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 attending: chief complaint: abdominal pain major surgical or invasive procedure: right internal jugular central venous catheter placement right brachial vein picc line placement history of present illness: (per admission note by dr. ) 62y/o f with a pmh of etoh abuse and multiple falls presenting with hypotension, abdominal pain and weakness. she reports n/v with increased abdominal pain x 2-3 days. she reports chills and decreased appetite over the past week, she last ate sometime last week. appetite limited by abd pain and nausea. + dysuria. the pt also reports one episode of brbpr x1 two days prior to presentation, denies previous episodes. reports last etoh was a "mixed drink" a few days ago. she smokes ppd but is unsure if she has used cocaine or ivdu in the last few weeks. denies cp/sob. denies diarrhea. reports productive cough of green sputum. denies ha, vision changes. . in the ed, initial vs were: t 98.2 p 84 bp 90/65 r 20 o2 sat 99% ra. pt dropped bp to 79/47 p 91. she had a central line placed and was given 6l ns, cipro 400mg iv, flagyl 500mg iv, morphine 4mg iv and zofran. urine and blood cultures sent. ct a/p negative for acute process, cxr negative for infiltrate. ua with 25-50 wbc and +leuks. . on arrival to the icu, the patient is awake, alert, oriented to situation. she complains of diffuse abdominal pain and le burning. . review of sytems: (+) per hpi (-) denies recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied shortness of . denied chest pain or tightness, palpitations. denied constipation no recent change in bowel or bladder habits. denied arthralgias past medical history: ckd stage iii hepatitis c emphysema mild mr mod tr mod pulm htn lll nodule gerd hiatal hernia polysubstance abuse left hip fracture s/p orif right hip osteoarthritis s/p thr psoriasis social history: alcohol pint vodka/day. tobacco 1 ppd x 30 years. cocaine use. ivdu within last year. lives with fiance and mother in , ma. family history: noncontributory. physical exam: admission physical exam vitals: t: 95.9 bp: 117/50 p: 71 r: 16 o2: 100% ra general: alert, oriented, uncomfortable appearing heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp flat, no lad, r ij in place lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, diffuse tenderness without rebound tenderness or guarding, no organomegaly ext: warm, 1+ pulses pt/dp, no edema pertinent results: 06:45am blood thrombn-13.9* 06:55am blood factvii-85 facviii-242* 06:30am blood inh scr-neg 11:05am blood pth-110* 06:55am blood hbsag-negative hbsab-borderline hbcab-positive 07:00am blood pep-polyclonal igg-2683* iga-607* igm-160 ife-no monoclo 07:00am blood hiv ab-negative 06:55am blood hcv ab-positive . time taken not noted log-in date/time: 6:57 pm blood culture #2. blood culture, routine (preliminary): escherichia coli. final sensitivities. escherichia coli. second colony morphology. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | escherichia coli | | ampicillin------------ =>32 r =>32 r ampicillin/sulbactam-- 16 i 16 i cefazolin------------- <=4 s <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ 4 s 4 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r . time taken not noted log-in date/time: 8:32 pm urine site: catheter **final report ** urine culture (final ): <10,000 organisms/ml. . 3:35 pm catheter tip-iv source: rij. **final report ** wound culture (final ): no significant growth. . time taken not noted log-in date/time: 3:16 pm immunology chem# y. **final report ** hcv viral load (final ): 8,720 iu/ml. performed by real-time pcr. detection range: 30 - 55,000,000 iu/ml. hcv genotype (final ): hepatitis c genotype, 1. . time taken not noted log-in date/time: 3:16 pm immunology chem# y. **final report ** hbv viral load (final ): hbv dna not detected. performed by pcr. detection range: 60 - 38,000 iu/ml. . 6:50 am immunology **final report ** hiv-1 viral load/ultrasensitive (final ): hiv-1 rna is not detected. performed by real-time pcr. . time taken not noted log-in date/time: 12:53 pm urine chem# y. **final report ** legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. . 5:55 pm stool consistency: soft source: stool. **final report ** ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. clostridium difficile toxin a & b test (final ): reported by phone to @ 5:50a . clostridium difficile. feces positive for c. difficile toxin by eia. . cxr findings: the lungs are well expanded and clear. atheromatous disease of the aortic arch is again identified. the cardiac silhouette is within normal limits for size. no effusion or pneumothorax is noted. the visualized osseous structures are unremarkable. impression: no acute pulmonary process. . ct abdomen: there is mild dependent bibasilar atelectasis. there is ct evidence of anemia. absence of intravenous contrast limits evaluation of the abdominal parenchymal organs and vasculature. diffuse atherosclerotic calcification of the abdominal aorta and its branches is not significantly changed. the