterotomy stricture at the hilum near the clips. the stricture was 5 mm in length. the left intrahepatic duct was dilated. given the presence of stricture and cholangitis, a 10f by 5 cm double pigtail plastic stent was placed in the left intrahepatic. otherwise normal ercp to third part of the duodenum 06:00am blood wbc-6.4 rbc-2.52* hgb-8.5* hct-24.6* mcv-98 mch-33.7* mchc-34.5 rdw-16.5* plt ct-97* 09:16am blood na-146* k-3.3 cl-119* 06:00am blood glucose-73 urean-8 creat-0.7 na-139 k-6.5* cl-104 hco3-28 angap-14 09:16am blood alt-3 ast-16 alkphos-88 totbili-0.3 04:18am blood tsh-26* 04:18am blood free t4-0.72* brief hospital course: discharge exam 140-160/80-96 89 afebrile flat affect, but smiled a few times clear breath sounds regular s1 and s2 mild discomfort epigastric region, no rebound or guarding no peripheral edema aox3, cooperative recent data hgb 8.5, plts improving at 96 65 year-old female with common hepatic duct stricture s/p multiple prior ercps with stricture stenting, removal of stent in , presented with fever, abdominal pain, and septic shock concerning for recurrent cholangitis, now s/p ercp with stenting and doing well with downtrending lfts and normal lipase. #septic shock requiring pressors in micu with evidence of arf that resolved with fluids, pressor support and therapy for cholangitis. # recurrent obstructive cholangitis: patient presented with pentad in septic shock likely from suppurative cholangitis. likely secondary to scar from prior cholecystectomy. she has had stricture with stenting in the past. she is s/p uncomplicated ercp and stent was placed. her lfts and tbili trended down and she remained afebrile. she initially required pressors, which were weaned off. per ercp recs, she will need repeat ercp in 5 weeks and ursodiol is not indicated as likely to be unresponsive. in addition, plan to continue with ercp as needed for at least a year before considering invasive surgery such as a hepatojejunostomy. her diet was advanced and her pain improved. her blood cultures from the osh grew klebsiella and e. coli (cipro resistant) with a third aerobic bottle growing pseudomonas (sensitive to zosyn). blood cultures here growing e. coli sensitive to zosyn and vre (enterococcus). she was continued on zosyn (day 1: ) and given her history of prior vre, vanc was switched to dapto (day 1: ). picc was placed, plan for 2 weeks course since first negative blood culture. her last day of antibiotics is planned to be on . **monitoring should include weekly ck, cbc and chem7 while on these antibiotics. # thrombocytopenia: differential includes sepsis vs. med induced. coags wnl, so unlikely dic. possibly represents partial dilution, given ivf resuscitation. also concern for med effect from linezolid. linezolid was discontinued. her platelets improved from 30 on admission to 96 on . she has not had signs of active bleeding and given improvement with direct treatment of sepsis, this should continue to improve. #anemia: hgb 8.5, no signs of active gi bleeding, no evidence of fe def or b12 def on labs, no signs of hemolysis on labs. trend and w/u as outpatient. # acidemia: combination metabolic acidosis and respiratory acidosis. metabolic acidosis likely a result of lactate production in the setting of infection. improved with fluids. #acute respiratory failure requiring intubation, mechanical ventillation in icu, uneventful extubation. # hypertension: home amlodipine was initially held in the icu. it was restarted on # hypothyroidism: continued levothyroxine. tsh was elevated and levothyroxine dose was increased # bipolar disorder: restarted home meds, risperidone # restless legs: this is the indication for carbidopa/levodopa per pcp # pain: restarted pregabalin, duloxetine and home fentanyl patch # smoking / nicotine dependence: nicotine patch # transitional -patient needs repeat ercp in 5 weeks, ercp team will arrange -please recheck tsh in 4 weeks as levothyroxine was recently increased -check weekly cbc, chem7, lfts, and ck while on iv antibiotics --remove picc when done with antibiotics medications on admission: preadmission medications listed are correct and complete. information was obtained from patientpharmacy. 1. nexium *nf* (esomeprazole magnesium) 40 mg oral 2. levothyroxine sodium 162 mcg po daily 3. calcium carbonate dose is unknown po bid 4. vitamin d dose is unknown po bid 5. lidocaine 5% patch 1 ptch td frequency is unknown 6. risperidone 2.5 mg po hs 7. duloxetine 60 mg po daily 8. carbidopa-levodopa cr (50-200) 1 tab po qhs 9. tiotropium bromide 1 cap ih daily 10. imitrex *nf* (sumatriptan;<br>sumatriptan succinate) 100 mg oral q12 prn headache 11. estradiol 0.5 mg po daily 12. fluticasone propionate 110mcg 2 puff ih 13. chantix *nf* (varenicline) 1 mg oral discharge disposition: extended care facility: maplewood care & rehabilitation center - discharge diagnosis: septic shock respiratory failure requiring mechanical ventilation acute cholangitis septicimia with ecoli, vre, pseudomonas discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were hospitalized with a serious infection called cholangitis that led to multiple bacteria growing in your blood including vre, pseudomonas and e coli resistant to cipro. you underwent procedure called ercp with biliary stent placement to open up passage of bile. all iv antibiotics are to end on transitional issues include labs weekly on antibiotics ck, chem7, cbc remove picc when no longer needed return to for ercp with stent removal in 5 weeks time followup instructions: please call patient's pcp to set up appt when d/c'd from rehab name: , a. location: health family practice address: , , phone: fax: department: digestive disease center when: thursday at 1 pm with: , md building: building (/ complex) campus: east best parking: main garage department: endo suites when: thursday at 1 pm procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours endoscopic insertion of stent (tube) into bile duct injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance diagnoses: acidosis thrombocytopenia, unspecified other chronic pain anemia, unspecified tobacco use disorder unspecified pleural effusion unspecified essential hypertension acute kidney failure, unspecified severe sepsis unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified acute respiratory failure septic shock infection with microorganisms without mention of resistance to multiple drugs other septicemia due to gram-negative organisms streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] cholangitis obstruction of bile duct bipolar disorder, unspecified pseudomonas infection in conditions classified elsewhere and of unspecified site restless legs syndrome (rls) other and unspecified escherichia coli [e. coli] other fluid overload 

Answer: The patient is high likely exposed to