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: egg attending: chief complaint: osh transfer for cholangitis major surgical or invasive procedure: #ercp w/ stent removal and replacement #placement of percutaneous billiary drain to clear abcess history of present illness: 84yo female with multiple medical problems including coronary artery disease s/p cabg, type 2 diabetes mellitus, chronic diastolic heart failure, and peripheral vascular disease was transferred from an osh for further evaluation of abdominal pain. she was admitted to from 7/25-29/09 to the surgical service for evaluation of abdominal pain. at that time, she underwent an ercp which demonstrated the following: "filling defect that appeared like a stone at the distal cbd, 2cm distal cbd narrowing and post obstructive dilation and measured 15mm in diameter. also there was intrahepatic dilation of the biliary tree." sphincterotomy was not performed as patient was on plavix at the time. follow-up cta abdomen was obtained which revealed "porta hepatis lymphadenopathy and suggestion of lower cbd soft tissue at the site of filling defect on ercp raises possibility of cholangiocarcinoma." cytology specimens were negative for malignancy and cea was 3.1 (not elevated). she was then discharged with plans to repeat the ercp and eus in weeks after cardiology evaluation and consideration of stopping aspirin and plavix prior to repeat procedure. in fact, she was scheduled to have a stress test performed on in anticipation of a likely repeat gi procedure; however, she presented to an osh on with ruq pain radiating to her substernal chest. she was admitted to for rule-out mi. her hospital course was complicated by a temperature to 100.5 and cxr demonstrating dilated pulmonary vasculature. she was started on unasyn and gentamicin for treatment of presumed cholangitis and was diuresed with iv lasix. upon arrival to , she reports feeling generally well and without abdominal pain. review of systems: (+) per hpi. abdominal pain as described above; low-grade temperature (-) denies pain, chills, night sweats, weight loss, headache, sinus tenderness, rhinorrhea, congestion, cough, shortness of breath, chest pain or tightness, palpitations, nausea, vomiting, constipation, change in bladder habits, dysuria, arthralgias, or myalgias. past medical history: 1. coronary artery disease - s/p cabg x 3 in at : lima to lad, svg to pda, svg to om - stent palced in 2. chronic diastolic congestive heart failure - - ef 70% 3. peripheral vascular disease - s/p bilateral cea 4. hyperlipidemia 5. aaa (unchanged since the 's) 6. type 2 diabetes mellitus - uncontrolled 7. gerd 8. hiatal hernia 9. osteoarthritis 10. melanoma s/p resection 11. spinal stenosis 12. anxiety / depression s/p ect therapy 13. h/o tobacco abuse social history: home: lives alone in ; very supportive and involved family occupation: homemaker etoh: denies drugs: denies tobacco: prior tobacco use - smoked < 1ppd x 35 years, quit 14 years ago family history: mother - died of pe at age 82 father - died at age 77 from complications of a stroke brother - died at age 67 with an mi physical exam: vitals: t: 101.3 bp: 110/70 p: 100 r: 22 o2: 94-96% on 3l nc general: rigoring initially, now more comfortable, initially slightly confused, then fully oriented heent: sclera anicteric, mm slightly dry, oropharynx clear neck: supple, right internal jugular line in place, slight ozzing from line. lungs: rales greater on left base over lower , and right side over base, moving good air cv: borderline tachycardic, regular rate and rhythm, hsm at the llsb and apex abdomen: soft, non-distended, bowel sounds present, tender to palpation in ruq, no rebound tenderness or guarding, no organomegaly. no guarding or rebound tenderness, no focal or reproducible tenderness. gu: foley in place ext: warm, well perfused, slightly damp, trace bilateral non pitting pedal edema bilaterally neuro: awake, alert, conversing appropriately pertinent results: osh labs: wbc 11 / hct 41.8 / plt 214 n 75 / l 16 / m 7 / e 1 / b 0 . wbc 17.6 / hct 40.8 / plt 221 n 72 / bands 13 / mono 5 / lymphs 10 na 136 / k 3.3 / cl 101 / co2 25 / bun 12 / cr 1.3 tuberculosis 4.9 / db 2.9 / ast 182 / alt 143 tp 6.6 / alb 3 / alk phos 373 bnp 840 ua - ph 6, 1.019, clear, 30 protein, 300 glucose, negative for ketones, negative blood, small bili, neg nitrite, large leuk est, 4 rbcs, 9 wbcs, few bacteria urine osm 558 / urine na 94 . results: wbc 13.5 / hct 34.3 / plt 326 n 75.7 / l 16.4 / m 5.2/ eos 2.6/ baso 0.1 pt 12.5 / ptt 32.8 / inr 1.1 glc 89 / bun 8 / cr 0.9 / na 139 / k 4.1 / cl 105 / hco3 25 alt 15 / ast 18 / ck 17 / ap 211 / t bili 0.5 ck-mb 3 / trop 0.05 ca 8.1 / phos 3.2 / mg 2.3 . osh microbiology: : urine cx ng : urine culture (final ): yeast. 