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: carbamazepine attending: chief complaint: chief complaint: fall, leg weakness reason for micu transfer: intubation, percutaneous transhepatic cholangiogram major surgical or invasive procedure: - ercp - ir percutaneous transhepatic cholangiogram with placement of 10f left internal/external drain - r cvl placement by ir - l cvl removal - ir placement of ivc filter - ir placement of stent and removal of biliary drain history of present illness: 69f h/o developmental delay, seizures, osa on cpap, gerd, who initally presented to with le weakness and fall, as well as blood in stools. she was found to have an increased troponin, anemia, and hyponatremia. she was given 2u rbc's and may have had a transfusion reaction although this is unclear from documentation. she is being transferred to from wooden (admitted for weakness and anemia). during a prep for cscopy, had afib with rvr, then developed hypotension briefly requiring pressors while on dilt gtt. she was rate controlled with dilt gtt thereafter and was volume resuscitated. she was electively intubated for increased work of breathing and respiratory distress at the osh. she was given vanc, ctx, flagyl for gpc's and gnr's in bcx (initially was on ctx and gent, but after speciated as klebsiella, gent was d/c'd). she was found to have increased tbili to 4, and ruq us was unrevealing but ct scan showed abnl gallbladder with markedly thickened gallbladder wall and dilated cbd. on arrival to the micu, patient is intubated and sedated. review of systems: (+) per hpi past medical history: developmental delay seizures - since a child osa on cpap copd gerd osteoporosis glaucoma ?chf and ?cad notes social history: lives in with partner . mobile and functional at baseline with help of a pca. no smoking, drinking, drugs. family history: note: mother: heart dz physical exam: admission physical exam: general: easily awakens to voice, no acute distress, intubated but not sedated. skin: jaundiced heent: sclera icteric, eomi neck: supple, jvp not elevated, no lad. left cvl in place. cv: irregular rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: coarse breath sounds with scattered rhonchi bilaterally, no wheezes abdomen: soft, obese and distended, bowel sounds present gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . discharge vs: 99.5 99.3 123-146/61-75 89-112 22-24 95% 2l bg 121-134 i/o: 1000/inc + 2bm 400/inc + 2bm gen: appears older than stated age. comfortable but not alert. cv: rrr, distant heart sounds, no m/r/g lungs: +rhonchorous breath sounds anteriorly, crackles at bases but only left lung examined in posterior position. abd: soft, distended, biliary drain in place with dressing c/d/i capped, +tenderness to palpation in ruq and epigastrium ext: palmar erythema and redness under right upper arm, left forearm noticeably large and more edematous than right arm, trace pitting edema in upper and lower extremities gu: incont neuro: eyes open and tracking shakes head "no" in response to "do you have pain?" she is not having shaking or pursing her lips. she does squeeze her right hand and lift it off the bed, she also wiggles her right toes on command. she does not follow commands on the left. left leg is held in external rotation and left toe is up going. pertinent results: admission labs: 10:36pm blood wbc-22.1* rbc-4.08* hgb-11.0* hct-34.0* mcv-83 mch-26.9* mchc-32.3 rdw-16.4* plt ct-130* 10:36pm blood neuts-91.3* lymphs-5.1* monos-3.1 eos-0.3 baso-0.2 03:30pm blood hypochr-1+ anisocy-1+ poiklo-2+ macrocy-occasional microcy-occasional polychr-occasional ovalocy-occasional schisto-1+ ellipto-occasional 10:36pm blood pt-39.5* ptt-36.7* inr(pt)-3.9* 10:36pm blood glucose-141* urean-22* creat-0.5 na-133 k-3.6 cl-107 hco3-20* angap-10 10:36pm blood alt-85* ast-132* ld(ldh)-277* alkphos-175* totbili-7.1* 06:08am blood ctropnt-0.13* 04:05am blood ctropnt-0.13* 10:36pm blood calcium-7.4* phos-1.3* mg-2.0 10:30pm blood type-art po2-116* pco2-26* ph-7.46* caltco2-19* base xs--2 -assist/con intubat-intubated 11:07am blood lactate-3.0* 06:09pm blood lactate-1.3 04:26am blood lactate-1.1 01:30pm urine color-dkamb appear-cloudy sp -1.044* 01:30pm urine blood-sm nitrite-neg protein-30 glucose-tr ketone-neg bilirub-lg urobiln-2* ph-6.0 leuks-sm 01:30pm urine rbc-41* wbc-21* bacteri-few yeast-none epi-2 transe-1 01:30pm urine castgr-2* casthy-2* . pertinent labs: 06:16am blood ret aut-3.2 06:25am blood cea-7.5* afp-5.7 06:16am blood caltibc-165* ferritn-361* trf-127* 06:50am blood ca -9 -50 ; blood cultures negative blood culture: yeast . radiology: - tte from : summary: lv size and wall thicknesses are nl; lvef is ~75%. - ct abd/pelvis from : two gallbladder-to-distal small bowel fistulas with associated severe gallbladder wall thickening. this is highly suspicious for gallbladder carcinoma with possible local invasion of the adjacent liver and adjacent loop of colon. alternatively, and probably less likely, this could be due to chronic inflammatory process of the gallbladder. severe extrahepatic and intrahepatic biliary ductal dilatation with pneumobilia. dilatation tapers at the level of the distal cbd without obvious obstructing mass lesion visualized. debris or sludge ball may be present in the distal cbd. no bowel obstruction. mild ascites and small b/l pleural effusions. - cxr bibasilar opacities are largely attrributible to small effusions and atelectasis, as seen on recent ct. a small opacity in the lingula could represent a small focus of pneumonia. - ruq u/s 1. limited study. irregularity in the gallbladder region as expected. no targetable liver lesion identified. 