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: biliary obstruction major surgical or invasive procedure: 1.ercp and ptbd placement in right biliary system 2. ct guided omental biopsy 3. internalization of right ptbd 4. ptbd placement into left biliary system, exchange of prior right biliary ptbd 5. right ptbd replacement and brushings, ptc of both drains history of present illness: ms. is a 77 year old lady admitted to on for new painless jaundice and pruritis,found to have a possible obstructive mass on ct and underwent ercp x2. this showed a hilar stricture and cytology concerning. final cytology was still pending at time of transfer. a 15cm plastic stent was placed but requires repeat ercp evaluation for repeat stenting. her course has been complicated by a post ercp pancreatitis (without pain) that appears to be rapidly resolving. she is transferred on on unasyn in prepartion for a repeat ercp. medical record from sturdy reviewed and confirmed with the patient. past medical history: ulcerative colitis, hypothyroidism, breast cancer with left modified radical mastectomy >17 yrs ago, also received chemo social history: widowed, lives alone with her dog. has 2 sons. quit smoking >50 years ago, occasional alcohol use. family history: mother: breast ca father: goiter physical exam: admission pe: general: well-appearing woman in nad, comfortable, appropriate. heent: nc/at, perrla, eomi, sclerae mildly icteric, mmm, op clear. neck: supple, no thyromegaly, no jvd, no carotid bruits. heart: rrr, no mrg, nl s1-s2. lungs: cta bilat, no r/rh/wh, good air movement, resp unlabored. abdomen: soft/nt/nd, no masses or hsm, no rebound/guarding. 2 capped ptbd drains in place extremities: bilateral le edema per patient's norm,non pitting. no c/c/e, 2+ peripheral pulses. skin: mildly icteric lymph: no cervical lad. neuro: awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout discharge pe: vs:98.8 hr 84 134/74 rr 20 o2 95% ra wt 71.9kg a&o mild scleral icterus rrr lungs diminished 1/3 up on right otherwise clear abd soft, non-distended. non tender. r and l ptcs capped. dressings clean/dry ext 2+edema pertinent results: microbiology: biopsy brushings: concerning for malignancy. studies: at osh: labs notable for wbc 9, hct 35.2,ast 106, alt 143, ap 238, t bili 8.2, d bil 6.6, nl cr 0.6, lipase had been 14,680. hepatitis serologies at osh pos only for hep a ekg: reviewed from osh, no abnormalities ctabd/pel : impression: 1. diffuse intrahepatic biliary obstruction due to an irregular, 6.2-cm mass centered in the region of the gallbladder and extending to the hepatic hilum. the appearance is suggestive of primary gallbladder carcinoma with involvement of the liver, or cholangiocarcinoma with involvement of the gallbladder. 2. no evidence of pancreatic ductal dilation or a primary pancreatic mass. stranding about the pancreatic tail with apparent nodularity is concerning for omental infiltration by tumor at this location. 3. stranding and apparent soft tissue density adjacent to the hepatic flexure of the colon could represent omental/serosal metastatic disease. no evidence of bowel obstruction. 4. 9-mm left adrenal nodule, not fully evaluated on this examination due to its small size and partial volume averaging effect, but could represent an adenoma. attention at next followup imaging is recommended. ct torso : impression: 1. diffuse intrahepatic biliary dilatation secondary to a large hypodense mass within the inferior right liver. the invasive nature of this lesion is suggestive of primary gallbladder carcinoma versus cholangiocarcinoma. stranding seen within the mesentery and omentum is concerning for carcinomatosis. 2. sclerotic lesion within the body of t7 could be a metastatic focus. 3. small left adrenal nodule which may represent an adenoma. attention on followup imaging is recommended. 4. small right pleural effusion, which is larger than prior. cxr : findings: frontal and lateral views of the chest demonstrate some linear atelectasis on the frontal view not visualized on the lateral, blunting of the cp angles that could be due to a small amount of pleural thickening or small effusion. no focal infiltrate. mild degenerative changes of the spine with sclerosis and anterior osteophytes. there is residual contrast in the bowel. tubing projects over the right side of the abdomen. bone scan : single focus of tracer uptake in the thoracic spine corresponding to t7 mixed lytic and sclerotic lesion seen on recent ct likely represents osseous metastasis. no other site of osseous metastatic disease is seen. attemped us guided biopsy : impression: biopsy not performed since no mass could be identified adjacent to the gallbladder or arising from the gallbladder wall and extending into the liver. mri : impression: 1. focal t1 hypointense nonenhancing lesion involving the t7 vertebral body with adjacent area of intrinsic t1 hyperintensity likely represents a bone island with adjacent hemangioma. however, given the history of primary gallbladder cancer/cholangiocarcinoma, possibility of a metastatic lesion cannot be entirely excluded and attention on followup imaging is recommended. 