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: fatigue and decreased po major surgical or invasive procedure: ercp history of present illness: 87m with h/o stage iv pancreatic cancer with liver mets presents with 2 days of generalized weakness, malaise, and poor po intake. reports one episode of shaking chills while watching television 3 days ago, did not take temperature and denies other chills or fever. denies abdominal pain, but does admit to a "tight" feeling in his abdomen. has chronic intermittent nausea for which he takes meds at home, no recent emesis. recently when he has the urge to urinate or defecate, he produces only a small volume of dark yellow urine and/or non-bloody stool. last bm 3 days ago. normally on laxative and stool softener with daily stools, no melena or hematochezia. also denies chest pain and sob. . in the ed, t 98.3 hr 110 irregular bp 72/43 rr 18 o2 99%/ra. labs showed elevated lfts with tbili 7.7 up from baseline 0.9 and alk phos 474 up from 261. abg 7.35/pco2 41/po2 62/hco3 24. ruq us showed contracted gallbladder with thickened wall and sludge with possible stones. blood pressure was low with sbp in the 70s but patient asymptomatic. bp improved with 6l ivf and 0.6 mg/hr levophed, vs at time of ed transfer were hr 108 map 89 bp 111/82 o2 96%/ra. creatinine elevated to 3.8 (past max 4.0, ckd), urine output 20-30 cc/hr. given 1 dose vancomycin, zosyn, zofran. rij triple lumen central line placed. surgery consulted, requested ct abdomen, deemed pt a non-operable candidate, and suggested ercp. of note, ercp in in the context of elevated lfts/nausea showed duodenal bulb stenosis likely tumor compression. 2cm stricture in lower cbd seen, sphincterotomy was performed with hepatobiliary stent placement. both lfts and nausea improved. today he is admitted directly to the icu for progressive weakness, decreased po intake, and hypotension with bilirubinemia and neutrophilic leukocytosis. past medical history: oncologic history: stage iv pancreatic cancer originally presented with a one month history of progressive vomiting (1-2 hrs after eating) and the inability to tolerate food, lost approximately 15-20 lbs in a month. he presented to his nephrologist, who was concerned and referred him to the ed for admission and inpatient workup. his labs were notable for a very high alk phos, and ct disclosed multiple lesions in the liver and pancreatic head fullness. an eus was performed which disclosed a 2cm mass in the head of the pancreas; fna was performed and returned as adenocarcinoma. his ca-19-9 was 352,000 at presentation. on he had a biliary stent placed with improvement in his alk phos and nausea symptoms. . was on regimen of weekly gemcitabine, given 3 weeks in a row with one week off. first dose 3/16; subsequently stopped due to side effects. . other past medical history: stage iv ckd hx of nephrolithiasis renal osteodystrophy papillary urothelial carcinoma s/p turbt, receiving bcg treatments hx of invasive scc of the head s/p mohs resection chronic l pleural effusion (neg for malignant cells on last thoracentesis, ) moderate aortic stenosis (av area 1 cm2) cad (prior inferior mi evident on ekg) hypertension dyslipidemia anemia (was on aranesp) glaucoma social history: -used to work for polaroid, also a retired wwii veteran -lives alone in an facility that provides evening meals. daughter visits x a month. -ambulates without assistance, drives, handles grocery shopping, bills, meds -prior extensive smoking hx, quit in the -occasional etoh use -no illicits family history: unable to recall if any family members have had coronary disease or cancer physical exam: admission exam: vs: t 98.7 hr 134 bp 107/74 rr 17 o2 96%/ra gen: jaundiced thin elderly man lying in bed watching baseball, nad heent: ncat eomi perrla +icteric sclera & sublingual jaundice mmm neck: supple jvp flat +lij cv: irregularly irregular +ii/vi systolic ejection murmur @lusb pulm: cta no rales or wheeze (anterior exam) abd: thin, soft, mild rebound no guarding, nontender to percussion or palpation, hypoactive bowel sounds, palpable liver edge 3 cm below costal margin, negative sign ext: warm and dry, +distal pulses, no cyanosis or edema neuro: aox3, cnii-xii intact, spontaneously moves all extremities skin: no rashes, some ecchymoses on forearms foley: draining clear yellow urine pertinent results: 10:05am wbc-13.8* rbc-3.22* hgb-10.6* hct-31.8* mcv-99* mch-32.8* mchc-33.2 rdw-15.3 10:05am neuts-91* bands-0 lymphs-1* monos-7 eos-0 basos-0 atyps-0 metas-1* myelos-0 10:05am lipase-10 10:05am alt(sgpt)-50* ast(sgot)-61* alk phos-474* tot bili-7.7* 10:05am glucose-134* urea n-83* creat-3.8* sodium-137 potassium-3.4 chloride-97 total co2-23 anion gap-20 10:25am lactate-3.2* 04:41pm lactate-1.5 . . micro: . 