2. no intrahepatic bile duct dilation. borderline common duct dilation. ptbd in place. - abdominal mri 1. circumferential gallbladder cancer erodes into a small bowel loop in the right upper quadrant (21: 24) and also possibly into the liver. two hepatic lesions are most consistent with bilomas. 2. no intrahepatic duct dilatation, the common bile duct is dilated within its central portion measuring up to 1.2 cm but tapers distally. 3. moderate ascites. 4. small bilateral pleural effusions - cxr ap chest compared to through 18: there are now more discrete areas of consolidation in the right mid and lower lung zones, which could be due to pneumonia. aeration in the left lower lobe is compromised but unchanged since , probably atelectasis. the heart is moderately enlarged. small bilateral pleural effusions are presumed. a right jugular line ends deep in the right atrium. no pneumothorax. - lue u/s: there is an occlusive clot in a short segment of the left cephalic vein. no evidence of deep vein thrombosis or hematoma. - lower extremity u/s: non-occlusive thrombus involving the distal left superficial femoral vein. no evidence of deep vein thrombosis in the right lower extremity deep veins. - echo the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is a mild resting left ventricular outflow tract obstruction. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. there is mild pulmonary artery systolic hypertension. impression: no echocardiographic evidence of endocarditis. small lv cavity size with hyperdynamic lv systolic function. consequently there is a mild left ventricular outflow tract gradient during systole. no significant valvular abnormality seen. mildly elevated pulmonary artery systolic pressure. if clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations. - ir 1. biopsies and brushings of the area of stricture in the cbd. 2. placement of 12 mm x 8 cm luminexx metal stent in the cbd across the stricture, with post-stent placement balloon dilatation. 3. placement of 10 french pigtail catheter with its tip in the duodenum to secure access. 4. the tube is currently capped. the patient can be brought in a few days for repeat cholangiogram and removal of the catheter, if there is no evidence of cholestasis or cholangitis. gallbladder brushings: scant glandular epithelium with atypia, see note. note: there is noticeable atypia in this scant glandular epithelium. given the scant material, additional evaluation should be considered if clinically appropriate. gallbladder cytology pending - ct head no acute intracranial process. - eeg (24 hour): this is an abnormal continuous icu monitoring study because of mild diffuse background slowing indicative of mild diffuse cerebral dysfunction with non-specific etiology. no epileptiform discharges or electrographic seizures are present. compared to the prior day's recording, there are no significant changes. note is made of an irregular heart rhythm with intermittent borderline tachycardia and occasional wide complex premature beats. - cxr lung opacities likely due to multifocal pneumonia. discharge labs 05:23am blood wbc-14.0* rbc-3.18* hgb-9.1* hct-29.5* mcv-93 mch-28.7 mchc-31.0 rdw-22.4* plt ct-282 05:23am blood pt-23.9* ptt-32.8 inr(pt)-2.3* 05:23am blood glucose-104* urean-20 creat-0.5 na-149* k-3.3 cl-110* hco3-25 angap-17 05:23am blood alt-9 ast-24 alkphos-323* totbili-1.6* 05:23am blood calcium-8.2* phos-2.4* mg-1.8 brief hospital course: 69f h/o developmental delay, seizures, osa on cpap, gerd, who initally presented to with weakness and fall, as well as blood in stools. there she was found to have an increased troponin, anemia, and hyponatremia. she was noted to have rising liver enzymes and a ct scan that showed an abnormal gallbladder with markedly thickened gallbladder wall and dilated common bile duct and possible gallbladder carcinoma. she was initially admitted to the as she was intubated for respiratory distress at the osh. she was then transferred to ir for biliary drainage, and findings were suspicious, but not diagnostic, for gallbladder cancer. at this point, the patient's hcp and partner, , made the decision to transfer to hospice care, despite no definitive diagnosis of cancer. active issues: # goals of care: meetings were held with hcp/partner, to discuss patient's likely diagnosis of cancer, for which the patient is not a surgical or chemo candidate. pt was transitioned to cmo/hospice on , with plan to discontinue vital signs and iv fluids. she was continued only on her anti-epileptics and pain medication as needed. she was given small doses of morphine for persistent right upper quadrant pain. she was originally on oral keppra, but was observed to choke/gargle even with minimal quantity of the liquid; thus she was transitioned to standing lorazepam that could be absorbed orally. she was discharged to hospice