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: penicillins / imipenem attending: chief complaint: septic unresponsive major surgical or invasive procedure: t-tube cholangiogram jejunal feeding tube placement percutaneous transhepatic cholangiogram exploratory laparotomy with extensive adhesiolysis. enterocutaneous fistula takedown and repair. takedown of end ileostomy and direct anastomosis to sigmoid. repair of a iatrogenic bladder injury. j tube placement. primary ventral hernia repair with component separation. history of present illness: this is a 38 year old male transfer to from osh on . he was found unresponsive at home back on . this followed with a 2 month history of postprandial nausea, vomiting and abdominal pain, for which he refused to seek medical attention. he apparently had hemoptosisa t some point at home and was brought to the hospital where he was found to be in profound shock and circulatory collapse with a sbp in the 40's, hypoglycemic and a hct of 13.5. he was taken to the or where upon entering the abdomen, 3-liters of gastric contents were drained. a perforation was identified at the distal antrum, close to the pancreas with a 3 cm necrotic area eroding posterior to the pancreas. he is pod 31, s/p distal gastrectomy w/ roux-en-y gastrojejunostomy for perforated gastric/duodenal ulcer. he is pod 20, s/p subtotal colectomy and end ileostomy for sigmoid perforation and "atonic colon", as well as a tracheostomy for respiratory failure. he is pod 17, s/p exploratory laparotomy, revison of end ileostomy, small bowel resection, cholecystectomy and t-tube placement, now transferred for sepsis w/ gpc in blood and wbc of 29. there is a concern for a possible common bile duct injury and now he has multiple enhancing intraabdominal collections (hepatic fluid collections) as seen on a ct scan. he was found to have an aortic clot at the level of (infrarenal) and thought to be possibly infected. a sump drain is putting out bile and a t-tube is close to the pancreatic head. past medical history: bipolar social history: history of substance abuse - cocaine and etoh. rehab x 3. + tobacco. expelled from high school. physical exam: vs: 102.9, 105, 98/38, 15, 100% trach mask gen: conversive, depressed mood heent: trach chest: decreased breath sounds, coarse. cv: rrr, bradycardic abd: soft, nontender, nondistended, open abdomen with vac in place, t-tube in place with bile draining. ileostomy rlq, pink. ext: +2 edema pertinent results: fistulogram/sinogram reason: please define anatomy of fistula indication: 39-year-old man with intracutaneous fistula. findings: the patient was placed supine on the fluoroscopy table. a preliminary scout radiograph again demonstrates evidence of multiple prior surgeries, a surgically placed jejunostomy catheter and the percutaneous biliary catheter terminating in the jejunum. a 7 french catheter was gently advanced slightly into the reported fistula site in the anterior abdomen just to the left of midline within the known large anterior open abdominal wound. approximately 30 cc of conray contrast was gently infused under fluoroscopic guidance. there was immediate opacification of a loop of small bowel just deep to the fistula site. no other communication was seen. impression: fistulogram demonstrate direct communication with a loop of small bowel immediately deep to the reported fistula at the patient's open abdominal wound. colon (barium enema) 12:22 pm colon (barium enema); small bowel only (gastrograf) reason: define anatomy between ileostomy, fistula, and rectum. impression: 1. the pouch ends at the mid sigmoid. 2. the fistula could not be demonstrated. if the fistula needs to be demonstrated, a fistulogram, upper gi with barium or a ct could be performed. small bowel only (gastrograf) 12:22 pm colon (barium enema); small bowel only (gastrograf) reason: define anatomy between ileostomy, fistula, and rectum. impression: 1. the pouch ends at the mid sigmoid. 2. the fistula could not be demonstrated. if the fistula needs to be demonstrated, a fistulogram, upper gi with barium or a ct could be performed. radiology final report sml bowel via entroclysis tube 2:37 pm sml bowel via entroclysis tube reason: ileostomy contrast study (not fistula). define anatomy betw impression: opacification of terminal loops of ileum and distal jejunum without evidence of contrast extravasation or visualization of enterocutaneous fistula. this suggests the fistula is more proximal. contrast did not definitely reach the jejunal-jejunal anastamosis. for further delineation of anatomy and evaluation of enterocutaneous fistula recommend fistulogram or oral contrast study. **final report ** urine culture (final ): pseudomonas aeruginosa. >100,000 organisms/ml.. aztreonam sensitivity testing confirmed by . at the request of dr. . #. intermediate to aztreonam. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 16 i ceftazidime----------- 16 i ciprofloxacin--------- =>4 r gentamicin------------ =>16 r imipenem-------------- 4 s meropenem------------- 4 s piperacillin---------- =>128 r piperacillin/tazo----- 64 s tobramycin------------ =>16 r **final report ** wound culture (final ): enterococcus sp.. >15 colonies. staphylococcus, coagulase negative. >15 colonies. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | staphylococcus, coagulase negative | | ampicillin------------ <=2 s clindamycin----------- <=0.25 s erythromycin---------- <=0.25 s gentamicin------------ 1 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin------------ 8 s =>0.5 r rifampin-------------- <=0.5 s tetracycline---------- 2 s vancomycin------------ <=1 s 2 s blood/fungal culture (final ): due to overgrowth of bacteria, unable to continue monitoring for fungus. reported by phone to 13:24. enterococcus faecalis. final sensitivities. 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: resistant to 1000mcg/ml of streptomycin. screen predicts no synergy with penicillins or vancomycin. consult id for treatment options. . enterococcus faecalis. final sensitivities. 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: resistant to 1000mcg/ml of streptomycin. screen predicts no synergy with penicillins or vancomycin. consult id for treatment options. . sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecalis | enterococcus faecalis | | ampicillin------------ <=2 s <=2 s penicillin------------ 8 s 4 s vancomycin------------ <=1 s <=1 s gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. smear reviewed; results confirmed. fluid culture (final ): enterococcus sp.. moderate growth. stenotrophomonas (xanthomonas) maltophilia. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | stenotrophomonas (xanthomonas) maltoph | | ampicillin------------ <=2 s penicillin------------ 4 s trimethoprim/sulfa---- <=1 s vancomycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated radiology final report change perc biliary drainage catheter 7:40 am reason: please perform cholangiogram through existing ptc tube. contrast: optiray impression: prompt biliary drainage into bowel via a tract that may represent the distal cbd. an 8 french drain is now capped to internal drainage. findings discussed by dr. with dr. on day of image acquisition. radiology final report cta abd w&w/o c & recons 11:04 am cta abd w&w/o c & recons; ct pelvis w&w/o c reason: please assess for patency of infrarenal aorta, iliacs. inclu contrast: optiray medical condition: 38 year old man with multiple medical problems, thrombus in infrarenal aorta. impression: 1. resolution of multiple fluid collections as described above. small subcentimeter resolving fluid collection in the gallbladder fossa remains. 2. no infrarenal aortic or iliac thrombus identified. radiology final report change perc biliary drainage catheter 9:24 am impression: 1. pullback percutaneous transhepatic cholangiogram performed which showed no evidence of leak. good drainage of contrast is identified from the intrahepatic bile ducts through the cbd into the bowel. 2. replacement of a 6 french nephroureteral-type catheter with the pigtail coiled within the common bile duct and the tip within the small bowel. the catheter was capped at this time and left for internal drainage. catheter, drainage 7:41 am impression: 1. percutaneous cholangiogram demonstrated no dilatation of the intrahepatic biliary ducts or common bile duct. contrast extravasation was noted in the region of the proximal common bile duct consistent with bile leak. 8-french percutaneous biliary drain with distal pigtail and middle interlocking loops was placed via the right intrahepatic bile duct into the common bile duct and into the bowel. the sideholes were positioned within the confluence of the right and left intrahepatic bile ducts and at the distal end. no sideholes were present throughout the common bile duct. 2. in situ t-tube was replaced with jejunostomy feeding tube. the catheter can be used immediately for feeding. chalnagiography via existing catheter 8:50 am reason: please assess for biliary leak/anastomotic breakdown contrast: optiray conclusion: draining of bile as described. i do not know exactly how much bile drains into the t tube; however, it may be possible to percutaneously place a catheter in the biliary tree and negotiate moving the glidewire down the path into the duodenum to establish internal biliary drainage. there was definitely no contrast material that entered the pancreatic duct however. . ct 150cc nonionic contrast 5:32 am ct abdomen w/contrast; ct pelvis w/contrast reason for this examination: please perform w/ po/iv contrast to assess for leak from anastomosis site(s), biliary leak, etc contraindications for iv contrast: none. impression: 1. gallbladder fossa fluid collection after cholecystectomy; this could be an infected collection or biloma. multiple irregular hepatic lesions are suspicious for abscesses. 2. unusual placement of t tube in the right upper quadrant with question of whether the one limb is within the common bile duct or outside it. t tube cholangiogram would be helpful to further evaluate. 