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: hypotension major surgical or invasive procedure: ercp ir guided biliary drain placement history of present illness: this is a 78 year old woman who lives in and referred to for abdominal pain, weight loss, and jaundice. her symptoms started with bilateral, crampy lower quadrant abdominal pain and an increase in bowel movements without true diarrhea. she also noted an 8 lb weight loss along with appetite loss since . most recently, her son noted jaundice, pale stools, and very dark urine. she underwnet a ct of the abdomen on in her area and revealed a double duct sign with dilation of the main pd to 4 mm along with dilation of the gallbladder. there was evidence of a hypodense focal lesion in the head of the pancrease measuring 1.4 cm as well as ill-defined hypodense lesions in the right and left lobes of the liver. because of these findings, she had an eus on which was not too helpfull. the eus showed multiple small sub-centimeter cysts in the head of pancreas without mass. the pd was dilated to 7 mm in head and 5 mm in body and was tortuous with a few dilated side branches. the gallbladder contained sludge. the cbd was dilated to 15 mm in diameter with no stones or strictures. she was also found to have a small superficial ulcer at the antrum of stomach. a biopsy to a polyp adjacent to minor ampulla was nondignostic. subsequently, she had mrcp on that showed biliary and pancreatic ductal dilatation which appears to be due to compression or involvement by a 1.9 cm mass concerning for malignancy such as due to invasive neoplasm in the setting of side branch ipmn; partially cystic adenocarcinoma, or cholangiocarcinoma. the mrcp also confirmed numerous hepatic lesions. today, , she underwent an unsuccessful attempt for an ercp. specifically, attempts to achieve deep bile duct cannulation were unsuccessful. post ercp, she developed low grade fever, relative hypotension, and tachycardia. ir, therefore, was contact for ptc to resolve the biliary obstruction for a possibility of cholangitis. in regards to review of systems, she was noted to have new dyspnea on mild exertion in the ercp recovery room. all remaining systems were reviewed and symptoms were negative. past medical history: 1. htn 2. gerd 3. breast cyst 4. hyperlipidemia 5. tobacco use 6. back surgery 7. vertigo social history: she lives alone in with 2 sons. recently deceased. one son lives about one hour away. she has never smoked. no alcohol abuse. family history: no pancreatic, liver, or gi cancers physical exam: general: frail elderly woman with generalized weakness and remarkable jaundice eyes: nc/at, perrl, eomi without nystagmus, remarkable jaundice ears/nose/mouth/throat: mmm, no lesions noted in op neck: supple, no jvd or carotid bruits appreciated respiratory: mild crackles at the very bases and decreased breath sounds bilaterally cardiovascular: tachycardia, heart rate 106 regular with as murmur gastrointestinal: soft, normoactive bowel sounds, no masses or organomegaly noted. tender diffusely without rigidity. skin: no rashes or lesions noted. extremities: leg edema, mild neurologic: -mental status: alert, oriented x 3. able to answer questions appropriately without delirium or focol motor deficits. generalized weakness. pertinent results: mrcp: 1. biliary and pancreatic ductal dilatation which appears to be due to compression or involvement by a 1.9-cm mass with non enhancing and hypoenhancing components and adjacent periductal hyperenhancement. these findings are concerning for malignancy, such as due to invasive neoplasm in the setting of side branch ipmn; partially cystic adenocarcinoma, or cholangiocarcinoma. 2. numerous hepatic lesions, at least one of which is consistent with perfusional abnormalities. others demonstrate both ring pattern of hyperenhancement and hypoenhancement and are concerning for metastasis although foci of infection could have a similar appearance. peri-biliary enhancement in segment viii is consistent with chronic biliary obstruction or cholangitis. 3. distended courvoisier-type gallbladder with small stones or sludge. there is no acute cholecystitis. 4. compression deformities of t11, t12, and l1 which are not fully imaged on this study. 