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: patient recorded as having no known allergies to drugs attending: chief complaint: s/p ercp, biliary stricture major surgical or invasive procedure: ercp percutanrous transhepatic cholangiography by ir intrinsic biliary stricture history of present illness: this is an 80 yo male s/p partial gastrectomy in with t2n2mx poorly differentiated gastric cancer who was transferred from to for ercp. he underwent ercp on , but procedure was unsucessful due to his gastric bypass surgery and could not reach ampulla. he reports that initially after his surgery in , he had been doing well. but over the past few months had developed decreased po intake, weight loss and progressive scleral icterus. he was admitted to on . there, he had many imaging studies, including an mrcp which documents a mid cbd stricture. additionally, his mri from the osh documents mild to mod ascites and a small r sided pleural effusion. was initially transferred to the floor on but developed hematemesis x 2, then transferred to the icu. there, he had no further episodes of ugib and went to ir for ptc. he was transiently hypotensive and responded to fluid bolus, did not receive pressors. his gastric biopsy returned positive for gastritis and + h pylori, and triple therapy was initiated. today, he feels well. he denies chest pain, abdominal pain, sob, orthopnea, nausea, or emesis. he has been afebrile, no chills, or nightsweats. he feels that his jaundice has improved since insertion of the biliary drain. also is complaining of back pain and reports that he has not had a bm after his tap water and mineral oil enema. past medical history: - s/p billroth ii in , poorly differentiated gastric cancer (t2n2mx) - htn - s/p appendectomy - s/p l knee arthoplasty social history: lives in , ma with his wife. active smoking, last cigarette was >20 years ago. drinks approximately 1 drink per week, no history of ivdu family history: no family history of cancer, dm, or htn physical exam: discharge exam: vitals: 99.2 tm 99.3 110/68 115 r20 92%5l nc gen: pleasant male, nad, bitemporal wasting; jaundiced heent: + scleral icterus, pupils 3mm, poorly reactive to light bilaterally, eomi, op is clear, edentulous, no cervical lad cv: +s1s2, rrr, no mrg appreciated, pmi not palpable, no jvd lungs: decreased bs at the b/l bases, occasional expiratory wheeze, otherwise ctab abd: mildly distended, drain from ruq without surrounding erythema, purulent drainage, well healed vertical scar over central abdomen, hypoactive bs, no tenderness to palpation. ext: trace edema in arms, no lle neuro: cn 2-12 intact, non-focal pertinent results: from cbc: 6 > 11.8/35.8 < 153 chem: 132 | 104 | 19 < 106 3.9 | 24 | 0.5 lfts: 118 > 13.1/385 < 109 ca 8 mg 1.9 phos 2 06:30am blood wbc-7.1 rbc-3.95* hgb-11.3* hct-33.9* mcv-86 mch-28.7 mchc-33.4 rdw-16.2* plt ct-256 06:30am blood pt-13.0 inr(pt)-1.1 06:00am blood glucose-107* urean-22* creat-1.0 na-138 k-3.5 cl-96 hco3-33* angap-13 09:15am blood alt-80* ast-99* alkphos-261* totbili-13.1* 06:15am blood alt-61* ast-84* alkphos-220* totbili-11.9* 06:30am blood alt-49* ast-73* ld(ldh)-304* alkphos-212* totbili-11.4* 06:00am blood alt-56* ast-89* ld(ldh)-388* ck(cpk)-33* alkphos-249* totbili-12.2* alt 56 ast 84 alkphos 219 totbili 14.4 06:30am blood calcium-8.2* phos-2.2* mg-1.7 : bcx negative (final) ucx negative (final) biliary fluid culture - gnr, see report below. : cxr bilateral pleural effusions with compressive atelectasis, enlargement of the cardiac silhouette most recent cxr: : pa and lateral upright chest radiograph was compared to . bibasilar atelectasis and bilateral pleural effusions are unchanged with no evidence of increase in the pleural effusion or consolidation, but definitely bibasilar opacities might represent infectious process. the upper lungs are clear. there is no pneumothorax. the draining catheter in right upper quadrant is redemonstrated. ir biliary dilatation: preliminary report: percutaneous transhepatic balloon dilatation of orifice of left main duct and orifice of right posterior duct via transhepatic access in right anterior duct. this was followed by dilatation and stenting of patient's known occlusive upper common bile duct stricture with a 10 mm x 6.8 cm wallstent, which extends through the ampulla. a 10 french internal-external drain was left through the stent, and patency and position should be checked early next week before drain removal. pathology: common bile duct brushings: suspicious. highly atypical glandular epithelial cells, suspicious for adenocarcinoma. thickened gastric fold, mucosal biopsy: 1. chronic active gastritis. 