3. open abdominal wound with subtotal colectomy and small bowel resection with right lower quadrant ostomy. diffuse small bowel wall thickening may be post-surgical, however, ischemia is a consideration. multiple rim-enhancing fluid collections throughout the abdomen could be infected. 4. thrombus within the infrarenal aorta at the origin of the and distal to it raises concern for traumatic or coagulopathic cause. the has contrast within it, however, it is uncertain whether this is retrograde or anterograde filling. 5. bilateral hypodense renal lesions could represent pyelonephritis or perfusion abnormalities. renal arteries and veins are patent. findings were called to dr. on the morning of . intro perc trnashepatic stent 7:41 am history: 38-year-old man status post gastrectomy with roux-en-y gastrojejunostomy with the postoperative course complicated with biliary leak and enterocutaneous fistula. radiologists: dr. and dr. who was present and supervising throughout the procedure. impression: 1. percutaneous cholangiogram demonstrated no dilatation of the intrahepatic biliary ducts or common bile duct. contrast extravasation was noted in the region of the proximal common bile duct consistent with bile leak. 8-french percutaneous biliary drain with distal pigtail and middle interlocking loops was placed via the right intrahepatic bile duct into the common bile duct and into the bowel. the sideholes were positioned within the confluence of the right and left intrahepatic bile ducts and at the distal end. no sideholes were present throughout the common bile duct. 2. in situ t-tube was replaced with jejunostomy feeding tube. the catheter can be used immediately for feeding. perc transhepatic cholangiography 9:24 am reason for this examination: increased percutaneous transhepatic biliary drainage for 48 hours. please perform a tube cholangiogram to assess the biliary tree. indication: status post gastrectomy, roux-en-y gastrojejunostomy with hepaticojejunostomy. previous biliary leak with t-tube in place. impression: 1. pullback percutaneous transhepatic cholangiogram performed which showed no evidence of leak. good drainage of contrast is identified from the intrahepatic bile ducts through the cbd into the bowel. 2. replacement of a 6 french nephroureteral-type catheter with the pigtail coiled within the common bile duct and the tip within the small bowel. the catheter was capped at this time and left for internal drainage. perc transhepatic cholangiography 7:40 am medical condition: 38 year old man with s/p gastrectomy, roux-en-y gastrojejeunostomy with subsequent t-tube placement and percutaneous transhepatic biliary drainage tube placement. there is drain in the subhepatic fossa near the cbd. impression: prompt biliary drainage into bowel via a tract that may represent the distal cbd. an 8 french drain is now capped to internal drainage. findings discussed by dr. with dr. on day of image acquisition. fistulogram/sinogram 10:35 am indication: 39-year-old man with intracutaneous fistula. impression: fistulogram demonstrate direct communication with a loop of small bowel immediately deep to the reported fistula at the patient's open abdominal wound. brief hospital course: he had a lengthy & complicated hospital course. original surgery was done for perforated gastric ulcer resulting in distal gastrectomy with roux-en-y. on it was noted that he has stool draining from his jp drain. he went back to surgery for a subtotal colectomy and ielostomy. he again returned to surgery on for cholecyctectomy, small bowel resection and ileostomy revision. #radiology: an abdominal ct showed an unusual placement of t tube in the right upper quadrant with question of whether the one limb is within the common bile duct or outside it. a t-tube study on showed a communication of the proximal ascending limb of the t-tube, which either lies in a remnant of the previous common bile duct or in the surrounding cavity; however, a short portion of the cbd does fill and there is reflux into the right and left hepatic ducts, and separately to the distal limb duodenum. on , a percutaneous cholangiogram demonstrated no dilatation of the intrahepatic biliary ducts or common bile duct. contrast extravasation was noted in the region of the proximal common bile duct consistent with bile leak. 8-french percutaneous biliary drain with distal pigtail and middle interlocking loops was placed via the right intrahepatic bile duct into the common bile duct and into the bowel. the sideholes were positioned within the confluence of the right and left intrahepatic bile ducts and at the distal end. no sideholes were present throughout the common bile duct. on , the radiologists pulled back the percutaneous transhepatic cholangiogram performed which showed no evidence of leak. good drainage of contrast was identified from the intrahepatic bile ducts through the cbd into the bowel. there was replacement of a 6 french nephroureteral-type catheter with the pigtail coiled