08:20am blood wbc-11.0 rbc-3.08* hgb-9.9* hct-29.7* mcv-97 mch-32.2* mchc-33.4 rdw-14.9 plt ct-495* 05:24pm blood wbc-7.0 rbc-3.04* hgb-10.0* hct-29.8* mcv-98 mch-33.0* mchc-33.6 rdw-15.1 plt ct-460* 04:18am blood wbc-6.6 rbc-2.17*# hgb-7.2*# hct-21.3*# mcv-98 mch-33.1* mchc-33.7 rdw-15.1 plt ct-299 03:53am blood wbc-8.8 rbc-2.66* hgb-8.5* hct-24.9* mcv-94 mch-32.1* mchc-34.2 rdw-17.1* plt ct-325 03:40am blood wbc-11.7* rbc-2.97* hgb-9.5* hct-27.0* mcv-91 mch-31.9 mchc-35.0 rdw-16.7* plt ct-376 03:26am blood wbc-11.8* rbc-2.99* hgb-9.6* hct-27.6* mcv-93 mch-32.2* mchc-34.8 rdw-16.3* plt ct-381 03:02am blood wbc-11.0 rbc-2.94* hgb-9.4* hct-27.6* mcv-94 mch-31.9 mchc-34.0 rdw-16.3* plt ct-371 02:55am blood wbc-14.3* rbc-3.03* hgb-9.9* hct-28.4* mcv-93 mch-32.5* mchc-34.8 rdw-16.0* plt ct-351 03:48am blood wbc-13.3* rbc-3.04* hgb-9.9* hct-29.3* mcv-96 mch-32.6* mchc-33.8 rdw-16.0* plt ct-323 04:10am blood wbc-14.7* rbc-2.84* hgb-9.3* hct-26.9* mcv-95 mch-32.6* mchc-34.4 rdw-16.0* plt ct-279 03:21pm blood wbc-18.4* rbc-3.04* hgb-10.0* hct-29.0* mcv-96 mch-32.9* mchc-34.4 rdw-15.9* plt ct-298 04:00am blood wbc-17.0* rbc-2.90* hgb-9.3* hct-27.4* mcv-94 mch-31.9 mchc-33.8 rdw-16.1* plt ct-255 05:24pm blood neuts-66 bands-2 lymphs-27 monos-3 eos-0 baso-0 atyps-0 metas-2* myelos-0 03:53am blood neuts-79.1* lymphs-14.0* monos-5.9 eos-0.6 baso-0.4 02:55am blood neuts-82.4* lymphs-13.5* monos-1.6* eos-2.4 baso-0.2 08:20am blood pt-14.2* ptt-22.9 inr(pt)-1.2* 04:00am blood pt-20.3* ptt-21.8* inr(pt)-1.9* 08:20am blood urean-7 creat-0.5 na-133 k-4.1 cl-100 hco3-25 angap-12 05:24pm blood glucose-80 urean-8 creat-0.6 na-135 k-3.6 cl-101 hco3-24 angap-14 04:18am blood glucose-139* urean-7 creat-0.4 na-132* k-3.1* cl-104 hco3-22 angap-9 03:53am blood glucose-173* urean-6 creat-0.4 na-131* k-3.0* cl-102 hco3-23 angap-9 04:59pm blood glucose-108* urean-6 creat-0.4 na-134 k-3.3 cl-101 hco3-25 angap-11 03:40am blood glucose-122* urean-4* creat-0.4 na-136 k-3.9 cl-104 hco3-26 angap-10 03:02am blood glucose-169* urean-6 creat-0.5 na-136 k-3.7 cl-97 hco3-31 angap-12 03:45pm blood glucose-170* urean-7 creat-0.5 na-133 k-3.8 cl-94* hco3-29 angap-14 02:55am blood glucose-135* urean-5* creat-0.4 na-133 k-3.3 cl-92* hco3-33* angap-11 12:56pm blood glucose-170* urean-5* creat-0.4 na-129* k-3.8 cl-90* hco3-30 angap-13 09:46pm blood glucose-145* urean-7 creat-0.4 na-130* k-3.8 cl-91* hco3-33* angap-10 03:48am blood glucose-121* urean-8 creat-0.4 na-128* k-3.8 cl-90* hco3-30 angap-12 05:26pm blood glucose-127* urean-9 creat-0.4 na-132* k-4.0 cl-94* hco3-32 angap-10 04:10am blood glucose-98 urean-7 creat-0.4 na-133 k-3.3 cl-97 hco3-31 angap-8 03:21pm blood glucose-95 urean-7 creat-0.4 na-133 k-3.7 cl-94* hco3-29 angap-14 04:00am blood glucose-125* urean-8 creat-0.5 na-135 k-3.2* cl-96 hco3-32 angap-10 08:20am blood alt-182* ast-189* alkphos-504* amylase-35 totbili-17.4* dirbili-13.6* indbili-3.8 03:26am blood alt-98* ast-102* alkphos-248* totbili-9.8* 03:21pm blood alt-223* ast-266* ld(ldh)-483* alkphos-317* totbili-12.7* 04:00am blood alt-226* ast-266* ld(ldh)-449* alkphos-284* totbili-12.4* 02:55am blood probnp-* 05:24pm blood calcium-8.6 phos-3.0 mg-1.4* 04:18am blood albumin-1.9* calcium-6.9* phos-3.4 mg-1.8 iron-25* 04:00am blood calcium-7.7* phos-2.3* mg-2.1 04:18am blood caltibc-130* ferritn-893* trf-100* 06:02pm blood type- po2-48* pco2-44 ph-7.35 caltco2-25 base xs--1 comment-greentop 04:33am blood type-art temp-37.7 rates-/16 fio2-50 po2-117* pco2-33* ph-7.42 caltco2-22 base xs--1 intubat-not intuba vent-spontaneou comment-simple fac 06:59am blood type-art temp-36.6 rates-/30 fio2-80 o2 flow-10 po2-56* pco2-42 ph-7.50* caltco2-34* base xs-7 aado2-473 req o2-80 intubat-not intuba comment-ventimask 4:15 pm bile **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs. smear reviewed; results confirmed. fluid culture (final ): klebsiella pneumoniae. sparse growth. viridans streptococci. isolated from broth media only, indicating very low numbers of organisms. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 8 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 anaerobic culture (final ): no anaerobes isolated. imaging ercp impression: limited exam due to inability to cannulate bile duct, however, partial filling of the bile duct demonstrated distal stricture with proximal dilation and pancreatic ductal dilation. . tte the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is mildly dilated with normal free wall contractility. