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: altace attending: chief complaint: fever/chills and coffee ground emesis major surgical or invasive procedure: percutaneous cholangiography with drain (external) history of present illness: 77yo man with h/o metastatic huerthle cell cancer of thyroid with known mets to pancreas and lung including s/p biliary stricture that was stented via ercp 4/. complicated by bleeding from mass in ampulla of vater requiring egd cauterization. he presents to the er today with cc of fever and chills for two days as well as 1 day of coffee ground emesis and weakness. per omr notes he has had recent transfusion-dependent anemia from suspected upper gi source - pt states last transfused about 2w ago. . in the er the pt was febrile to 102. blood and urine cultlures were sent and ua was negative. cxr revealed bilateral nodules and masses and a possible retrocardiac opacity. he received vanc/levo/flagyl and 3l crystalloid. ng lavage revealed coffee ground return. he was guaiac positive. a r ij line was placed and was adjusted after cxr showed poor positioning. he received 3u prbc and protonix iv. gi was notified and will follow patient. . ros: denies sob/cp/nausea/vomiting, notes decreased appetite marginally better with marinol. constipation with no bm x 4 days. no change in his baseline cough, no phlegm. past medical history: 1) hurthle cell thyroid ca - metastatic to lungs, pancreatic head-dx by eus bx in , neck) - s/p total thyroidectomy on (8x7x6 cm mass extending to the capsule. follicular carcinoma, hurthle cell variant with clear cell features. vascular invasion) - s/p rai rx in - s/p resection of neck recurrence () - s/p distal cbd stent stricture from pancreatic head () 2) type ii diabetes mellitus 3) malignant melanoma: resected approximately 10-12 years ago 4) bph 5) s/p inguinal herniorrhaphy 6) s/p right total knee replacement 6 or 8 years ago social history: the patient is a dairy farmer from upstate . he chews tobacco, but has never smoked and consumes alcohol limited to one beer a day. family history: colon cancer in two siblings physical exam: on admission: temp 100.4, hr 103, bp 111/57, rr 19, o2 99% ra gen: nad, talkative, more interested in changing subject than giving history heent: ncat, conjunctivae pale, op not injected, dentures in place, perrl, eomi, r eye ptosis, ng tube in place neck: r ij in place , no lad, supple cor: s1s2, high pitched holosystolic murmur heard best at apex, nonradiating pulm: trace wheezes bilaterally abd: soft, scaphoid, ntnd, no hsm, +bs ext: no c/c/e, w/w/p skin: no rashes pertinent results: 09:05am blood wbc-8.0 rbc-4.15* hgb-12.5* hct-37.3* mcv-90 mch-30.2 mchc-33.6 rdw-17.8* plt ct-120* 05:30am blood wbc-7.2 rbc-2.72* hgb-8.4* hct-24.4* mcv-90 mch-31.1 mchc-34.6 rdw-17.4* plt ct-83*# 01:15am blood wbc-10.8# rbc-2.64* hgb-8.5* hct-23.7* mcv-90 mch-32.4*# mchc-36.0* rdw-18.0* plt ct-99* 06:00am blood neuts-89.0* lymphs-5.0* monos-3.0 eos-3.0 baso-0 06:15am blood pt-21.9* ptt-49.8* inr(pt)-2.1* 01:15am blood pt-12.8 ptt-25.1 inr(pt)-1.1 09:05am blood glucose-102 urean-10 creat-1.0 na-138 k-3.9 cl-100 hco3-23 angap-19 01:15am blood glucose-190* urean-16 creat-0.7 na-135 k-3.8 cl-93* hco3-24 angap-22 09:05am blood alt-24 ast-36 alkphos-253* totbili-3.1* 01:15am blood alt-365* ast-842* alkphos-1389* amylase-36 totbili-3.7* 06:10am blood lipase-9 01:15am blood lipase-50 09:05am blood mg-1.5* 05:50am blood calcium-8.0* mg-1.6 06:10am blood albumin-2.4* calcium-7.7* phos-3.0 mg-1.5* 01:15am blood albumin-3.4 calcium-9.5 phos-3.5 mg-1.7 12:50pm blood hapto-199 02:50am blood cortsol-41.5* 02:50am blood crp-255.8* 05:45am blood lactate-4.0* 01:17am blood lactate-5.4* 12:13am blood lactate-1.8 01:17am blood hgb-8.8* calchct-26 02:56am urine color-amber appear-clear sp -1.015 02:56am urine blood-lge nitrite-neg protein-100 glucose-neg ketone-50 bilirub-sm urobiln-neg ph-5.0 leuks-sm 02:56am urine rbc-292* wbc-42* bacteri-none yeast-none epi-<1 05:47pm urine wbc clm-rare blood culture aerobic bottle-pending; anaerobic bottle-pending inpatient stool clostridium difficile toxin assay-final {clostridium difficile} inpatient blood culture aerobic bottle-final; anaerobic bottle-final inpatient bile gram stain-final; fluid culture-preliminary {enterococcus sp., gram negative rod #1, gram negative rod #2, gram positive bacteria} inpatient blood culture aerobic bottle-final; anaerobic bottle-final inpatient urine urine culture-final inpatient urine urine culture-final inpatient mrsa screen mrsa screen-final inpatient swab r/o vancomycin resistant enterococcus-final {enterococcus sp.} inpatient mrsa screen mrsa screen-final inpatient urine urine culture-final emergency blood culture aerobic bottle-final; anaerobic bottle-final emergency blood culture aerobic bottle-final {escherichia coli}; anaerobic bottle-final {escherichia coli} emergency portable ap chest radiograph: the study is limited secondary to respiratory motion. again seen are pleural opacities along the right pleural surface, and nodular opacities within the right upper lobe, corresponding to the patient's history of known metastatic nodules. additionally, there are bilateral pleural effusions and an area of opacity at the right lung base which may represent associated atelectasis and/or consolidation. the cardiac and mediastinal contours are relatively stable. there is an area of opacity in the left lung base, which may represent an area of pleural thickening or atelectasis, though there is limited evaluation secondary to motion. no definite pneumothorax is seen. an internal external biliary stent is seen overlying the right upper quadrant. impression: 1. again seen are findings from the patient's known history of metastatic malignancy, including areas of pleural opacity and thickening within the right hemithorax. 