2:25 pm blood culture site: arm set#2. blood culture, routine (preliminary): klebsiella pneumoniae. final sensitivities. piperacillin/tazobactam sensitivity testing confirmed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 4 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s aerobic bottle gram stain (final ): reported to and read back by @ 6pm . gram negative rod(s). blood cx - pending blood cx - pending urine cx negative . imaging: . cxr for ?pna one view of the chest: the lungs are well inflated in the upper zones with bilateral lower lobe opacities. bilateral pleural effusion are noted, moderate on left, small on right. the cardiac silhouette is poorly assessed. the mediastinal silhouette and hilar contours are normal. no pneumothorax is present. impression: bilateral effusions and lower lobe opacities may reflect atelectasis and/or pneumonia. . ruq us right upper quadrant ultrasound: the liver demonstrates a heterogeneous echotexture with multiple focal nodules, findings consistent with known metastatic pancreatic carcinoma. the main portal vein is patent with hepatopetal flow. evaluation of the pancreas is limited due to overlying bowel gas. there is a mild amount of perihepatic ascites and a small right pleural effusion. the gallbladder is contracted and demonstrates diffuse wall thickening. dirty shadowing within the gallbladder is likely secondary to air given the history of known biliary stent. a moderate amount of sludge is also identified within the gallbladder. the common bile duct measures 2 mm and is not dilated. impression: 1. air and fluid filled gallbladder with diffuse wall thickening, likely secondary to third spacing from hepatic dysfunction. 2. multiple hepatic masses consistent with known metastatic pancreatic carcinoma. 3. limited evaluation of the pancreas due to overlying bowel gas. 4. small amount of perihepatic ascites and a small right pleural effusion. . ct abd non-contrast ct abdomen without intravenous contrast: moderate bilateral pleural effusions are identified with associated compressive atelectasis. no definite focal mass or nodule identified. the heart size is normal, and there is no pericardial effusion. complete evaluation of the abdominal viscera is limited due to the non-contrast technique. multiple hypoattenuating lesions are identified within the liver, findings consistent with known metastatic disease from pancreatic carcinoma. a biliary stent remains in standard position within the distal common bile duct and appears grossly patent. an ill-defined soft tissue mass in the head of the pancreas, appears similar compared to prior, though is incompletely evaluated on this non-contrast examination. no pancreatic ductal dilatation is identified in the body or tail. the local extent of the mass is not well-evaluated on this examination. the spleen and adrenal glands are normal. the gallbladder is air and fluid-filled, likely secondary to a combination of sludge and air from the stented biliary tree. in the midpole of the left kidney, there is a stable 12 mm hyperdense lesion, likely a hemorrhagic cyst (2:32). an exophytic lesion in the lower pole of the left kidney also appears unchanged and measures 2.2 x 2.3 cm, likely a simple cyst (2:42). bilateral perinephric stranding appears slightly increased compared to prior. there is a large amount of ascites and a significant amount of mesenteric fat stranding, findings consistent with diffuse edema. the abdominal aorta demonstrates mild ectasia, though no frank aneurysmal dilatation. scattered mesenteric and retroperitoneal lymph nodes are identified, though are difficult to evaluate on this non-contrast examination. bone windows: no bone destructive lesion or acute fracture is identified. impression: 1. biliary stent in standard position in the distal common bile duct and grossly patent. 2. new moderate abdominal ascites and significant mesenteric stranding, findings consistent with severe edema. 