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: sepsis major surgical or invasive procedure: -endoscopic retrograde cholangiopancreatography x 3 -percutaneous transhepatic cholangiography -biliary drain placement and removal -hemodialysis -interventional radiology tunneled line hemodialysis line in the right internal jugular vein -interventional radiology placement of peripherally inserted central catheter (picc) line -mechanical ventilation history of present illness: patient is a 71 y/o female with copd, dm type ii, pud s/p gastro-jejunostomy, mild dementia, and schizophrenia who was admitted to hospital on with fever to 101 at her nursing home, decompensated heart failure with hypoxia to 85% on ra, and mat. she was complaining of sob, dysuria, abdominal pain, diarrhea, weakness, and fatigue. in the ed, she was bolused and started on diltiazem gtt for mat and diuresed with iv lasix for her chf. she was started on levaquin for +u/a. upon admission, she then became hypotensive to systolic of 70s, so her dilt gtt was d/c'ed and she was bolused with saline. she was on neo and vasopressin gtts until am. her abx were expanded to vanc/zosyn/levaquin and hydrocortisone, currently weaned to 50 q8 (despite stim of 50.7->73->67.3). she was subsequently found to have gnrs in her blood and urine cultures, as well as group b strep in urine. her course was complicated by demand ischemia with trop i peak of 0.85 and arf with creatinine peak of 2.08. . she was doing well until 48 hours ago. she was found to have increasing lfts with tuberculosis of 2.6, db 2.1, alk phos 600 though no abdominal pain. inr went from 2.1 to 6.5 on , which is now down to 1.35 after vitamin k. she had a ruq ultrasound that showed gallbladder and cbd sludge v. stone v. mass and associated intra- and extrahepatic biliary tree dilatation. "this has worsened significantly since ." pt was transferred here for gi evaluation and possible ercp given complicated anatomy. past medical history: 1. chf 2. hyperlipidemia 3. copd 4. htn 5. dm2 6. anemia 7. gastritis/pud 8. schizophrenia 9. dementia 10. dysphagia 11. urinary incontinence 12. h/o le cellulitis 13. h/o klebsiella uti 14. chronic sinusitis 15. h/o acute cholecystitis social history: patient lives at a nursing home. she was widowed. she quit smoking 2 years ago. she denies any etoh, ivdu. family history: unable to obtain physical exam: admission physical exam: general appearance: no acute distress, overweight / obese, diaphoretic eyes / conjunctiva: perrl, sluggish head, ears, nose, throat: normocephalic lymphatic: cervical wnl, supraclavicular wnl cardiovascular: (s1: normal), (s2: normal), tachy peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (breath sounds: crackles : coarse bilaterally) abdominal: soft, bowel sounds present, tender: inconsistent extremities: right lower extremity edema: trace, left lower extremity edema: trace, venous stasis changes skin: warm neurologic: no(t) attentive, no(t) follows simple commands, responds to: verbal stimuli, oriented (to): , , --, movement: not assessed, tone: not assessed . discharge physical exam: gen: elderly female lying in bed in nad. mental status: able to count 10 to 1 backwards. can respond to questions appropriately. very alert. alert to year and person. breathing comfortably. neck: rt ij dialysis catheter in place without erythema. clean, dry and intact dressing at site. heent: peerl, sclera anicteric, op clear cv: tachycardic. regular rhythm. normal rate, no mrg pulm: coarse breath sounds. clear to auscultation bilatearlly. no ronchi, wheezing or crackles. abd: +bs, obese, soft. distended with umbilical hernia. mild tenderness in abdomen. limbs: 2+ edema present in right arm, legs with trace edema bilaterally improving. neuro: alert to person, place, not time. can interact and answer simple questions. poor concentration. able to follow simple commands. can count back from 10 to 1. pertinent results: admission labs: 10:40pm wbc-16.3* rbc-3.52* hgb-9.4* hct-30.1* mcv-85 mch-26.7* mchc-31.3 rdw-17.1* 10:40pm neuts-87* bands-5 lymphs-3* monos-3 eos-0 basos-0 atyps-1* metas-1* myelos-0 10:40pm plt smr-normal plt count-200 10:40pm glucose-131* urea n-34* creat-1.3* sodium-139 potassium-3.5 chloride-110* total co2-20* anion gap-13 10:40pm calcium-7.9* phosphate-2.1* magnesium-2.3 10:40pm alt(sgpt)-34 ast(sgot)-42* alk phos-479* tot bili-3.4* 11:27pm lactate-1.7 10:40pm pt-12.8 ptt-32.4 inr(pt)-1.1 11:27pm type-art po2-71* pco2-35 ph-7.38 total co2-22 base xs--3 ---------------- : ruq ultrasound impression: 1. intra- and extra-hepatic biliary dilatation with common duct measuring up to 2.8 cm. 2. pneumobilia, compatible with recent history of ercp. 3. multiple stones, air and gallbladder wall thickening, with pericholecystic fluid. changes may be secondary to ercp, however, ct is recommended for further assessment. 