2. right pleural effusion and associated opacity which may represent volume loss and/or consolidation. 3. area of opacity in the left lower lobe which is not well evaluated secondary to respiratory motion. ct abdomen: within the visualized lung bases, there are bilateral pleural effusions with enhancing pleural metastases. adjacent compressive atelectasis is also evident, greater on the right. numerous parenchymal nodules are identified. a percutaneous biliary drain is present and terminates within the duodenum. two plastic stents are identified within the common bile duct and duodenum. there is no significant intrahepatic biliary duct dilatation. multiple low attenuation lesions are identified scattered throughout the liver. a small amount of perihepatic fluid is identified, new from the previous examination. the pancreatic head is enlarged, and a mass is identified within the pancreatic tail. there is soft tissue within the porta hepatis. a 1 cm right adrenal nodule is again identified. the left adrenal gland appears unremarkable. the kidneys show cysts, but are otherwise unremarkable. there is no evidence of hydronephrosis. note is made of small retroperitoneal lymph nodes. free fluid is identified within the pelvis, which is of increased attenuation, and likely hemorrhagic. there is no evidence of colonic obstruction. there are multiple osseous metastases noted within the left femoral head, right iliac crest, left l3 vertebral body. note is made of gas within the urinary bladder likely incident to instrumentation. impression: 1. other than a small increase in perihepatic fluid, there has been no appreciable change compared to the examination. the high- attenuation fluid within the pelvis (likely hemorrhagic) has not appreciably increased in size. 2. widespread metastatic disease. ct of the abdomen with iv contrast: the lung bases show interval progression of both parenchymal and pleural-based nodules, consistent with metastatic disease. there are bilateral low-density pleural effusions with adjacent areas of opacity most likely to represent atelectasis. numerous metastases in the liver were much better demonstrated on the recent ultrasound from . there is a new percutaneous biliary drain extending into the right lobe of the liver and terminating in the duodenum. there is interval improvement in the degree of intrahepatic biliary ductal dilatation. there is again pneumobilia within the left lobe. ill-defined abnormal soft tissue is present in the hepatic hilum. a large mass in the head of the pancreas is perhaps minimally increased in size, now measuring 6.2 x 4.8 cm in axial dimensions, compared to 5.9 x 4.8 cm previously. a further mid body metastasis which is new is seen also. a stent in the distal common bile duct is in an unchanged position. there is a new stent in the duodenum since the prior study with partial opacification by contrast in its proximal course, although not distally. however, contrast passes freely and is present in the colon. the stomach is not dilated. there is a new small right adrenal nodule of 10 mm in diameter raising concern for metastatic disease. otherwise, the adrenal glands are unremarkable. the spleen is within normal limits. a left-sided renal cyst is unchanged.a new left sided retroperitoneal; deposit is seen-represewnting progressive mets. the small and large bowel are within normal limits. there is a small rim of high-density ascites about the liver anteriorly. there are multiple small retroperitoneal lymph nodes, not meeting size criteria for pathological enlargement. ct of the pelvis with iv contrast: there is a small-to-moderate amount of high- density ascites, up to 40 hounsfield units in the lower pelvis, most consistent with recent hemorrhage, probably related to recent percutaneous drain placement. the distal ureters and bladder are within normal limits, although air is noted in the bladder. this appearance could be seen in recent catheterization. there is sigmoid diverticulosis, without diverticulitis. contrast has passed to the rectum. there is no pelvic or inguinal lymphadenopathy. subcutaneous tissues show edema. bone windows: there is a new lytic lesion in the left femoral head. in fact, there are increased lucencies in both femoral heads. there is also a new soft tissue mass along the right iliac crest with bony destruction, measuring 2.8 x 2.0 cm in axial dimensions, new since the prior study. there is also a new soft tissue mass with bony destruction along the posterior aspect of the left l3 vertebral body, also new since the prior study. it is about 1 cm in diameter and extends slightly into the spinal canal. impression: 1. status post placement of percutaneous biliary catheter and duodenal stent. 2. hemoperitoneum in the pelvis, which may relate to recent instrumentation, as well as small amount of hemoperitoneum adjacent to liver. 