2. right pleural effusion. osh radiology: ct abd pelvis: neoplastic lesion in the porta hepatis most likely cholangiocarinoma invading common biliary duct, surrounded gb with significant abnormality in the right lobe of the liver most likely infiltration by neoplasm vs liver necrosis. osh us abd: fatty liver, cholelithiasis with borderline thickness of gb wall, no evidence of acute cholecystitis 9:30 pm blood culture 1 of 2. **final report ** blood culture, routine (final ): enterococcus faecium. final sensitivities. daptomycin = 3.0 mcg/ml. daptomycin sensitivity testing performed by etest. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. linezolid susceptibility testing requested by dr.,gowri pager . sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecium | ampicillin------------ =>32 r daptomycin------------ s linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ 1 s anaerobic bottle gram stain (final ): gram positive cocci in pairs and in short chains. reported to and read back by 1751. aerobic bottle gram stain (final ): gram positive cocci in pairs and in short re 10:00 pm bile **final report ** gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): enterococcus sp.. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r penicillin g---------- =>64 r vancomycin------------ 1 s anaerobic culture (final ): no anaerobes isolated. 6:00 am urine source: cvs. **final report ** urine culture (final ): escherichia coli. 10,000-100,000 organisms/ml.. presumptive identification. piperacillin/tazobactam sensitivity testing performed by . dr. () requested sensitivities to piperacillin/tazobactam . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- 2 s ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ 4 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- r tobramycin------------ =>16 r trimethoprim/sulfa---- =>16 r 04:52am blood wbc-6.0 rbc-3.64* hgb-10.2* hct-30.8* mcv-85 mch-28.0 mchc-33.2 rdw-17.6* plt ct-284 06:00pm blood pt-14.6* ptt-52.5* inr(pt)-1.4* 04:52am blood pt-13.5* ptt-58.8* inr(pt)-1.3* 08:46am blood pt-14.0* ptt-55.1* inr(pt)-1.3* 04:52am blood glucose-112* urean-19 creat-1.0 na-138 k-3.6 cl-109* hco3-21* angap-12 06:45am blood alt-123* ast-113* alkphos-226* totbili-14.3* 04:52am blood alt-61* ast-70* alkphos-305* totbili-3.8* 01:40pm blood afp-3.2 04:52am blood vanco-22.9* 13:40 ca -9 test result reference range/units ca -9 191 h <37 u/ml brief hospital course: 77 year old woman with a history of ulcerative colitis who presented with painless jaundice. cta report () found diffuse intrahepatic biliary obstruction due to an irregular, 6.2-cm mass centered in the region of the gallbladder and extending to the hepatic hilum. the appearance was suggestive of primary gallbladder carcinoma with involvement of the liver, or cholangiocarcinoma with involvement of the gallbladder. stranding about the pancreatic tail with apparent nodularity was concerning for omental infiltration by tumor at this location. ms. was admitted to dr. service on . she underwent ct guided biopsy of the omentum on . biopsy was without evidence of lymphoma or metastases. she was febrile to 101 on . cxr was negative for pneumonia. blood and bile culture from isolated vanco sensitive enterococcus faecium. vanco and zosyn were started on . on , cholangiogram was done noting complete occlusion of the proximal cbd adjacent to the confluence of the right and left biliary ducts. an 8 french internal-external drain was placed through the right anterior biliary system into the duodenum. she spiked a temperature to 101 post procedure. repeat blood cultures were negative. urine culture isolated <10,000 colonies of yeast. lfts trended down with t.bili decreasing from 12.3 to 4.1. right ptc (biliary drain)remained open to gravity drainage. urine culture from isolated highly resistant e.coli sensitive to , gent and cefepime. zosyn was switched to cefepime on . on , cholangiogram was performed and an internal-external drain was placed into the left biliary system. the right-sided biliary drain was exchanged with another internal-external 8 french biliary drain. both biliary drains were left to gravity drainage. lfts continued to trend down. ursodiol was started. on , a bone scan was performed to assess for metastases. a single focus of tracer uptake in the thoracic spine was noted corresponding to t7 mixed lytic and sclerotic lesion seen on ct was concerning for osseous metastasis. no other site of osseous metastatic disease were seen. neuro-interventional consult was obtained. recommendations were to obtain mri to further evaluate. mri to t spine demonstrated focal t1 hypo intense non enhancing lesion involving the t7 vertebral body with adjacent area of intrinsic t1 hyperintensity likely representing a bone island with adjacent hemangioma. neuro-intervention felt this was not consistent with a met and a biopsy was deferred. on , a cholangiogram was done to obtain brushings as attempt to biopsy under repeat liver us did not demonstrate any liver mass adjacent to the stone-filled gallbladder or elsewhere in the liver. biliary brushings from cholangiogram demonstrated atypical glandular/ductal epithelial cells. a liver duplex us was done to evaluate ct finding from of new thrombosis of the right portal