4. marked splenomegaly. 5. moderate ascites. . ct abd/pelvis impression: 1. markedly dilated biliary tree, with the cbd measuring up to 2.2 cm, with a large impacted stone. an underlying infectious process such as cholangitis cannot be excluded, and is the most likely septic source. 2. the biliary stent has migrated into the duodenum or proximal jejunum. 3. moderate ascites. 4. nondilated gallbladder with air and sludge and/or old contrast. 5. no evidence of bowel obstruction or perforation. 6. right inferior and superior minimally-displaced rami fractures of unknown chronicity, with evidence of healing. . echocardiogram: the left atrium is dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: no vegetation or abscess seen (cannot exclude). mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. a focal wall motion abnormality cannot be excluded. mild to moderate mitral regurgitation, trace aortic regurgitation. , ct of the chest/abdomen/pelvis impression: 1. improved biliary dilatation with residual hyupodense areas in the left lobe which are not well defined or delineated. if clinically indicated, ultrasound could be considered since these could represent small fluid collections in the left lobe. 2. focal pulmonary opacities suggesting multifocal pneumonia. 3. increased ascites. 4. prior pelvic fractures. abdominal ultrasound, : 1. no evidence of hepatic abscess. 2. gallbladder stones and sludge with cbd stent and mild extrahepatic biliary dilatation; no intrahepatic biliary dilatation. 3. ascites. brief hospital course: *** see attending d/c letter for attending note: following is by dr. a/p: pt is a 75 yo female with history of chf, copd, dm2, schizophrenia who presented with e. coli sepsis, requiring vasopressors initially, transfered to for ercp given increasing total bilirubin. . # severe septic shock from vre cholangitis/bacteremia: the source of the vancomycin enterococcus bacteremia was likely biliary. pt had an ercp on to work-up the common bile duct obstruction seen on the ruq ultrasound from the osh. ercp showed multiple stones, ranging in size from 8 mm to 15 mm, that were causing partial obstruction of the common bile duct. there was also post-obstructive dilation with the cbd measuring 20mm and dilation of the intrahepatic biliary tree; the stone was not extracted on this occasion. a 7cm by 7fr cotton biliary stent was placed successfully to establish effective biliary drainage, which later become dislodaged and was removed. after her ercp, she was become septic again, requiring levophed (which was switched to neo given svt), and abx were broadened to vanc and meropenam. blood cultures from later grew vre, and she was switched from vanc to linezolid. ct abdomen suggested cholangitis. surgery was consulted. she went to ir for ptc drain on , which was later switched for a larger drain, 10 french, given her thick bile. the drain needed to be revised multiple times for biliary sludging. she needed at 50 cc/day of biliary draining and climbed to 400 cc/day, likely representing obstruction of the drain. since the biliary drain was not a longterm option, she underwent ercp on for stone extraction, sphincteroplasty, and sphincteromy. she tolerated the procedure well and her biliary drain was removed. post-procedure, the patient had mild abdominal pain to palpation with a normal lipase. she was able to tolerate a regular diet. she will be continued on cipro/flagy post-procedure for 1 day after discharge. she does not need ercp followup. . # acute renal failure leading to end-stage renal disease: pt developed anuric acute kidney injury, likely from acute tubular necrosis during hypotensive episodes due to sepsis. the patient was started on cvvh in the intensive care unit and then switched to ultrafiltration on the medicine floor to remove volume. she converted over to hemodialysis while on the floor. overall, her volume status has greatly improved. there were initially signs of renal recovery, however, the patient still needs dialysis. furosemide 160 mg was tried to remove fluid on non-dialysis days, however, it was unsuccessful. she was continued on dialysis on a schedule of monday, wednesday, and friday. . # anasarca: the patient developed anasarca due to fluid boluses, acute exacerbation of diastolic heart failure, and poor po intake. she underwent dialysis for fluid removal. her po intake increased and her albumin has beeen improving. she had significant le edema which has resolved. she continues to have upper extremity edema bilaterally. she underwent an ultrasound of her right arm which was negative for dvt (she remained anticoagulated on heparin sc