2. stain is positive for bacteria morphologically consistent with h. pylori. hep a igg positive, igm negative hep b sag negative hcv neg . chest ct: impression: 1. no pulmonary embolus or aortic dissection. 2. stable thoracic aortic aneurysm without focal area of dilation as depicted above. 3. bilateral pleural effusions and consequent consolidations. these are likely atelectatic, though an underlying infectious component is not excluded. 4. ascites. 5. fluid column in the esophagus. correlate for possible reflux and out of concern for potential aspiration-risk. ______________________________________________________ pertinent micro: 4:00 pm fluid,other biliary drain. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): non-fermenter, not pseudomonas aeruginosa. isolated from broth media only, indicating very low numbers of organisms. sensitivity testing performed by microscan. cefepime. <=2mcg/ml. levofloxacin. <=2mcg/ml. meropenem. <=1mcg/ml. trimethoprim/sulfamethoxazole. <=2/38mcg/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ non-fermenter, not pseudomonas aeruginosa | cefepime-------------- s ceftazidime----------- <=2 s ceftriaxone----------- <=4 s ciprofloxacin--------- <=0.5 s gentamicin------------ <=1 s imipenem-------------- <=1 s levofloxacin---------- s meropenem------------- s piperacillin---------- <=8 s piperacillin/tazo----- <=8 s tobramycin------------ <=1 s trimethoprim/sulfa---- s anaerobic culture (final ): no anaerobes isolated. brief hospital course: this is an 80 yo male with a history of poorly differentiated gastric cancer who developed jaundice secondary to biliary stricture. * cholangitis/biliary stricture - ercp failed. s/p successful ptc and with improvement in lfts and pain. his blood cultures have remained negative, but his fluid culture has gnr growing and currently on zosyn. recurrent brushing were done to check for maligant cells. stricture results with atypical glandular cells, suspicious for adenocarcinoma. intrinsic stent placed on . interventional radiology would like to see pt back as an outpatient for cholangiogram and reevaluation of biliary stent/drain. . susceptabilities returned and antibiotics were narrowed to ceftriaxone for 14 day course. . * likely recurrent gastric cancer: s/p bilroth ii. gastric biopsies were taken during ercp at the suture line of the gastric mucosa, and noted to be chronic active gastritis and findings c/w h pylori. he was initiated on clarithromycin, zosyn and ppi for therapy. biopsy results showed chronic gastritis, despite suspicious appearance on egd. however, as above stricture brushings was malignant with atypical glandular cells. discussed with his primary oncologist, and decision made in conjunction with family to transfer back to home facility to continue treatment and evaluation. * hematemesis: 2 episodes of 100cc of hematemesis were noted following the patient's ercp. he did not require transfusions and has not had any subsequent episodes. it is thought that his bleeding was secondary to the biopsy site, from his gastritis or esophagitis. * nausea and vomiting: he had persistent nausea and vomiting early morning . he had a recent chest ct scan that showed a fluid filled esophagus. his nausea and vomiting subsequently resolved with treatment with zofran and did not recur. * hypoxia: this is likely to his bilateral pleural effusions and may have some contribution from ascites. his effusions likely increased in the setting of his fluid resuscitation and low albumin. gentle diuresed gently with lasix. given progressive hypoxia and concern for aspiration, he underwent a chest ct which