on . inpatient issues: # cholangitis, bacteremia: at osh, pt had gpc's and gnr's in blood cultures. she was found to have increased tbili to 4, and ct scan showing abnormal gallbladder with markedly thickened gallbladder wall and dilated common bile duct, suggesting biliary tract was likely source. in the icu, she was treated with cefepime, vancomycin, and flagyl. patient had gallbladder drain placed, which was discontinued on . following this, patient's over clinical condition improved. she was weaned off pressors, and her white count improved. she was narrowed to unasyn on to complete a 2-week course of antibiotics. # fungemia: blood cultures positive for yeast from , though subsequent surveillance culture were negative. felt to be from gallbladder source. echo evaluation for endocarditis and ophthalmology evaluation for endopthalmitis were negative. patient was started on micafungin (day 1: ) and completed a 13-day course on . # likely gb malignancy: mrcp suggestive of malignancy with formation of enteric fistulas and some sign of hepatic involvement. ercp was unsuccessful in entering cbd so patient underwent biliary stenting and biopsy by ir. per hepatobiliary surgery, patient is poor surgical candidate. hem/onc also feels chemotherapeutic options are limited. final pathology from brushings/biopsy revealed glandular atypia but no definitive carcinoma. the option of biopsy was presented to the patient's hcp and partner, , as the patient was not able to communicate her own desires at this point. opted for comfort measures and declined the biopsy, wishing to focus on hospice care. # anemia: had hct in high 20's upon admission to osh but was 34.0 upon admission to icu. reportedly had blood in stools recently. was going to undergo evaluation with colonoscopy and egd at osh, but this could not be completed due to patient instability. iron studies revealed anemia of chronic inflammation and some hypoproliferation. her stools remained guaiac positive while here but without frank blood. she received 1u prbc transfusion in the setting of coffee-ground emesis (see below) but was otherwise stable. # left lower extremity dvt: non-occlusive thrombus found in left leg after patient complained of some leg pain. heparin drip started on , which was later stopped after patient developed coffee-ground emesis. patient underwent ir-guided ivc filter placement on . # ugib: developed coffee ground emesis on , though maintained stable vitals and hematocrit. her heparin drip was discontinued. ng tube placement was attempted but not tolerated. kub was negative for obstruction. she received 1u prbc transfusion. she was started on iv ppi and gi was made aware, who felt there was no need for urgent intervention at this time as she was hemodynamically stable. she had no further episodes. she was kept npo as she was not able to swallow. # extremity weakness: per chart, patient has history of left-sided weakness, though at baseline is able to walk with a cane. weakness, left side greater than right, is notable on physical exam. likely worsened by her deconditioning due to critical illness. the patient's weakness worsened as her overall clinical status worsened. # hypoxia/intubation: pt was not intubated at the osh for respiratory failure, but rather acidosis and increased work of breathing. she did not require any sedation. after her ir-guided biliary drain placement, she remained intubated for mrcp. she was later extubated without event and did well. she was saturating well on 2l o2 on the floor. her persistent hypoxia on the floor was felt due to a combination of ventilator-associated pneumonia, copd, osa, pulmonary edema, and possible aspiration events in setting of upper gi bleed. she completed a course for vap and was diuresed daily to help with volume overload. she was continued on cpap nightly for osa. she was initially npo and kept on aspiration precautions until time of discharge, at which time it was felt that tube feeds were not in keeping with her goals of care. # afib with rvr: this appears to be new onset and began at during colonoscopy prep. there, she was maintained on diltiazem drip and then transitioned to oral diltiazem. in the icu, she entered into a fib with rvr, and eventually needed to be put back on a diltiazem drip when boluses did not break the rvr. patient converted into sinus rhythm and was weaned off the diltiazem drip. she was transitioned to her home dose of metoprolol. on the floor, she had intermittent bursts of supraventricular tachycardia but no further atrial fibrillation while hospitalized. # previous hypotension: pt was normo- to hypertensive on admission, but she had lower bp's to the 100's after being started on a diltiazem drip. this was similar to what happened at , where she developed hypotension briefly requiring pressors while on diltiazem drip. she was started on pressors after her drain was placed, and her blood pressure continued to improve. she was weaned off pressors and did not require any further pressors while in icu. her blood pressures remained in the 130-140 range on the floor. # elevated inr to 3.9 upon admission: remained elevated throughout despite improvement of lfts. likely due to hepatic involvement of malignancy and poor nutrition. chronic