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: lisinopril / plaquenil / haldol attending: chief complaint: lethargy and abdominal pain major surgical or invasive procedure: : retroperitoneal mass biopsy : exploratory lap ( unresectable) history of present illness: 89f mild dementia at baseline, ra, htn, anemia, cri from nursing home for evaluation of lethargy. per report, her baseline is awake, alert and fully oriented. this morning she was reportedly arousable to verbal stimuli but lethargic. abdominal tenderness was also noted. . in the ed, initial vs were: 8 100.1 100 114/73 18 95%. exam was significant for aaox3, marked abdominal tenderness with guarding, and guiaic positive brown stool. labs significant for lactate 5.5, clean ua with granular and hylanine casts, cr 1.9 (baseline 1.1), hco3 21, glc 135 with small ag, alt 122, ast 226, alp 130, wbc 23.3 with 73% n and 11 % band, hgb 7.8 (baseline ~ 9), inr 2.2. blood and urine cultures were obtained. imaging including abdominal us, ct abd and plevis without contrast were suggestive of gangrenous cholecystitis with wall thickening and probable hemorrhage with no frank perforation. ct showed dilated gallbladder with pericholecystics stranding and irregular wall contour again raising concern for gangrenous cholecystitis less likely surgery was consulted with initial impression of gangrenous cholecystitis with suggestion of perc chole but further review may suggest a gallbladder mass with secondary infection. she was given vancomycin and zosyn in addition to apap for fever. she also received 3 l of ns. vs on transfer: 96 110/98 25 100% 3l with access consisting of 2 18g piv. on the floor, the patient was smiling, non-toxic, and complained mostly of arthritis. past medical history: 1. erosive ra - previously on plaquenil (off >10 years). also h/o chronic nsaid use. no dmards or biologics in the past per rheum note 04/. on prednisone 10mg daily (likely started 04/). 2. aortic insufficiency (1+ on echo in ) 3. htn 4. anemia - previous labs c/w anemia of chronic inflammation, also h/o b12 deficiency 5. cri (baseline cr around 1.4-1.5) 6. hyperlipidemia 7. vitiligo (secondary to plaquenil use) 8. hx of esophageal tear 9. positive ppd in past, per pcp no /o inh treatment social history: originally from . currently in nursing home facility ( senior healthcare of ). has one sister, who lives out of state. no children. tobacco: no smoking history per medical records. no etoh or illicit drug use. family history: none relavent to this presentation physical exam: admission exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: abdominal ct :impression: 1. abnormal dilated gallbladder with an irregular margin and a small amount of pericholecystic stranding. central density is intermediate but increased from normal. no pericholecystic fluid is seen. the findings raise concern for gangrenous cholecystitis versus gb mass. ultrasound is recommended for further evaluation of the gallbladder. 2. mild intrahepatic biliary ductal dilatation as seen on mri . 3. no small-bowel obstruction. 4. indeterminant left adrenal nodule is stable from . nchct : impression: no acute intracranial process. abdominal ultrasound : impression: abnormal gb with irregular mass-like wall thickening. the appearance is atypical for acute cholecystitis, although the clinical picture suggests infection. the possiblity of gallbladder neoplasm with micro-perforation should be considered. if clinically indicated, mrcp could be performed for further evaluation. blood cx : gram negative rod(s). 8:00 am blood culture #1. **final report ** blood culture, routine (final ): escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing confirmed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 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 bottle gram stain (final ): reported to and read back by @ 2209 on - cc6d. gram negative rod(s). aerobic bottle gram stain (final ): gram negative rod(s). ct chest abd and pelvis: mpression: 1. gallbladder enlargement with mural thickening and hyperenhancement in keeping with a gallbladder carcinoma. the mass is closely related to the first and second parts of duodenum, transverse colon and right lobe of the liver. however, there is no evidence of frank invasion of these structures. 2. no enlarged adjacent lymph nodes. no liver metastasis. 