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: history of present illness: the patient is an 80 year old man with history of coronary artery bypass graft, pacemaker, type 2 diabetes, chronic obstructive pulmonary disease, who was recently admitted for acute cholangitis with failed endoscopic retrograde cholangiopancreatography attempt and biliary drain placement who returns with acute renal failure and repeat endoscopic retrograde cholangiopancreatography. since the patient's recent discharge he has been readmitted to hospital with acute renal failure. at the time of that admission he had a creatinine of 5.5 which was likely due to dehydration. given the concern for continued cholangitis, the patient received gentamicin during that admission. his creatinine rose to 6.6 and at the time of transfer to it was 5.5. since his discharge on , the patient has been using levofloxacin and flagyl for cholangitis and escherichia coli positive blood cultures at a prior outside hospital. the patient was transferred to for endoscopic retrograde cholangiopancreatography. during that procedure, he became hypoxic with oxygen saturation dropping into the 70s and was intubated at the time of the procedure. the procedure was completed successfully with stent placement and removal of percutaneous drainage tube. he was then transferred to the intensive care unit on ventilatory support. the patient's desaturation was likely due to medications received during the procedure and the patient was easily weaned from the ventilator in the intensive care unit. upon awakening from the sedation, the patient denied fever or chills. the patient also denied abdominal pain but did report prior right-sided pain which had not recurred. the patient denied any urinary symptoms. he reports improvement in his jaundice. the patient did report some dysarthria and memory difficulties which were still present but improved since the last admission. past medical history: 1. type 2 diabetes. 2. chronic obstructive pulmonary disease. 3. coronary artery disease, status post coronary artery bypass graft 15 years prior. 4. cholangitis, recent discharge on . stent placement on . 5. pacemaker secondary to bradycardia. 6. history of gallstones. 7. question of aortic stenosis. 8. neuropathy. 9. history of bladder cancer. 10. history of transient ischemic attacks. 11. acute renal failure. 12. carotid bruits. allergies: no known drug allergies. medications at home: insulin nph 50 q. am; insulin regular 8 q. am, 12 q. pm; protonix 40 q. day; aspirin 325 q. day, stopped ; levofloxacin 250 q. day; flagyl 500 t.i.d.; pentoxifylline 400; valsartan 160; gabapentin 300 t.i.d.; detrol 2 mg q. day; metoprolol xl 75 q. day; multivitamin q. day. physical examination on admission: temperature 99.9, heart rate 120, blood pressure 182/74, respirations 30, sating 100% on ventilatory support. on original admission the patient was intubated, however, at extubation was alert and awake. head, eyes, ears, nose and throat: pupils equal, round and reactive to light and extraocular movements intact. mucous membranes were moist. cardiovascular: regular rhythm, tachycardiac, normal s1 and s2. pulmonary revealed clear to auscultation bilaterally. abdomen was soft, nontender, nondistended. extremities revealed 2+ bilateral lower extremity edema and also revealed swelling diffusely in the right upper extremity, good pulses throughout. neurologic: the patient was alert and oriented times three after extubation. cranial nerves were grossly intact. the patient was moving all extremities. laboratory data: prior culture data files from the 16th, enterococcus coagulase negative staphylococcus, and vial from the 9th grew enterococcus. chest x-ray had a question of left lower lobe infiltrate versus atelectasis but chronic in appearance since . electrocardiogram revealed a paced rhythm at 120 beats/minute. laboratory values on admission revealed white count 15.1, hematocrit 39, platelets 230. chem-7 with sodium 139, potassium 5.5, chloride 110, bicarbonate 15, bun 70, creatinine 5.6. ast was 30, alt 31, ldh 272, ck 42, alkaline phosphatase 218, total bilirubin 1.4, amylase 78, lipase 51, albumin 3.2. hospital course: 1. gastrointestinal - the patient with recent cholangitis. endoscopic retrograde cholangiopancreatography on this admission showed a nonbleeding 2 cm ulcer in the anterior bulb of the duodenum and also revealed an ulcerated major papilla. a biliary stent was placed during this procedure and percutaneous biliary drain was removed. the patient was continued on empiric antibiotics of levofloxacin and flagyl, though no further biliary cultures were obtained. the patient's liver function tests remained stable post endoscopic retrograde cholangiopancreatography. he was continued on levofloxacin and flagyl for nine days post procedure. 2. gastrointestinal - diarrhea, patient with diarrhea after this admission. given the patient's recent history of antibiotics the patient's stool was checked for clostridium difficile and culture samples were negative at the time of discharge. 3. acute renal failure - patient with renal failure, likely originally due to dehydration and subsequent with acute tubular necrosis, possibly from medications received. the patient's renal function improved both with time and with intravenous hydration. all medications were renally dosed. the patient's baseline creatinine was 0.8. the patient did have a renal ultrasound which showed no evidence of obstruction for post renal cause of his acute renal failure. the patient's urine sediment and laboratory data were consistent with components of dehydration as well as likely acute tubular necrosis. the renal team consulted on this patient throughout his hospitalization and followed him through this admission. the patient's creatinine was improving significantly at the time of discharge, however, this should be monitored carefully as an outpatient to ensure resolution of his acute renal failure. 