10,000-100,000 organisms/ml.. : blood cx pending , : c. diff x2 ng . imaging: cxr (osh) - questionable nodule identified overlying the heart and possibly in the left lower lobe. it is visible on a chest radiograph from and has not changed. no active disease seen elsewhere . abdominal us (osh) - choledocholithiasis and cholelithiasis. there is gallbladder sludge present and there is borderline mural thickening. there is choledocholithiasis noted and pneumobili. by report, the patient has undergone recent biliary stenting which would account for the pneumobili. no definite intrahepatic biliary dilatation is seen . portable cxr (osh) - left ventricular dilatation. post-surgical changes in left hemithorax. lungs are well expanded. oval nodular density at the left base behind the heart. remainder of the lungs are clear. . : ercp: scout view demonstrates a plastic biliary stent in the right upper quadrant. subsequent images demonstrate cannulation of the common bile duct with irregularity in the region of the stent, and stable common bile duct and intrahepatic ductal dilatation. no definite filling defects are seen. stent removal and replacement is noted. please refer to the operative note for further details. . : abd u/s: 1. gallbladder sludge. no evidence of acute cholecystitis. 2. pneumobilia, presumably related to recent ercp procedure. . cxr decrease in lung volumes with superimposed mild-to-moderate volume overload. repeat radiography following appropriate diuresis recommended to assess for underlying infection. . : cxr: in comparison with study of , there is persistent enlargement of the cardiac silhouette _____ the patient following cabg procedure. there is a breakage of the upper portion of the two most superior sutures, as on the study of . evidence of increased pulmonary venous pressure persists with bibasilar atelectasis, especially in the retrocardiac region. dense calcification is seen in the region of the mitral valve. right ij catheter tip again extends to the lower portion of the svc. . cxr: improved pulmonary edema and lower lobe atelectasis. stable mild cardiomegaly. rounded calcification projected over the mitral valve,on review of a prior ct confirms this calcification is in/attached to the mitral valve, correlation with echo is recommended. . ct abd: 1. contained gallbladder perforation into the right lobe of the liver. cholelithiasis. 2. atrophy of the interpolar left kidney. atherosclerotic changes of the left renal artery, not well assessed on this non-angiographic study. 3. fibroid uterus. . gb drainage,intro perc tranhep bil us: 1. successful ct and ultrasound-guided placement of percutaneous cholecystostomy catheter. approximately 130 cc of purulent material was aspirated, with subsequent decrease in size of both the gallbladder and the adjacent hepatic abscess. samples were sent for culture and gram stain. 2. small right lateral abdominal wall hematoma. monitoring of hematocrit is recommended to assess for hematoma expansion in this patient on aspirin and plavix. this was discussed with dr. at approximately 3:30pm by dr. . . cxr: bibasilar atelectasis related to low lung volumes. no overt evidence for pneumonic consolidation or edema. . ct abd: 1. drainage catheter at the perihepatic abscess next to the largely decompressed gallbladder. 2. new 2 x 5-cm collection at the lower edge of the liver. be due to the bile leak with subcapsular collection formation, or another point of perforation of the gallbladder. abscess cannot be excluded. 