liver is unremarkable. gallbladder is markedly distended, with a small punctate calcification along the posterior wall, either representing a tiny gallstone or mural calcification. there is no wall thickening or pericholecystic inflammatory change. the pancreas, spleen, and adrenal glands are unremarkable. lobulated contour of both kidneys is unchanged. stomach and intra-abdominal loops of bowel are unremarkable. there is no free air, free fluid, or abnormal intra-abdominal lymphadenopathy. ct pelvis: evaluation of the pelvic structures is limited by streak artifact from bilateral hip fixation hardware. urinary bladder is decompressed with a foley catheter in place. pelvic loops of large and small bowel are grossly unremarkable. mild degenerative changes in the lower lumbar spine, including grade 1 anterolisthesis of l5 on s1 are stable. impression: no specific ct findings to explain the patient's symptoms. distended gallbladder, with a single tiny mural calcification or gallstone, but no sign of acute cholecystitis. . kub findings: there is no free intraperitoneal air. a non-obstructive bowel gas pattern is evident. scattered gas is noted throughout the colon. no organomegaly or ascites detected. there is marked degenerative change in the lower lumbar spine. a dynamic hip screw is present on the left. a total hip arthroplasty is present on the right. the bones are diffusely osteopenic. there is evidence of prior healed trauma of the right pelvis. impression: non-obstructive bowel gas pattern with no free air seen. . abd u/s the gallbladder is quite markedly distended measuring 5.4 x 12.4 x 5.6 cm. there is a small freely mobile stone in the body of the gallbladder measuring 3-4 mm in diameter. no stone is seen in the neck nor is there evidence of focal wall edema or sludge. the entire abdomen was somewhat tender but there is no specific tenderness at the gallbladder. the common bile duct measures between 6 and 12 mm in size but appears to taper proximally into the liver and distally into the pancreas. no stones are seen within the duct. there is no intrahepatic bile duct dilatation. the liver is normal in size and echogenicity and there are no focal liver lesions seen. there is a very small amount of perihepatic ascites as well as a small right pleural effusion and an equally small left pleural effusion. the kidneys are normal in size but show increased echogenicity of the cortex suggestive of chronic parenchymal renal disease. the spleen is not enlarged. there is no evidence of hydronephrosis, renal stones or masses. conclusion: 1. borderline common duct dilatation and enlarged gallbladder. there are no specific signs of cholecystitis, but this diagnosis cannot be excluded. further evaluation with biliary scintigraphy is recommended, as discussed with the medical resident, dr. . 2. echogenic renal parenchyma suggestive of chronic renal disease. 3. small bilateral effusions and minimal perihepatic ascites . liver/gallbladder ultrasound: -scale and color doppler son images were obtained that demonstrate no ascites. limited views of the liver are normal. the patient recently ate and the gallbladder is small with a thickening of the gallbladder wall (which could relate to contracted state or edema) but no pericholecystic fluid, cholelithiasis intra- or extra-hepatic bile duct dilatation with the common bile duct measuring 5.3 mm. impression: 1. no ascites. 2. nondistended gallbladder with possible wall edema in the wall but no intra- or extra- hepatic bile duct dilatation is nonspecific and differential includes hypoalbuminemia, fluid overloard, and hepatitis. 3. acute cholecystis is unlikely given gallbladder nondistention. . findings: the right kidney measures 12 cm, and the left kidney measures 12.1 cm. there is no hydronephrosis or nephrolithiasis. note is made of multiple hypoechoic masses in the kidneys bilaterally, of varying sizes. these appear new since the ultrasound of and were not well assessed on the non-contrast ct from . notably, these lesions show internal vascularity on color doppler analysis. the urinary bladder is unremarkable. impression: multiple, bilateral hypoechoic renal masses as detailed above. these findings appear new, and given the infectious history, diagnostic considerations include bilateral focal bacterial nephritis. the internal vascularity argues against the formation of bilateral renal abscesses. additionally, considerations include lymphoma given the mass-like nature of these lesions as well as the vascularity. . mri abdomen w/o contrast findings: there is diffuse, heterogeneous signal abnormalities throughout both kidneys in rounded, linear, and wedge-shaped configurations. within some of the regions of abnormal t2 hypointensity in the kidneys, there is central t2 hyperintensity (for example, images 22 and 34, series 4 in the left kidney). there is associated perinephric stranding. no focal renal or perinephric abscess. no evidence of hydronephrosis. irregularity of the collecting system in the superior pole of the right kidney is