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a very small pericardial effusion. impression: normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. mildly dilated right ventricle. mildly dilated ascending aorta. mild to moderate tricuspid regurgitation. moderate pulmonary artery systolic hypertension. left pleural effusion. very small pericardial effusion. . leni impression: no evidence of dvt . ct chest moderate bilateral effusions with adjacent compressive atelectasis. extensive fibrotic lung disease with an apical predominance. 3mm rml perifissural nodule is probably a lymph node. no pulmonary mass. the heart size is normal. there is no pathologic mediastinal or hilar lymphadenopathy. right ij line is in svc. abdominal contents notable for ptc biliary ring cath, small hh, right renal cyst. brief hospital course: this is a 78 year old woman who lives in and referred to for abdominal pain, weight loss, and jaundice. he blood tests and examination were consistent with obstructive jaundice (ap: 504 tbili: 17.4). she underwent several studies including ct of the abdomen, eus, mrcp, and failed ercp (today). these studies so far suggest head of the pancreatic cancer with metastatic liver disease. today, the unsuccessful attempt for an ercp failed to achieve deep bile duct cannulation. post ercp, she developed low grade fever, relative hypotension, dyspnea, and tachycardia. ir, therefore, was contact for immediate ptc to resolve the biliary obstruction for a possibility of cholangitis. i spoke to her son, who wished for dnr and dni status. i explained the very likelihood of metastatic pancreatic cancer as well as a possibility of cholangitis. she would need iv fluid support, broad spectrum antibiotics aimed at biliary pathogens (e-coli and enterococcus are the most important 2 pathogens), and discontinuation of her antihypertensive medications (except for atenolol, gradual weaning unless she is frankly hypotensive or septic). we will order bile and blood cultures. we will also order cxr pa/lateral because of subtle hypoxia. she should be monitored for ards from cholangitis. micu treatment maybe indicated despite dnr/dni wishes. she will remain npo. further management will depend on family wishes and ptc. *icu course* pt was admitted from ercp to for continued monitoring given hypotension and pressor requirement during biliary drain placement concerning for post-procedure cholangitis. she was weaned from neo prior to arrival to floor however required multiple ivf boluses with 2l normal saline and 2l lr to maintain blood pressures >100 sbp. r radial arterial line was placed to monitor map with goal >65. cvl in r ij placed for additional hemodynamic monitoring of cvp and volume resuscitation. she was started on vasopressin with improvement in her pressures. # resp failure: pt developed worsening o2 requirement concerning for volume overload and worsening pleural effusions on chest xray after large volume fluid resuscitation. she was started on lasix gtt with tolerance from her bp and treated empirically for copd exacerbation w steroids which was stopped after 2 days wo improvement. her chest xray supported volume overload with evidence of pleural effusions, compressive atelectasis and her exam was notable for crackles. she was trialed on bipap which she was only able to tolerate r a few hours before becoming very agitated overnight and self-dc'ing the apparatus. she was placed back on nrb face mask. ct chest was ordered when her hypoxia did not improve after 3 days of diuresis. results of the cat scan were notable for extensive fibrotic changes throughout the lungs most likely c/w lymphangitic carcinomatosis related to her likely pancreatic ca. she continued on a nrb face mask. family meeting was held and decision was made to discharge her to an ltac per her wishes. she was made dnr/dni. morphine iv was started for palliation of her dyspnea. lasix drip was continued with the hope that aggressive diuresis might improve her comfort given the extensive