during her hospitalization) . # diabetes mellitus type ii: pt was moderately controlled on insulin ss. her home glyburide was held. her glucose has been ranging from 150-200. as she increases her po intake, she might need lantus at night. in addition, can also consider starting on oral medications. . # normocytic anemia: the patient developed a normocytic anemia while in the hospital. she presented with a hematocrit of 30.1 which trended down to 23.0. she was pan-scanned to rule out any bleed and it showed no evidence of bleeding. her labs did not show any hemolysis. her anemia was likely related to iron deficiency and bone marrow suppression in the face of multiple medical issues. she required 2 units of blood to be transfused during her hospitalization. on the last week before discharge, the patient's hematocrit remained stable and she did not need any transfusions. . # severe septic shock from e. coli urinary tract infection/bacteremia: pt was found to be in septic shock at osh with e. coli in blood and urine. at the osh, pt was treated wtih vanc/zoysn, which was transitioned to ctx on arrival here. she was later switched to linezolid and meropenem and cleared her blood cultures. . # diarrhea: the patient developed diarrhea while in the hospital. multiple c diff tests and stool cultures were negative. her diarrhea most likely relates to medication side effect vs. bacterial overgrowth. if she continues to have massive amounts of diarrhea, requiring a rectal tube, she should be further evaluated. she was started on loperamide on to slow its progression. the patient had a flexiseal placed on . . # atrial fibrillation/flutter: the patient was noted to have an episode of tachyarrhthmia on the morning of to 200s, which broke with carotid massage. levophed was changed to neo in the evening, she had recurrent svt initially to 200s, which came down to 150s with carotid massage. at the time, adenosine showed underlying atrial flutter. she remained hemodynamically stable during these tachycardic events. she received dilt x 2 without change and was thus started on amoidarone. she was loaded with amiodarone and continued on a maintainence dose of 200 mg daily. she remains on aspirin for anticoagulation. she would benefit from coumadin, though this decision will be deferred to outpatient where she will be more stable. aspirin was stopped after her ercp procedure and should be started on . . # hypoactive delirium: the patient developed a hypoactive delirium while in the intensive care unit. the initial etiologies were due to toxic/metabolic effects, use of sedatives during intubation and renal/hepatic failure. a head ct was negative for intracranial bleed. she was started on cvvh in the icu. her increased transaminases were likely due to cholangitis/liver congestion. she was initially on rifaxamin and lactulose for treatment of hepatic encephalopaty (had elevated ammonia), but it was stopped. with treatment of her underlying disease processes and orientation, the patient became more alert. she was able to count from 10 to 1 backwards and alert to person and place. she was interactive, though does not realize the full extent of her disease. her home celexa, trazodone and trifluphenazine were held since they can alter mental status. . # multifocal pneumonia: the patient was found to have a multifocal pneumonia with stable hemodynamics. she completed a ten day course of vancomycin and zosyn. . # chronic obstructive pulmonary disease: the patient was on high dose steroids during her stay in the icu. the patient was transferred to the floor and developed increasing respiratory distress on . she was transferred to the icu and started on high dose steroids and nebulizers for treatment of copd exacerbation. she was quickly tapered off of her steroids and her last day was . she was continued on albuterol/ipratropium nebulizers and had no signs of respiratory distress. . # hypoxic and hypercapneic respiratory failure: pt was electively intubated for ercp and remained intubated afterwards for somnolence. she was extubated and did not need further intubation. she developed acute respiratory distress on while on the medical floor. she was transferred to the icu where she was diuresed, started on treatment for copd, and started on antibiotics for hospital acquired pneumonia. she was transferred back to the floors without any respiratory distress. she continues to be fluid overloaded, which likely causes increased shortness of breath. at rest, she does not need oxygen. . #pancytopenia: while on linezolid, the patient developed anemia, thrombocytopenia, and leukopenia. the pancytopenia was likely multifactorial and related to linezolid, other medications and infection. as the patient became more stable, her