within the common bile duct and the tip within the small bowel. the catheter was capped at this time and left for internal drainage. on the drain was d/c'd. on a cholangiogram showed prompt biliary drainage into bowel via a tract that may represent the distal cbd. he had additional studies to establish his anatomy. #abdomen/gi: an ngt tube was in place and he was npo. his abdomen was open with a wound vac in place. a sump drain to low wall suction was putting out large amounts of bilious drainage. a t-tube to gravity was draining small amounts of bilious drainage. he will need to continue the suction on the sump drain in order to avoid ostomy maceration. see "ostomy nurse notes". #vascular: a ct showed an aortic thrombosis at the origin of the . a hit panel was checked and a tte performed. the tee showed an ef >55%. an argatroban drip was started and then switched to a heparin drip for an aortic clot. coumadin was dosed and his inr was closely monitored. he was receiving 7.5 to 10 mg daily. the coumadin was d/c'd prior to his or date on . #id: he was placed on broad spectrum antibiotics. vancomycin, levofloxacin, and flagyl were started. pertinent microbiology includes: blood: enterococcus (vse), staphylcoccus, (mrse). sputum: neg; bactrim () blood fungal culture: enterococcus faecalis. peritoneal: enterococcus & xanthomas, blood culture: enterococcus and coag neg staph. cath tip: enterococcus, staphylcoccus, coagulase negative. blood cultures were negative x 2. , , : mrsa and vre negative. stool: c.diff neg ua: leuk mod blood sm wbc epi <1; started levo urine culture: p. aeruginosa, to zosyn, imipenem, meropenem. urine culture: pseudomonas aeruginosa. #psychiatry: the patient has a long history of bipolar disorder vs. schizoaffective d/o, chronic paranoia, etoh abuse. he seems cognitively intact and at his baseline. his current exam is notable for low level agitation, auditory hallucination and ?paranoia. recommendations were for haldol for agitation if needed. haldol was d/c'd and ativan, olanzapine were added. he was psychiatrically stable on celexa and klonopin. #respiratory: he required routine suctioning of thick white secretions. he was able to tolerate a passy muir valve and had a strong productive cough. on his trach was decannulated and his was respiratory status was stable. #ostomy care: the ostomy nurse performed routine ileostomy changes. on a fistula is noted on the left lateral portion of the wound. the wound undermines on each side and the drainage is green with a pungent odor. by the wound has decreased in size with healthy granulation tissue. the fistula is still putting out loose to thick brown/green stool. there is only mucous draining from the ileostomy. ileostomy pouched with seal and convatec active life pouch. the fistula was pouched with convatec's large wound manager pouch with seals. the inside seal was sealed with coloplast paste strips. a 33 fr cath was exited thru the pouch and stabilized with a nu hope catheter holder peri-wound and peristomal skin are intact. over the next months, he was stable and continued with wound care every 2 to 3 days. the ostomy nurses did an excellent job at closing his abdomen with serial ostomy changes that are well documented. on - repouched him using convatec medium fistula pouch and two piece natura system with seal for the ileostomy. have placed a 30 fr cath into the wound bed brought it out through the pouch using a coloplast drain port to secure the cath through the pouch. the cath was placed to suction set at 60, use the 16 gage intracath as a vent in the catheter. have protected the wound bed and fistula with adaptic. #nutrition: he was started on tpn for nutritional support upon admission to . on , there was successful placement of dobhoff feeding tube within the stomach. on the in situ t-tube was replaced with jejunostomy feeding tube. tube feedings were slowly advanced depending on the drainage output. his albumin was slowly increasing from 2.2 on to 2.9 on . his tube feeds were being cycled 1/2 strength tpn at 90cc/hr and boost shakes were ordered . ------fe-----------tibc-----------trf-------alb ---28------------319------44-------245-------3.1 --28------------328------35-------252-------2.9 --30------------361------30-------278-------3.0 --33------------367------18-------282-------3.1 --34------------400------12-------308-------3.1 --33------------429------12-------330-------3.5 --47------------434------12-------334-------3.5 --31------------439------11-------338-------3.4 --35------------458------10-------337-------3.4 ------------438------9.1------352-------3.5 ------------460------9--------354-------3.4 #physical therapy: the physical therapist worked with him on a regular basis using exercise bands and transferring him out of bed to chair. he eventually was walking the halls and had improved his strength dramatically. #foot a foot ulcer was noted from his prolonged hospital stay. multipodis boots were ordered and his heel was kept elevated. this improved as he became more mobile and resolved. after a prolonged hospitalization, he went to the or on with dr. and dr. . the following was performed: 1. exploratory laparotomy with extensive adhesiolysis. 