3. fluid and air within the gallbladder, likely secondary to ercp. 4. large soft tissue density mass in the pancreatic head, though incompletely characterized on this non-contrast examination. . ercp findings: esophagus: limited exam of the esophagus was normal stomach: limited exam of the stomach was normal duodenum: limited exam of the duodenum was normal major papilla: a metal stent placed in the biliary duct was found in the major papilla. cannulation: cannulation of the biliary duct was successful and deep with a balloon using a free-hand technique. contrast medium was injected resulting in partial opacification. biliary tree: many small stones / sludge that were causing obstruction were seen at the lower third of the common bile duct and middle third of the common bile duct within the metal stent. partial opacification of the upper third of the duct and birfucation showed on evidence of obstruction proximal to the stent. given cholangitis, a high pressure injection into the bile duct was not performed. procedures: copious amouts of sludge / small stone fragments were extracted successfully using a balloon. impression: stent in the major papilla obstruction of metal stent by sludge / stone frgaments was noted. no obstruction proximal to the stent was noted. sludge / stone fragments were removed using a balloon. (cannulation)(stone extraction) otherwise normal ercp to third part of the duodenum recommendations: return to icu. continue iv antibiotics and supportive care. watch for complications - bleeding , perforation, pancreatitis brief hospital course: 87 yo m w/known stage iv pancreatic cancer & liver metastases s/p recent biliary stent placement, ckd, htn, & cad p/w acute-onset fatigue, malaise, decreased pos with elevated wbc and t-bili suspicious for septic cholangitis. . #goals of care-based on the patient's multiple co-morbidities and poor prognosis, discussions were held with him and his family about goals of care. the palliative care service was involved in his care. ultimately, the decision was made to focus on mr. comfort per his request. pt was made officially comfort measures with hospice care on . all seasons hospice was involved in patient's care, initially pt did not meet inpatient level of hospice care and plan was for discharge to a with hospice care. however, on , pt became hypoxic and was very clear (aaox3) that he did not want any further medications and wanted to focus solely on comfort care. he did not want any measures that would prolong his life. this was discussed with pt's hcp/dtr and his nephew. seasons hospice became involved and pt was then made full inpatient hospice care. social work, chaplain were involved to help family wiht coping. pt was given morphine, ativan and antiemetics for comfort care. he died comfortably on the evening of . hcp/dtr notified. . #sepsis. pt presented with syndrome of malaise/fatigue/decreased pos, found to be jaundiced and hypotensive with elevated lfts and elevated neutrophilic wbc. ruq ultrasound suggested acute obstructive cholangitis with cholelithiasis. obstruction of recently-placed metal cbd stent seen on ct provides a good explanation for elevated bilirubin and acute cholangitis. patient's hypotension on admission responded well to 5l ivf in the ed but he continued to require levophed at 0.1 mg/hr to maintain sbp >90 and map>60 during the first 24h the icu. ivf was given judiciously for low urine output/hypotension due pt history of moderate aortic stenosis/chronic pleural effusions. blood cultures sent in the ed grew gnr. he was initially continued on broad-spectrum antibiotics (vancomycin and zosyn), which were narrowed to ceftriaxone once microbiology showed cftx-sensitive klebsiella. ceftriaxone was stopped on based on discussions surrounding goals of care. #biliary obstruction/acute cholangitis. tbili was acutely increased to 7.7, pt with painless jaundice on exam. cbd stent placed in was seen on ct abdomen to be obstructing biliary flow. source of possible obstruction include tumor ingrowth within the cbd stent, external compression from stricture proximal to the stent site, or stones/sludge. surgery was consulted in the ed and recommended ercp. ercp team was consulted, procedure performed the morning after admission. during ercp, cbd stent obstruction with stones and sludge was seen and evacuated. additional stones/sludge seen within the biliary tree but no flushing done because of current cholangitis. importantly, no tumor invasion seen during ercp. immediately following ercp lfts trended upward, tbili max 9.7, and decreased to 7, but then had proceeded to increase to 13.2 with elevated d bili above 11. ercp team felt that this was likely due to tumor progression in liver. given goals of care, decision was made to not proceed with further imaging or repeat ercp. #atrial fibrillation. no history of atrial fibrillation in medical record, therefore afib likely started in context of sepsis. of note, pt takes 12.5 mg po metoprolol tartrate at home for a history of cad and he did not take any of his