3. stable scarring and parenchymal calcification in the right upper lobe likely secondary to prior granulomatous disease. the staff radiologist has reviewed the images and the report. ct head: no acute intracranial process. gallbladder biopsy: the specimen consists predominantly of fragments of necrotic tissue, but a few well preserved markedly atypical glands are present in a fibrotic stroma consistent with adenocarcinoma. brief hospital course: 89f multiple medication issues presenting with gram negative bacteremia from a biliary source thought to represent a gallbladder mass with probable superinfection. # sepsis: patient presented with sirs criteria and gnr bacteria from a likely billiary source. she was treated initially with broad spectrum antibiotics but narrowed to zosyn only for the gnr bacteremia. her lactate cleared (5.2 --> 5.5 --> 1.9) with fluid resuscitation. blood pressures were stable without need for pressor support. her bacteremia grew e coli pansensitive and she was given ceftriaxone. pt's last positive blood cx was positive on . surveilance cultures since then have been negative. bactrim will be continued as outpatient to complete a 14 day course # gallbladder mass- adenocarcinoma: abdominal ct and us was notable for a markedly dialated and tortuous gallbaldder. imaging was initially concerning for a gangernous cholangtitis, but upon further review suggested a billiary mass (carcinoma) with overlaying super infection. pt had mass biopsy which showed adenocarcinoma. surgery and oncology services were consulted for palliative care. pt went to or on but decision was made not to remove gallbladder given extent of her disease. # arf: patient presented with a cr of 1.9 from a base line of 1.1. in the setting of her sepsis this was felt to be pre-renal versus atn given the pressence of granular and hyaline casts. her creatinine began trending down after fluid resuscitation and was stable at the time of transfer (1.1). # transaminitis: felt to be secondary to gallbladder pathology (adenocarcinoma) versus a primary hepatic issue. trended down over the course of her hospital stay. alk phos remained in the 120s and ast and alt in the 30s at time of discharge. # anemia/thalassemia: patient's baseline hgb was 30 on admission her hct feel to 20 in the setting of blood streaked stool. she was transfused a total of 4 units prbc while in the micu and her hct went to 28 and was stable at the time of transfer. heme/onc evaluated her smear and noticed she had signs on her smear of thalassemia. # history of pe: the patient suffered a significant pe in . was on warfarin at home. switched to heparin here given bleed. she went home on no anticoagulation as the pe was > 6 months ago. oncology did not recommend continuing the anticoagulation due to tumor thrombus concerns. # dementia: patient appeared to be aaox3 and appropriate to situation. # rheumatoid arthritis: continued prednisone medications on admission: - norvasc 5 mg po qd - caltrate 600 and vit d 200 units po daily - colace - senna - lidoderm patch prn knee pain - mirtazapine 15 mg po qhs - prednisone 10 mg po qd - tramadol 25 mg po qd - coumadin 4.5 mg po qd - cipro hc otic 2 drops to l ear twice daily discharge medications: 1. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 2. senna 8.6 mg tablet sig: one (1) tablet po twice a day. 3. mirtazapine 15 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 4. colace 50 mg capsule sig: one (1) capsule po twice a day. 5. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain/fever. 7. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po bid (2 times a day) for 5 days. 8. oxycodone 5 mg tablet sig: 0.5 tablet po q4h (every 4 hours) as needed for pain. discharge disposition: extended care facility: senior living discharge diagnosis: adenocarcinoma of gallbladder: unresectable e coli bacteremia thalassemia discharge condition: mental status: confused - sometimes. level of consciousness: mostly alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: please call dr office at for fever, chills, nausea, vomiting, increased abdominal pain, incisional redness, drainage or bleeding or other concerning symptoms. coumadin was stopped during this hospitalization asn patient is > 6 months out from pe, oncology does not recommend anticoagulation in this patient due to tumor. please consult with patients pcp regarding this medication, not continued due to fall risk. patient is unresectable and will have oncology follow up followup instructions: provider: , md phone: date/time: 11:00 provider: . phone: date/time: 11:00 dr office () does not need to see patient in follow up, please have pcp see patient in next 2 weeks md, procedure: laparoscopy closed [percutaneous] [needle] biopsy of intra-abdominal mass diagnoses: anemia in chronic kidney disease acute kidney failure, unspecified severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified other persistent mental disorders due to conditions classified elsewhere chronic kidney disease, unspecified septic shock long-term (current) use of anticoagulants rheumatoid arthritis personal history of venous thrombosis and embolism septicemia due to escherichia coli [e. coli] acute cholecystitis other thalassemia nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] arthropathy, unspecified, site unspecified malignant neoplasm of gallbladder personal history of infections of the central nervous system 

Answer: The patient is high likely exposed to