3. progressive metastatic disease, including new osseous metastases, progressive lung nodules, and perhaps slightly increased size of pancreatic mass. possibly because of the phase of contrast administration, the liver metastases are not as conspicuous as on the recent ultrasound. 4. bone metastases include a small mass in l3 with slight posterior extension into the spinal canal. it is doubtful that this lesion produces mass effect on the spinal cord at present, although posterior extension into the canal may become a consideration later if it were to become larger. 5. no evidence of obstruction, with free distal passage of contrast. approved: sun 9:59 am ptc: impression: 1. cholangiogram demonstrating intrahepatic biliary ductal dilation as well as dilation of the common bile duct; contrast extended into the duodenum. sludge and debris were seen within the common bile duct. a common bile duct as well as a duodenal stent were in situ. 2. successful placement of a 10-french internal-external biliary drain from the right approach. the catheter was connected to a bag for gravity drainage. approximately 30 ml of dark brown bile and sanguinous material were extracted during the procedure. ercp ercp: three fluoroscopic images were obtained in the ercp suite without the presence of a radiologist. metallic stent is seen in the region of the cbd. duodenoscope could not be negotiated past a reported extrinsic stenosis of the post-bulbar duodenum. subsequent image shows deployment of an incompletely expanded metallic stent across the stenosis. for further details, please see the ercp report of the same day. echo: conclusions: the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. transmitral doppler and tissue velocity imaging are consistent with grade i (mild) lv diastolic dysfunction. right ventricular chamber size and free wall motion are normal. the aortic root is moderately dilated. the ascending aorta is mildly dilated. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. us: conclusion: large pancreatic/portahepatus mass, which has increased in size compared to the ct of . more significantly, there has been blossoming of diffuse hepatic metastatic disease with very extensive progression since the ct scan. there is also mild-to-moderate dilatation of the common hepatic and intrahepatic bile ducts, despite the presence of biliary stent. brief hospital course: # acute blood loss anemia: from gi bleeding - coffee ground emesis/: with most likely source is bowel invasion of tumor given pt's history. was transfused as needed and also given platelet transfusion. treated with ppi. the patient also had hemoperitoneum which could be from tumor bleeding which was slightly increased on a subsequent ct. he was managed conservatively with general surgery, gi and ercp teams followed. # acute cholangitis - due to vre - on culture from the bile. ptc done by ir with external drain in place. lft improved. # c diff colitis - during the course in the hospital, pt developed c diff diarrhea that was treated with flagyl. # pulmonay metastasis - caused intermittent hemoptysis. # thrombocytopenia: pt is below baseline. was possibly due to bone marrow invasion by tumor. required transfusion. also has dm, hypothyroidism - medically managed. during the ast few days, the patient developed severe hypotension, tachycardia and severe abdminal pain. end of life issues were discussed by dr , (palliative care team) and me with the family and patient and given the very poor long term prognosis of the patient, comfort measures were maintained. the patient died on at 11-15 am. family was present at bedside and did not request an autopsy when offered. medications on admission: synthroid 200 mcg po daily, metformin 500 mg po daily, doxazosin .4 mg po daily, ferrous gluconate 324 mg po daily, and prilosec 1 tab po daily, ibuprofen 600mg po tid prn arthritis pain. baby asa . ( per pt never takes his albuterol 1-2 puffs q6-8 prn. benzonatate capsules tid prn, flovent 2 sprays per nostril ) discharge medications: none discharge disposition: expired discharge diagnosis: death due to metastatic thyroid cancer c diff colitis acute cholangitis intestinal obstruction hypotension discharge condition: died from metastatic thyroid cancer discharge instructions: died from metastatic thyroid cancer followup instructions: died from metastatic thyroid cancer procedure: venous catheterization, not elsewhere classified transfusion of packed cells other irrigation of (naso-)gastric tube other percutaneous procedures on biliary tract transfusion of platelets dilation of intestine percutaneous hepatic cholangiogram diagnoses: acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis pneumonitis due to inhalation of food or vomitus blood in stool intestinal infection due to clostridium difficile secondary malignant neoplasm of lung hematemesis septicemia due to escherichia coli [e. coli] cholangitis knee joint replacement personal history of malignant melanoma of skin hemoperitoneum (nontraumatic) secondary malignant neoplasm of other digestive organs and spleen personal history of malignant neoplasm of thyroid secondary malignant neoplasm of small intestine including duodenum other postablative hypothyroidism other obstruction of duodenum 

Answer: The patient is high likely exposed to