vein. duplex did reveal occlusion of the posterior right portal vein branch and a heparin drip was started. coumadin was then started on at 3mg a day. she received this on and . inr was 1.3 on . heparin was stopped on and lovenox 70mg sq started. picc line was placed on . cxr confirmed right picc catheter tip projects over cavoatrial junction. percutaneous transhepatic catheters (ptcs)were capped with lfts remaining stable. she remained afebrile. id was consulted and noted hospital course of fever, ruq pain, and hyperbilirubinemia consistent with cholangitis and associated vse bacteremia s/p biliary decompression with antibiotics for biliary pathogen fever. antibiotic course was set for minimun of 3 weeks. duration will depend on surgical/oncologic plan, which has not yet been determined. she will follow up as an outpatient with both id and hepatobiliary , w. . of note, surveillance blood cultures prior to and were finalized as negative. blood cultures from and were negative to date at time of discharge. diet was tolerated fairly well. appetite improved over the course of the hospital stay. carnation instant breakfasts with meals was recommended by nutrition. of note, she did receive a iv fluid and experienced fluid retention. lasix was given on and (lasix 20mg iv)with good diuresis. weight was 71.9 on . admission weight was 71.5kg. pt worked with her and recommended rolling walker which she used with supervision. the plan was to send her to rehab near her son's home. life care in had a bed available and she will transfer there today to continue iv antibiotics via picc line. weekly labs will be required and time per week inr checks as she is currently on lovenox and coumadin. medications on admission: medications: mesalamine 1200mg po tid mvi 1 tab po daily naproxen 220mg po bid probiotic (risaquad) prilosec 20mg po daily levothyroxine 75mcg po daily . transfer medications: lidocaine patch tp daily heparin 5000 units sq tid synthroid 75mcg po daily ativan 0.5 iv q6 prn anxiety asacol 1200mg po tid mvi 1 cap po daily zofran 4mg iv q4 prn nausea pantoprazole 40mg iv daily unasyn 1.5g iv q6 hours discharge medications: 1. mesalamine 400 mg tablet, delayed release (e.c.) sig: three (3) tablet, delayed release (e.c.) po tid (3 times a day). 2. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 3. levothyroxine 75 mcg capsule sig: one (1) capsule po once a day. 4. oxycodone 5 mg tablet sig: one (1) tablet po q3h (every 3 hours) as needed for pain. 5. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed for heart burn. 6. lovenox 80 mg/0.8 ml syringe sig: seventy (70) mg subcutaneous twice a day: until inr therapeutic. 7. warfarin 1 mg tablet sig: three (3) tablet po once a day: for thrombosis of right posterior portal vein. inr goal . 8. cefepime 2 gram recon soln sig: one (1) recon soln injection q24h (every 24 hours): stop date to be determined by id in follow up. 9. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 10. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 11. vancomycin in d5w 1 gram/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours): stop date to be determined by id in follow up. 12. clobetasol 0.05 % gel sig: one (1) appl topical (2 times a day): please apply to oral ulcer . 13. outpatient work weekly labs: cbc with diff, bun, creatinine, ast, alt, alk phos, tbili and trough vanco level with results fax'd to clinic attn: rn and rn vancomycin trough, cbc with differential, bun, creatinine, and liver enzyme panel 14. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 15. outpatient work pt/inr x per week goal discharge disposition: extended care facility: life care center of discharge diagnosis: jaundice with presumed gall bladder malignancy cholangitis e.coli uti, highly resistant vanco sensitive bacteremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you will be transferring to life care rehab in attelboro for iv antibiotics thru the iv picc line you will need weekly blood work for monitoring you were also prescribed a 3 week antibiotic course. you may shower, but should pat drain sites dry and cover with dry gauze dressing daily. observe for redness or drainage. followup instructions: provider: , md phone: date/time: 9:00 provider: , md, phd: date/time: 3:20 provider: , md phone: date/time: 10:00 md, procedure: other endoscopy of small intestine other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract percutaneous biopsy of gallbladder or bile ducts replacement of stent (tube) in biliary or pancreatic duct closed [percutaneous] [needle] biopsy of intra-abdominal mass diagnoses: urinary tract infection, site not specified unspecified acquired hypothyroidism candidiasis of other urogenital sites personal history of malignant neoplasm of breast sepsis loss of weight long-term (current) use of anticoagulants ulcerative colitis, unspecified streptococcal septicemia cholangitis obstruction of bile duct acute pancreatitis malignant neoplasm of intrahepatic bile ducts portal vein thrombosis acquired absence of breast and nipple other and unspecified escherichia coli [e. coli] other obstruction of duodenum other digestive system complications 

Answer: The patient is high likely exposed to