showed primarily bilateral effusions with associated atelectasis. he remained on low flow oxygen. pt was breathing comfortably, satting 92% on 5l nc at the time of discharge. * urinary obstruction: on morning of , patient noted difficulty urinating, and pt was bladder scanned with finding >500 cc. foley was placed with relief of discomfort. * goals of care - discussed with family, but decision made to return to primary hospital under care of pcp, service, surgeon, all well known to patient and family for continued evaluation and treatment. medications on admission: clarithromycin 500 mg po bid duration: 14 days trazodone 25 mg po hs:prn insomnia docusate sodium 100 mg po bid senna 1 tab po bid:prn constipation piperacillin-tazobactam 4.5 g iv q8h bisacodyl 10 mg pr hs:prn constipation ondansetron 4 mg iv q8h:prn nausea pantoprazole 40 mg iv q12h discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 3. clarithromycin 250 mg tablet sig: two (2) tablet po bid (2 times a day) for 14 days. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily). 6. furosemide 20 mg tablet sig: one (1) tablet po once (once) for 1 doses. 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: inhalation every six (6) hours as needed for cough. 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 9. ceftriaxone in dextrose,iso-os 1 gram/50 ml piggyback sig: one (1) intravenous q24h (every 24 hours) for 7 days. 10. pantoprazole 40 mg recon soln sig: forty (40) recon soln intravenous q12h (every 12 hours). 11. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day). 12. heparin (porcine) 5,000 unit/ml solution sig: one (1) ml injection tid (3 times a day). 13. dextromethorphan-guaifenesin 10-100 mg/5 ml syrup sig: five (5) ml po q6h (every 6 hours) as needed for cough. 14. ondansetron 4 mg iv q8h:prn nausea 15. lasix - pt receiving intermittent dosing as needed discharge disposition: extended care facility: discharge diagnosis: mid cbd stricutre s/p billroth ii procedure htn s/p appendectomy s/p l knee arthoscopy discharge condition: stable for transfer to discharge instructions: you were admitted because you had a narrowing of your bile duct. the initial ercp was unable to reach the narrowing and you were admitted to get a drain placed. you then vomited blood and were transferred to the icu. you did not need to get transfused and your bleeding stabilized. you received the drain into the bile duct and will need to have this removed at a later date. you were found to have likely cancer causing the blockage. we placed a metal stent to relieve the blockage. . you need to follow up with ir in 1 week for repeat bile duct study. until then you will have the biliary drain in place. followup instructions: one week with ir for tube study and cholangiogram per radiology service note: biliary drainage should be managed in as follows: external drainage can be capped tomorrow. bilirubins should be monitored daily. if elevated bilirubin, external drain can be reconnected to bag drainage. flushing of the catheter is not recommended. patient should return in five to fourteen days for biliary catheter check under all circumstances. our service will contact family for facilitation of retransfer or outpatient appointment. please call for any questions. patient family contact number: wife daughter (chicky) (home) (work) cell (cell) procedure: other cholangiogram other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract percutaneous biopsy of gallbladder or bile ducts percutaneous hepatic cholangiogram endoscopic retrograde cholangiopancreatography [ercp] replacement of stent (tube) in biliary or pancreatic duct replacement of stent (tube) in biliary or pancreatic duct diagnoses: unspecified pleural effusion unspecified septicemia unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia nausea with vomiting hemorrhage complicating a procedure hypoxemia cholangitis obstruction of bile duct oliguria and anuria secondary malignant neoplasm of other digestive organs and spleen jaundice, unspecified, not of newborn personal history of malignant neoplasm of stomach 

Answer: The patient is high likely exposed to