3. further noted increased stranding surrounding decompressed gallbladder. . cardiac imaging: echo ()- ef > 55%; dilated left atrium; mild symmetric lvh; moderate aortic stenosis with 1-1.2cm; 2+ mr; 2+ tr; severe pulmonary artery systolic hypertension . pathology: : stent (common bile duct): negative for malignant cells. bile pigment and few degenerated epithelial cells. . ekg : atrial fibrillation, average ventricular rate 131. intraventricular conduction delay with qrs duration of 98 milliseconds. there are marked st segment depressions in leads i, ii, avl and leads v2-v6. compared to the previous tracing of these changes are similar but somewhat more prominent. brief hospital course: course: mrs. is an 84 year old female who was admitted to post ercp on the , presenting with fever, rigors, and tachycardia. #cholangitis: her post-ercp fevers, rigors, and tachycardia were most likely related to the cholangiogram with subsequent transient sepsis. osh blood culture grew e. coli sensitive to cefazolin, ampicillin, and piperacillin. she was started on zosyn to cover her bacteremia. due to her continuing spiking fevers and abnormal urine analysis consistent with possible infection, ciprofloxacin and vancomycin were started as empiric coverage, however they were then discontinued after negative culture data for 24-48 hours. she continued to spike fevers, at which vancomycin was added back to her regimen. her subsequent blood/urine cultures remained without growth. through her icu course, she has ruq pain, which was felt to be due to a musculoskeletal, pleuritic, or cholestatic source. a right upper quadrant ultrasound demonstrated no evidence of cholecystitis and she had remained afebile with a decreasing leukocytosis. her pain was controlled with prn percocet. throughout her course, her map has been maintained above 65 with levophed and small fluid boluses. she was weaned off of the levophed. upon discharge from the icu to the floor, picc line was placed for continuation of zosyn and her a-line. she was transferred to floor after being off pressors for 24 hr. she was subsequently readmitted to the on for fever, tachycardia, hypotension. on the morning of , she developed fever 102, systolic blood pressure in the high 80's, and rigors. repeat cultures were obtained and she was re-started on ciprofloxacin, flagyl, and vancomycin. an abg 7.44/26/61 demonstrated, with lactate 5.9. she was transfered to the for further management and given small fluid boluses. after she was stabalized, she underwent a ct abdomen showed perforated loculated gallbladder, loculated in the right liver lobe. surgery was consulted who recommended percutaneous drainage by ir. ir was consulted for procedure to be done. at that time, however, after extensive discussion with patient and her daughter (her hcp), the patient elected not to pursue ir drainage, and wished her code status to be dnr/dni, with conservative management only. for her antibiotic regimen, she was started back on vancomycin, zosyn, and flagyl. after c. difficile x2 came back negative, flagyl was discontinued. on the morning of , she experienced an episode of chest heaviness that radiated to both arms that resolved within a minute after sl nitroglycerin administration. she stated she has experienced this type of pain before, but was less in severity in comparison to her regular anginal pain. ekg showed t-wave inversions/st depressions in leads v2-v5. asa dose was increased to 325, sl nitro prn, msir 7.5mg prn, o2 nc, metoprolol 25mg, repeat ces, and ekgs were ordered. troponin after event was 0.05. subsequent ekgs showed no further change. the palliative care and infectious disease teams were involved in her care. several family meetings and meetings with the patient took place to discuss potential options going forward, regarding getting the patient home on antibiotics and discussion of surgery. there still remains a question of underlying malignancy given the stenosis initially seen on her first ercp in , at which time biopsy was not pursued as she remained on plavix. the patient continued to do well in the , and was transitioned to flagyl and ceftriaxone on the recommendations of the infectious disease team. over the weekend of , patient decided she wished to re-consider the surgical option for management of her contained perforation. she was transferred to the floor on for further management and ongoing discussion with surgical and infectious disease teams about next steps. social work and palliative care also will continue to be involved. an insulin sliding scale was maintained for her dmii. for her cad, antihypertensives were