issues: # osa on cpap: was initially intubated, and then continued on cpap at night while on the floor. # gerd: continued ppi. # seizure disorder: history of complex partial seizures, none during her current stay, confirmed on 24h eeg. continued keppra, which was transitioned to lorazepam at time of discharge. # developmental delay/paranoia: held risperidone while npo # chronic pain: held gabapentin while npo transitional issues: # code status: dnr/dni . # issues of care: - hospice, focus on comfort. po lorazepam dissolving, instead of po keppra given pt's gargling/choking on even 2cc's of liquid keppra. . # contact: hcp & long term partner medications on admission: nystatin powder aspirin 81 mg daily calcium/vitamin d combivent inhaler qid prn docusate 100 mg flunisolide 2 sprays fosamax 35 mg weekly kenalog 0.1% prn keppra 1500 lisinopril 10 mg daily metoprolol 50 mg neurontin 400 mg omeprazole 20 gm daily risperdal 1 mg qpm risperdal 0.25 mg qhs spectazole 1% to breast rash acetaminophen prn zocor 40 mg daily dilantin 200 mg discharge medications: 1. collagenase clostridium hist. 250 unit/g ointment sig: one (1) appl topical daily (daily). 2. morphine concentrate 100 mg/5 ml (20 mg/ml) solution sig: 2-10 mg po q2h (every 2 hours) as needed for pain or shortness of breath. disp:*200 ml* refills:*2* 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob/wheezing. 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation every six (6) hours as needed for shortness of breath or wheezing. 5. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day): apply to skin folds. 6. diazepam 12.5-15-17.5-20 mg kit sig: twenty (20) mg rectal q1h as needed for seizure. disp:*100 * refills:*2* 7. lorazepam intensol 2 mg/ml concentrate sig: 1-2 mg po q30min as needed for seizure. disp:*100 * refills:*2* 8. lorazepam intensol 2 mg/ml concentrate sig: one (1) mg po every six (6) hours: as antiepileptic. disp:*120 * refills:*2* discharge disposition: extended care facility: rehab discharge diagnosis: primary ?cholangiocarcinoma cholangitis bacteremia dvt secondary seizure disorder developmental delay discharge condition: level of consciousness: lethargic and not arousable. activity status: bedbound. discharge instructions: dear , you were admitted to because you had a serious infection of your gallbladder and bloodstream likely due to an underlying cancer. you were initially in the intensive care unit on medications to help support your blood pressure. when you moved to the floor, your infection improved. a blood clot was found in a vein in your leg so a filter was placed in your vein to help prevent it from moving. a drain and stent were also placed in your gallbladder to open up blockages, help relieve pain and help drain the infection. a sample of tissue was taken from the gallbladder which showed a very advanced cancer. unfortunately, our surgeons and cancer doctors did not feel there was a safe treatment for this disease. at this point, you were transitioned to hospice care. it was a pleasure taking care of you and we wish you all the best. please note the medication list which is attached as there have been many changes to your medications in order to make you comfortable. followup instructions: none md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours interruption of the vena cava enteral infusion of concentrated nutritional substances endoscopic sphincterotomy and papillotomy non-invasive mechanical ventilation injection or infusion of other therapeutic or prophylactic substance removal of t-tube, other bile duct tube, or liver tube other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract percutaneous biopsy of gallbladder or bile ducts percutaneous hepatic cholangiogram angiocardiography of venae cavae central venous catheter placement with guidance diagnoses: acidosis thrombocytopenia, unspecified anemia of other chronic disease obstructive sleep apnea (adult)(pediatric) esophageal reflux malignant neoplasm of liver, secondary congestive heart failure, unspecified friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site acute posthemorrhagic anemia acquired coagulation factor deficiency unspecified septicemia unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia severe sepsis chronic airway obstruction, not elsewhere classified atrial fibrillation septic shock pressure ulcer, lower back streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] encounter for palliative care obesity, unspecified do not resuscitate status acute venous embolism and thrombosis of deep vessels of proximal lower extremity hemorrhage of gastrointestinal tract, unspecified encephalopathy, unspecified staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus ventilator associated pneumonia cholangitis obstruction of bile duct localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy hemiplegia, unspecified, affecting unspecified side other and unspecified mycoses pressure ulcer, stage i unspecified hemorrhoids with other complication malignant neoplasm of gallbladder fistula of gallbladder acute venous embolism and thrombosis of superficial veins of upper extremity unspecified delay in development body mass index 39.0-39.9, adult 

Answer: The patient is high likely exposed to