4. neurologic - the patient with some confusion and dysarthria on admission. per report of the patient and family this has improved since his last admission. the patient's dysarthria was likely secondary to dry mouth post intubation and confusion possibly secondary to a recent infection and sedation. the patient did have a head computerized tomography scan to rule out bleed which revealed no evidence of acute intracranial hemorrhage. it did show evidence for prior small lacunar infarct. the patient's mental status improved throughout his hospitalization. 5. cardiac - the patient with a history of coronary artery disease. his aspirin was held at the time of this admission given that he had evidence of a large ulceration in his duodenum and with guaiac positive stool. the patient was continued on his beta blocker. the and hydrochlorothiazide were held given his renal failure. 6. pump - the patient had an echocardiogram on this admission given the aggressive hydration due to dehydration and echocardiogram revealed left atrial and left ventricular dilation and ejection fraction of 30%. it also revealed global left ventricular hypokinesis, 1 to 2+ aortic regurgitation and 2+ mitral regurgitation. care was given with giving the patient's fluids and his oxygen saturations remained stable. 7. blood pressure - patient with hypertension, and his hydrochlorothiazide and had been held during this admission. the patient was continued on the beta blocker and in addition to this was given hydralazine for blood pressure control. hydralazine was keeping the blood pressure within good control, however, will consider switching as an outpatient for more convenient dosing as the patient's renal function improves. 8. anemia - the patient had a baseline hematocrit of approximately 34. this decreased to 30 during this admission, likely secondary to rehydration. in addition, the patient did have guaiac positive stools and evidence of a duodenal ulcer, given that the patient's hematocrit dropped below 30 during this admission and had a history of coronary artery disease, he was transfused 1 unit. on discharge the hematocrit was stable. 9. right upper extremity swelling - the patient had right upper extremity swelling on admission and ultrasound showed superficial clot in the brachial and basilic vein. the patient was not anticoagulated given the presence of ulcer on film as well as guaiac positive stools and the fact that the clot was superficial and not truly representative of deep venous thrombosis. this should be monitored as an outpatient closely. 10. diabetes mellitus - the patient was kept on insulin drip on the intensive care unit. on transfer to the floor, he was given a regular insulin sliding scale. as the patient began to take better p.o., his insulin nph was restarted. the patient was discharged on a lower dose than he takes at home and this should be increased as an outpatient as his p.o. intake continues to increase. 11. heme - patient with elevated inr on admission to 6.3. this was due to malnutrition, as the patient responded well to vitamin k. the patient was given vitamin k during this admission and the inr returned to 1.3 at the time of discharge. 12. gastrointestinal, duodenal ulcer - appreciated at the time of scope, although this was nonbleeding during scope, the patient did have guaiac positive stools. the patient's hematocrit although decreased during this admission likely due to hydration did not represent or suggest acute active blood loss. the patient was given protonix b.i.d. for ulcer, he also had helicobacter pylori checked which was negative. the patient should continue on protonix and follow up as an outpatient. 13. fluids, electrolytes and nutrition - patient with significant malnutrition at the time of admission and low albumin as well as evidence of vitamin k deficiency as represented by his increased inr. the patient's diet was advanced and he was given supplements to his diet. the patient will continue with nutrition, maintaining a cardiac and diabetic diet at the time of discharge. 14. hypoxia - patient with hypoxic respiratory failure on admission. this was likely due to the sedation received during the procedure. he was easily extubated and weaned from the ventilator. he was given nebulizers prn and encouraged to use an incentive spirometer. the patient also may likely have significant sleep apnea as he is overweight and this should be pursued as an outpatient. the patient's tachycardia resolved as he was restarted on his medications and oxygenations but off of the ventilator there was no evidence for pulmonary embolus. condition on discharge: stable. discharge status: to rehabilitation facility. discharge diagnosis: 1. cholangitis. 2. status post biliary stent placement. 3. hypoxia secondary to respiratory failure. 4. acute renal failure. 5. anemia. 6. malnutrition. 7. diabetes. 8. hypertension. discharge medications: 1. calcium acetate 2 tablets b.i.d. 2. levofloxacin 250 q.o.d. for two days. 3. multivitamin q. day. 4. albuterol and ipratropium nebulizers prn. 5. flagyl 500 t.i.d. for two days. 6. miconazole powder prn. 7. hydralazine 20 mg p.o. q. 6 hours. 8. pantoprazole 40 p.o. b.i.d. 9. metoprolol 75 mg p.o. b.i.d. 10. regular insulin sliding scale. 11. insulin nph 15 units q. am follow up plans: the patient will follow up with his primary care physician within one week following discharge. in addition to this, the patient will follow up with gastroenterologist and renal doctors. , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube endoscopic insertion of stent (tube) into bile duct transfusion of packed cells diagnoses: acute kidney failure with lesion of tubular necrosis unspecified protein-calorie malnutrition sepsis cholangitis other specified antibiotics causing adverse effects in therapeutic use septicemia due to gram-negative organism, unspecified complications affecting other specified body systems, not elsewhere classified 

Answer: The patient is high likely exposed to