held. asa and plavix were continued. for her hyperlipidemia, zetia was continued while simvastatin was added back after her lfts came down within normal limits. for depression/dementia, her celexa, remeron and abilify were continued while holding her ativan. for prophylaxis, sc heparin and ranitidine were implimented due to the interaction between ppi and plavix. she is dnr/dni and is hemodynamically stable upon transfer back to floor status. floor course #cholangitis- prior to arrival on floor, pt had ct-guided percutaneous drain was placed on to drain a localized gallbladder fluid collection, and was stabilized on iv ceftriaxone and iv flagyl. however, pt's abscesses were multiple and loculated, requiring additional drain placement and/or repositioning for cure. however, given that first drain placement had caused her significant abdominal pain and could not guarantee cure, pt felt that additional drain placement was not in line with her wishes. on floor, patient was evaluated by surgery, though given her significant cad history, pt was deemed not a surgical candidate. she was again evaluated by ir for placement of second drain, however pt declined. care was focused on comfort and symptom control. pt plans to go home with hospice, and efforts were made to adjust her in-hospital care to what she would receive at home. pt's family felt strongly regarding continuing antibiotics to avoid the discomfort of septicemia. patient's antibiotics can be continued for 3-4 weeks as long as there are no complications from therapy or picc line. if there is difficulty continuing iv ceftriaxone, pt's family is open to considering changing ceftriaxone to cefpidoxime po. she will continue flagyl po at home. physician following pt's care . #a-fib w/ rvr: on floor, pt went into atrial fibrillation w/ rvr (130s), though pt was asymptomatic. given pt's age, h/o biatrial enlargement on echo, significant h/o cad, heart failure, and ongoing infection, she has many risk factors for atrial fibrillation. her heart rate was controlled w/ diltiazem, which was titrated up to 90mg po qid, and metoprolol 12.5mg po tid. when decision was made for hospice, pt and family preferred to be off telemetry and treat heart rate symptomatically only. patient developed anginal pain with faster heart rates, which was treated with slng and po morphine to good effect. . #hyperlipidemia-once decision was made for hospice care, efforts made to minimize medication regimen. zetia and simvastatin were discontinued. . #diabetes mellitus-once decision was made for hospice care, efforts made to minimize medication regimen, and iss was discontinued. . #anxiety / depression- stable. home medications (celexa, remeron and abilify) except ativan were continued. initially, ativan was avoided given propensity to cause delirium in elderly. however, pt takes standing ativan at home and pt strongly requested ativan for anxiety. pt tolerated ativan well. . #pain-palliative care was consulted and recommended a regimen of basal ms-contin with concentrated morphine sulfate solution as needed for breakthrough pain. pt was discharged with home hospice. her adult children have been very involved in her care and will continue to care for her at home with the additional help of private duty nursing. medications on admission: home medications: 1. glipizide 5mg po daily 2. plavix 75mg po daily 3. lasix 40mg po daily 4. toprol xl 25mg po daily 5. cozaar 50mg po daily 6. aspirin 81mg po daily 7. abilify 2mg po daily 8. celexa 20mg po daily 9. ativan .5mg po bid 10. glipizide 10mg po qhs 11. imdur 30mg po qhs 12. zetia 10mg po qhs 13. zocor 80mg po qhs 14. remeron 45mg po qhs prn 15. colace 16. senna 17. slng prn transfer medications: 1.ativan .5mg po bid 2.losartan 50mg po daily 3.toprol xl 25mg po daily 4.remeron 45mg po qhs 5.simvastatin 80mg po qhs 6.heparin sc tid 7.novolog insulin sliding scale 8.imdur 30mg po daily 9.oxycodone 5mg po q4-6h prn pain 10.abilify 2.5mg po daily 11.aspirin 81mg po daily 12.citalopram 20mg po qhs 13.plavix 75mg po daily 14.ezetimibe 10mg po daily 15.furosemide 20mg iv bid 16.glipizide 5mg po daily / 10mg po q pm 17.unasyn 3g iv q12h 19.gentamicin 120mg iv q daily discharge medications: 1. aripiprazole 2 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. mirtazapine 15 mg tablet sig: three (3) tablet po hs (at bedtime). disp:*90 tablet(s)* refills:*0* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 6. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). disp:*30 tablet, chewable(s)* refills:*0* 8. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. disp:*1 vial* refills:*0* 9. white petrolatum-mineral oil 42.5-56.8 % ointment sig: one (1) appl ophthalmic prn (as needed) as needed for itchy. disp:*1 vial* refills:*0* 10. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*0* 11. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 12. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*0* 13. morphine 15 mg tablet sustained release sig: one (1) tablet sustained release po q8h (every 8 hours). disp:*90 tablet sustained release(s)* refills:*0* 14. dilt-xr 240 mg capsule,degradable cnt release sig: one (1) capsule,degradable cnt release po once a day. disp:*30 capsule,degradable cnt release(s)* refills:*0* 15. dilt-xr 120 mg capsule,degradable cnt release sig: one (1) capsule,degradable cnt release po once a day. disp:*30 capsule,degradable cnt release(s)* refills:*0* 16. morphine concentrate 20 mg/ml solution sig: 10-20 mg po q1h as needed for pain/dyspnea. disp:*20 ml* refills:*0* 17. ceftriaxone in dextrose,iso-os 2 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours). disp:*14 doses* refills:*1* 18. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: one (1) intravenous q8h (every 8 hours) for 10 days. disp:*42 doses* refills:*0* 19. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. disp:*14 ml(s)* refills:*0* 20. lorazepam 2 mg/ml concentrate sig: 0.5 mg po three times a day. disp:*10 ml* refills:*0* 21. zofran odt 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. disp:*20 tablet, rapid dissolve(s)* refills:*0* 22. hospice care discharge disposition: home with service facility: discharge diagnosis: primary: #cholangitis #sepsis #atrial fibrillation w/ rvr secondary: #coronary artery disease #type 2 diabetes mellitus #chronic diastolic congestive heart failure #peripheral vascular disease #anxiety discharge condition: gaurded discharge instructions: you were admitted for fevers and abdominal pain and were found to have infected bile stent. you underwent a procedure to remove and replace the stent, but despite this procedure, you ended up with e.coli bacteria in your blood, causing you to have very low blood pressure, high fevers, and fast heart rate. you were given antibiotics and stabilized briefly, however your gallbladder wall ruptured and created a localized abscess. during this time, you blood pressure again dropped very low due to overwhelming infection. because your blood pressure was so low, you sustained a minor heart attack. again, you were stabilized, and you were given intravenous antibiotics and a drain was placed under ct-guidance to drain the abscess. however, the abscess was complex and would require multiple drain placements to clear, which you chose to decline given that it as not in line with your goals of care. surgery was consulted, however your case was deemed not amenable to surgical intervention. you and your family decided in favor of returning home with hospice. followup instructions: none md procedure: venous catheterization, not elsewhere classified arterial catheterization endoscopic insertion of stent (tube) into bile duct removal of t-tube, other bile duct tube, or liver tube percutaneous aspiration of gallbladder endoscopic retrograde cholangiopancreatography [ercp] diagnoses: esophageal reflux congestive heart failure, unspecified acute kidney failure, unspecified severe sepsis atrial fibrillation acute on chronic diastolic heart failure coronary atherosclerosis of unspecified type of vessel, native or graft aortocoronary bypass status peripheral vascular disease, unspecified diaphragmatic hernia without mention of obstruction or gangrene other and unspecified hyperlipidemia septic shock diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled abdominal aneurysm without mention of rupture septicemia due to escherichia coli [e. coli] cholangitis personal history of malignant melanoma of skin infection and inflammatory reaction due to other internal prosthetic device, implant, and graft perforation of gallbladder 

Answer: The patient is high likely exposed to