visualized (image 22, series 3). the liver is unremarkable without findings to suggest cirrhosis. a trace amount of perihepatic fluid is visualized. no evidence of intrahepatic bile duct dilation. common bile duct measures approximately 9 mm and tapers smoothly to the level of the ampulla. two gallstones layer dependently within the gallbladder. no evidence of choledocholithiasis. spleen, pancreas, and adrenal glands appear normal. visualized bone marrow signal is unremarkable. patient is status post right hip replacement. screws transfix the left femoral neck. impression: diffuse, heterogeneous signal abnormalities throughout both kidneys. given the clinical setting, bilateral pyelonephritis is a possibility, however given the mass-like appearance of much of the abnormalities, renal lymphoma is a concern. . renal u/s findings: the right kidney measures 12 cm and the left kidney measures 12.1 cm. there is no hydronephrosis or nephrolithiasis. multiple hypoechoic masses are noted within the kidneys bilaterally, of varying sizes, which appear relatively stable of the short interim. the masses demonstrate internal vascularity. the partially full urinary bladder has normal appearance. impression: stable bilateral hypoechoic renal masses, which are compatible with the reported history of focal bacterial nephritis. the internal vascularity argues against the formation of bilateral renal abscesses. . pa and lateral radiographs of the chest: the heart size is normal. aorta is tortuous. hilar contours are normal. there is a new nodular density near the left cardiac border. there is also consolidation within the right lower lobe. a small right pleural effusion is also noted. no pneumothorax is detected. the findings are concerning for multifocal pneumonia. . ct chest w/o contrast findings: note that presence of pulmonary embolus cannot be evaluated in this study obtained without administration of intravenous contrast. presence of severe centrilobular and paraseptal emphysematous change are more prominent in the right upper lobe where large bulla can be identified. the left lower lobe opacity suggested in the chest x-ray cannot be identified on the present ct study. small right lower lobe consolidation is associated with a small amount of right pleural effusion. a 4.6 mm lung nodule is located in left lower lobe (3:30, 4:116), that was not covered in prior abdominal cts. enlarged mediastinal lymph nodes, the largest one measuring up to 18 mm located in ap window. heart size is within normal limits. presence of coronary artery calcifications. small amount of pericardial effusion is present. aorta is normal in size and present with atherosclerotic calcifications. pulmonary artery is normal in size. presence of hiatal hernia. study was not tailored for subdiaphragmatic evaluation but note is made of heterogeneous density in the bilateral renal cortex. bone windows: there is a healed rib fracture in 10th right rib impression: 1. right lower lobe consolidation with small amount of right pleural effusion. 2. enlarged mediastinal lymph nodes, measuring up to 18 mm in ap window. 3. pericardial effusion. 4. coronary artery calcifications. 5. severe emphysema more prominent in right upper lobe. 6. 4.6 mm nodule in left lower lobe. a follow up chest ct is suggested in three months. 7. heterogeneous density noted in renal cortex bilaterally. please correlate with recent renal ultrasound. 8. hiatal hernia. . tte the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: normal global and regional biventricular systolic function. mild mitral regurgitation. moderate tricuspid regurgitation is seen. moderate pulmonary artery systolic hypertension. no vegetations found, but if clinically suggested, the absence of a vegetation by 2d echocardiography does not exclude endocarditis. . brief hospital course: #septic shock - the patient was admitted to the micu and treated with central line placement, aggressive ivf, vasopressors, and iv abx. she was hemodynamically stable for transfer to the medical floor on hd#3. blood culture grew fq-sensitive e. coli. surveillance cultures remained negative. radiological evaluation revealed severe bilateral pyelonephritis. completed a 14-day course of ciprofloxacin on . repeat mri in ~4 weeks to ensure resolution was recommended. given the possibility that the findings on u/s and mri could represent renal lymphoma, the patient may benefit from biopsy if repeat imaging does not show interval improvement with antibiotic therapy. . #c. difficile colitis - toxin assay positive on . initially started on po flagyl, switched to po vancomycin based on the recommendation of the consulting id team. will continue on oral vancomycin for 14 days beyond the completion of her antibiotic course for pneumonia. . #nosocomial pneumonia - started on empiric vancomycin and cefepime. will complete a 10 day course on . cough treated with supportive therapy. . #acute on chronic renal insufficiency - attributed to prerenal azotemia and atn in the setting of shock. creatinine improved with ivf and