home medications on the day of admission. upon admission to the icu he was given 1 dose iv metoprolol and an increased po dose (25 mg). digoxin was started given need for rate control in this patient with pressor-dependent hypotension but then held given elevated dig level. lopressor stopped because of relative hypotension on floor (bps 90s) and heart rates that remain <100. #malnutrition: cachexia secondary to cancer and hypoalbumenia. third spacing. pos as tolerated. . #pancreatic cancer. diagnosed 6 months ago, pt is s/p several weeks of chemotherapy which was discontinued as an outpatient given intolerance of side effects in the context of metastatic disease. tumor growth a likely contributor to his current clinical picture. no intervention for now, as patient, family and pcp have agreed to proceed with comfort care. he was continued on his home midodrine and compazine prn. outpatient primary care physician/gastroenterologist dr. followed the pt while in the icu and assisted with patient/family communication. #hx lue and lle dvt. pt not currently on anticoagulation. heparin gtt was initiated during his hospitalization when lue and lle dvts were discovered, but it was stopped soon thereafter when he developed hematemesis. no pain or swelling of his extremities noted on exam. pt denies dyspnea, chest pain, or neurologic symptoms. . #anticoagulation. of note, patient not on anticoagulation despite dvt earlier this year because of upper gi bleeding while on heparin gtt and asa. now with atrial fibrillation, chads scores 2. team discussed plan for anticoagulation with pcp . and considered dabigatran vs. aspirin vs. no anticoagulation. none started in icu. patient considered to be a poor candidate for coumadin given nutritional status. . #worsening chronic constipation. pt chronically constipated, on home laxative and stool softener which produce daily bms. last bm was three days prior to admission; a stool-filled colon was seen on ct abd. he was continued on his home bowel regimen w/additional enemas in the icu prn. did have multiple bowel movements but remained constipated. . #hx and hypertension: d/c'd lopressor and lasix given volume status and hypotension . #ckd w/renal osteodystrophy. baseline cr . 3.8 in icu, and began rising on floor to 4.6 as of . likely intra-vascular volume depletion with total volume overload. not an hd candidate. supportive care. . #hx bladder cancer, s/p turb. urine output monitered by foley. #bph. continued home tamsulosin. #insomnia. held home ambien. gave trazodone as needed. #glaucoma. continued home timolol eyedrops. #code: dnr/dni (confirmed with patient)/comfort measures. confirmed with patient, hcp/pt's daughter. based on the patient's multiple co-morbidities and poor prognosis, discussions were held with him and his family about goals of care. the palliative care service was involved in his care. ultimately, the decision was made to focus on mr. comfort. he died comfortably on the evening of . medications on admission: metoprolol 12.5 mg midodrine 2.5 mg tid omeprazole 40 mg qd calcitriol qod 0.25 mg sodium bicarbonate 650 mg furosemide 40 mg qd zolpidem 5 mg qhs sennosides 8.6 mg qd aranesp (on hold) prochlorperazine 5 mg tid prn nausea sevelamer 800 mg tid w/meals tamsulosin 0.4 mg er qhs ferrous sulfate 325 mg qd timolol eyedrops qd discharge medications: pt expired discharge disposition: expired discharge diagnosis: acute on chronic renal failure metastatic pancreatic cancer cholangitis discharge condition: expired discharge instructions: expired followup instructions: expired procedure: endoscopic removal of stone(s) from biliary tract central venous catheter placement with guidance diagnoses: acidosis anemia in chronic kidney disease coronary atherosclerosis of native coronary artery malignant neoplasm of liver, secondary unspecified pleural effusion acute kidney failure, unspecified unspecified septicemia severe sepsis chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified aortic valve disorders hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) constipation, unspecified malignant neoplasm of head of pancreas septic shock old myocardial infarction personal history of malignant neoplasm of bladder other septicemia due to gram-negative organisms personal history of venous thrombosis and embolism encounter for palliative care do not resuscitate status dehydration cholangitis insomnia, unspecified calculus of bile duct without mention of cholecystitis, with obstruction malnutrition of moderate degree renal osteodystrophy 

Answer: The patient is high likely exposed to