2. enterocutaneous fistula takedown and repair. 3. takedown of end ileostomy and direct anastomosis to sigmoid. 4. repair of a iatrogenic bladder injury. 5. j tube placement. 6. primary ventral hernia repair with component separation. post-operatively, he did well. pain: his post-op pain was controlled with epidural and pca. he was transitioned to po percocet and had excellent pain control prior to discharge. gi: he was npo with a ngt. he complained on loose stool on pod 6 after his tube feedings were increased. he was started on imodium and the diarrhea began to resolve. . abd: he had 3 drains that were placed to low wall suction. these were then put to a jp bulb suction. he subsequently had the drains removed as the output decreased. the last drain was removed the day of discharge. his staples were removed on his discharge day. his abdomen was well healed without signs of infection. the t-tube in the right flank was secured to his side and will remain in place for now. . gu: the foley remained in place for 10 days due to the bladder injury while intraop. this was d/c'd and he was voiding without incident. . fen: he continued with his tpn. the j-tube was to gravity. j-tube feedings were started on pod 4. these were slowly increased. he started on strength impact and ramped up as tolerated. the tpn was stopped and his po diet was increased slowly. he had calorie counts which showed an intake of ~2000kcal and ~100gm of protein. he was tolerating a regular diet and the tube feedings were discontinued. . activity: he was ambulating the halls and moving independently. medications on admission: morphine, epogen 40,000 q weekly, thiamine, ativan, lovenox 40 q daily, protonix, diflucan discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. disp:*qs tablet(s)* refills:*0* 2. olanzapine 10 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs (once a day (at bedtime)). disp:*qs tablet, rapid dissolve(s)* refills:*2* 3. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qam (once a day (in the morning)). disp:*qs tablet, rapid dissolve(s)* refills:*2* 4. citalopram 20 mg tablet sig: two (2) tablet po daily (daily). disp:*qs tablet(s)* refills:*2* 5. clonazepam 0.5 mg tablet sig: one (1) tablet po daily (daily). disp:*qs tablet(s)* refills:*2* 6. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain for 1 months. disp:*60 tablet(s)* refills:*0* 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. metoclopramide 10 mg tablet sig: one (1) tablet po qidachs (4 times a day (before meals and at bedtime)). disp:*qs tablet(s)* refills:*2* 9. loperamide 1 mg/5 ml liquid sig: ml po every eight (8) hours as needed for diarrhea. disp:*qs ml* refills:*0* 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home with service facility: and southern nh vna discharge diagnosis: sepsis pancreaticobiliary injury with a major biliary leak. open abdominal wall with exposed jejunum ventral hernia wound end ileostomy entercutaneous fistula discharge condition: good discharge instructions: you may resume your regular diet. you may shower. allow water to run over the wound and pat dry. no baths for 4 weeks. * increasing pain * fever (>101.5 f) * inability to eat or persistent vomiting * inability to pass gas or stool * other symptoms concerning to you take all new medications as directed. do not drive while taking narcotic pain medication. continue to walk several times/day followup instructions: please follow-up with dr. . provider: , md phone: date/time: 9:30 procedure: venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances other enterostomy other enterostomy closure of stoma of small intestine other endoscopy of small intestine enteral infusion of concentrated nutritional substances other lysis of peritoneal adhesions other small-to-large intestinal anastomosis other repair of abdominal wall arteriography of other specified sites transfusion of packed cells closure of fistula of small intestine, except duodenum other cholangiogram incisional hernia repair other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract percutaneous hepatic cholangiogram percutaneous hepatic cholangiogram percutaneous hepatic cholangiogram other repair of bladder diagnoses: anemia, unspecified urinary tract infection, site not specified hyposmolality and/or hyponatremia sepsis accidental puncture or laceration during a procedure, not elsewhere classified peritoneal adhesions (postoperative) (postinfection) incisional hernia without mention of obstruction or gangrene pressure ulcer, heel streptococcal septicemia bipolar disorder, unspecified pseudomonas infection in conditions classified elsewhere and of unspecified site delusional disorder tracheostomy status fistula of intestine, excluding rectum and anus other suppurative peritonitis attention to ileostomy 

Answer: The patient is high likely exposed to