the patient continued to be non-oliguric. started on calcitriol for secondary hyperparathyroidism and sodium bicarbonate for non-ag metabolic acidosis. she will be seen in nephrology clinic as an outpatient. . #anemia of iron deficiency and chronic inflammation - transfused a total of 7 u prbc. low reticulocyte index consistent with a hypoproliferative anemia. the patient will likely benefit from outpatient iron supplementation and screening colonoscopy. . #hepatitis c - genotype 1, hcv viral load 8,720 iu/ml. no clinical stigmata or radiographic evidence of cirrhosis or portal hypertension. hiv and hbv viral loads were negative. will be seen in hepatology clinic as an outpatient. . #coagulopathy - attributed to decreased hepatic synthetic function and profound malnutrition. corrected only temporarily after administration of vitamin k. no evidence of dic, factor deficiency, or factor inhibitor by laboratory evaluation. heparin products were held. given protein supplements with meals. . #lll nodule - repeat chest ct recommended for . . #polysubstance abuse - the patient was given thiamine, folate, and multivitamin and monitored on a ciwa scale but did not display signs or symptoms of withdrawal. she was seen in consultation by social work but declined assistance with substance abuse issues. . #vre colonization - urine culture on with 10-100,000 cfu; as she has clinically improved and her initial organism on blood cultures was e. coli, this likely represents colonization in the setting of prolonged antibiotics vs. contamination from feces. repeat u/a on did not show signs of infection. urine cx is pending. . #chest pain - diffuse intermittent chest pain, partially reproducible with palpation. likely related to longstanding coughing and musculoskeletal discomfort, as it is exacerbated by coughing, movement, and palpation. she was comfortable on exam, often found to be sleeping after complaining of the pain. started on a low dose of ultram in the morning for relief. medications on admission: none discharge medications: 1. nicotine 7 mg/24 hr patch 24 hr sig: one (1) patch 24 hr transdermal daily (daily). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 3. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. ipratropium bromide 0.02 % solution sig: one (1) neb ih inhalation q6h (every 6 hours) as needed for sob/wheezing. 7. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed) as needed for sore throat. 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 16 days. 10. cefepime 2 gram recon soln sig: one (1) recon soln injection q24h (every 24 hours) for 2 days: last dose . 11. simethicone 80 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 12. tramadol 50 mg tablet sig: 0.5 tablet po qam (once a day (in the morning)) as needed. 13. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 14. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 15. benzonatate 100 mg capsule sig: one (1) capsule po tid (3 times a day) as needed for cough. 16. trazodone 50 mg tablet sig: 0.5-1 tablet po hs (at bedtime) as needed for insomnia. discharge disposition: extended care facility: roscommon discharge diagnosis: *)primary - bilateral pyelonephritis - eschericia coli bacteremia - clostridium difficile colitis - hospital-acquired pneumonia . *)secondary - new diagnosis of hepatitis c - coagulopathy - hypertension - history of substance abuse - possible vre colonization discharge condition: - stable discharge instructions: - please complete all courses of antibiotics - please follow-up with hepatology and with a primary care provider once you are discharged from the rehabilitation facility abdominal pain, fever, blood in your stool, nausea/vomiting, chest pain, shortness of , new or concerning symptoms followup instructions: - hepatology: , md phone: date/time: 10:30 . - with a primary care provider (pcp) 2-3 days after you are discharged from the rehabilitation facility: find-a-doc @ 1- for new pcp . - with dr. on : call to confirm procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnoses: acidosis anemia in chronic kidney disease esophageal reflux tobacco use disorder acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified chronic hepatitis c without mention of hepatic coma hyposmolality and/or hyponatremia severe sepsis alcohol abuse, unspecified cocaine abuse, unspecified chronic kidney disease, stage iii (moderate) pneumonitis due to inhalation of food or vomitus septic shock intestinal infection due to clostridium difficile infection with microorganisms without mention of resistance to multiple drugs other emphysema other diseases of lung, not elsewhere classified secondary hyperparathyroidism (of renal origin) acute diastolic heart failure septicemia due to escherichia coli [e. coli] other and unspecified coagulation defects other psoriasis diseases of tricuspid valve nutritional marasmus carrier or suspected carrier of other specified bacterial diseases acute pyelonephritis without lesion of renal medullary necrosis 

Answer: The patient is high likely exposed to