fluid collections noted on imaging. on she was made cmo, started on a morphine drip with ativan and all other non-comfort medications were discontinued. she was unable to be discharged to an ltac given her rapid decompensation on the intended day of her discharge. she passed away in the icu. # hypotension: likely related to sepsis physiology from post-instrumentation cholangitis. received multiple ivf boluses for resuscitation and pressure support with vasopressin. she was initially started on unasyn, flagyl, and cipro for biliary microbial coverage; however, preliminary bile cultures revealed gpc's in pairs, gnr, gnc and so antibiotics were changed to linezolid and zosyn for better coverage. speciation revealed pan-sensitive klebsiella and rare strep viridans. blood and urine cultures were and were negative during her stay. linezolid was stopped after 7 days however zosyn was continued until the day she was made cmo and passed away. . # biliary stricture: new stricture, liver lesions, and head of pancreas mass since , concerning for malignancy in setting of constitutional symptoms. s/p unsuccessful ercp. biliary drain output was monitored. biliary cultures as mentioned above grew pan-sensitive klebsiella. pain was treated with dilaudid and she was eventually transitioned to morphine drip when she was made cmo. . # anemia: likely anemia of chronic inflammation with drop in hematocrit secondary to hemodilution from aggressive volume resuscitation. she was transfused 1u prbc on the day after admission for low hct likely felt to be hemodilution. thereafter hct was monitored closely and remained stable. . # malignancy: symptomatic with fatigue, weight loss, malaise for the past few months with imaging concerning for pancreatic mass causing biliary obstruction and liver metastases. initial family wishes were for ir guided drain placement with biopy/brushing to obtain official diagnosis and pathology however the pt's worsening respiratory issues prohibited this elective procedure. ct chest findings were felt to be lymphangitic carcinomatosis related to her underlying malignancy however it is possible for her to have had ipf with chronic symptoms at baseline. code status: confirmed w hcp/son , , initially dnr/ok to intubate and changed to dnr/dni. medications on admission: alendronate 70 mg tablets po every week atenolol 75 mg po daily hctz 12.5 daily aspirin 81 mg daily discharge medications: deceased discharge disposition: expired discharge diagnosis: metastatic ca, unknown underlying primary but likely pancreatic fibrotic lung disease discharge condition: deceased discharge instructions: you were admitted to the hospital after you had low blood pressure and an infection in your bile. you had an ercp what was unable to open the compression in your bile system caused by the mass in your pancreas. interventional radiology placed a drain to relieve the obstruction. you required high volume fluid resuscitation after the procedure for your low blood pressure. this caused fluid to build up in your lungs due to the high volume needed as well as your low protein. you developed worsening shortness of breath that we believe was secondary to volume overload. we started you on a diuretic drip which took off excess fluid on your lungs. we obtained a ct chest when you didn't improve after taking off fluid and it showed extensive scarring either chronic underlying lung disease or scarring related to an extension of your cancer. a family meeting was held and the decision was made to discharge you to a care facility which could accomodate your oxygen/breathing needs. followup instructions: none md procedure: other percutaneous procedures on biliary tract endoscopic retrograde cholangiopancreatography [ercp] injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance diagnoses: acidosis esophageal reflux tobacco use disorder malignant neoplasm of liver, secondary unspecified essential hypertension unspecified septicemia severe sepsis acute respiratory failure do not resuscitate status obstruction of bile duct secondary and unspecified malignant neoplasm of intrathoracic lymph nodes dizziness and giddiness malignant neoplasm of other specified sites of pancreas 

Answer: The patient is high likely exposed to