thrombocytopenia and leukopenia resolved. she still has an anemia. . # schizophrenia: abilify was initially held for her altered mental status and started once the patient's mental status became clear. her home trifluphenazine and celexa were held on discharge. if warranted, she can start these medications as an outpatient. . # stage ii sacral ulcer: patient has a sacral ulcer. wound care was provided to the area. . # vaginal/inguinal candiasis: the patient developed candiasis while on antibiotics. she received one dose of fluconazole on and it improved. she was continued on topical antifungals . # gastritis/peptic ulcer disease: on lansoprazole. no signs of active bleeding or gastritis. . contact: daughter (hcp) (work) (home) outpatient followup: 1. as an outpatient, might need anticoagulation with coumadin for atrial fibrillation 2. diabetes: will likely need lantus based on insulin needs 3. diarrhea: consider further workup. flexiseal placed on 4. aspirin: 81 mg daily should be started on 5. antibiotics: the patient will need iv antibiotics for one day after discharge medications on admission: home medications: captopril 50 mg q8 glyburide 10 mg daily neurontin 300 mg q8 trifluoperazine 5 mg daily abilify 20 mg daily celexa 30 mg daily trazodone 100 mg qhs omeprazole 20 mg daily zantac 300 mg daily beclomethasone diproprionate hfa 40 mcg inh daily zyrtec 10 mg daily spiriva 18 mcg inh daily advair 100/50 mcg ferrous sulfate 325 mg daily vitamin d 50,000 units q friday . transfer medications: zosyn 2.25 gm iv q6 (day 5) vancomycin 250 mg iv q24 hr (day 5) levaquin 750 mg q48 hr (day 5) hydrocortisone 50 mg q8 protonix 40 mg daily iv abilify 20 mg daily stelazine 5 mg daily neurontin 300 q8 mg celexa 20 mg daily tylneol 650 mg daily zyrtec 10 mg daily becloven 1 puff daily advair 100/50 1 puff detrol la 4 mg qhs vitamin k 10 mg daily iron 325 mg daily humalog iss spiriva 18 mcg daily discharge medications: 1. ferrous sulfate 300 mg (60 mg iron) tablet : one (1) tablet po daily (daily). 2. heparin (porcine) 5,000 unit/ml solution : one (1) ml injection tid (3 times a day). 3. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed for rash. 4. aripiprazole 20 mg tablet : one (1) tablet po once a day. 5. beclomethasone dipropionate 40 mcg/actuation aerosol : one (1) spray inhalation once a day. 6. fluticasone-salmeterol 100-50 mcg/dose disk with device : one (1) disk with device inhalation (2 times a day). 7. nystatin 100,000 unit/g cream : one (1) appl topical (2 times a day) as needed for yeast infection. 8. ipratropium bromide 0.02 % solution : one (1) nebulizer inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) nebulizer inhalation every 4-6 hours as needed for shortness of breath or wheezing: mix with ipratropium. 10. b complex-vitamin c-folic acid 1 mg capsule : one (1) cap po daily (daily). 11. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr po bid (2 times a day). 12. amiodarone 200 mg tablet : one (1) tablet po daily (daily). 13. spiriva with handihaler 18 mcg capsule, w/inhalation device : one (1) inhaler inhalation once a day. 14. vitamin d 50,000 unit capsule : one (1) capsule po once a week. 15. loperamide 2 mg capsule : one (1) capsule po bid:prn as needed for constipation. 16. insulin lispro 100 unit/ml solution : see sliding scale subcutaneous asdir (as directed). 17. ciprofloxacin in d5w 400 mg/200 ml piggyback : four hundred (400) mg intravenous q24h (every 24 hours) for 1 days. 18. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback : five hundred (500) mg intravenous q8h (every 8 hours) for 4 doses. discharge disposition: extended care facility: - discharge diagnosis: primary: -choledocolithiasis complicated by cholangitis -sepsis due to e. coli and vancomycin resistant enterococcus bacteremia -acute oliguric renal failure needing dialysis -hypoactive delirium -respiratory failure requiring intubation and mechanical ventilation . secondary -type ii diabetes mellitus -hypertension -schizophrenia -normocytic anemia -diarrhea discharge condition: mental status:clear and coherent (poor attention span, can count from 10 to 1 backwards) level of consciousness:alert and interactive activity status:bedbound discharge instructions: dear mrs. , . you were had fevers and you were transferred here for an ercp. you had an infection in your bile ducts. one gallstone was too large to be removed and an external drain was placed to drain the bile. it was later removed. you were very sick and had to be in the intensive care unit with breathing help from a ventilator and medicines to maintain your blood pressure and dialysis. fortunately, you improved on antibiotics. . you developed multiple problems while in the hospital. you had infectious complications of pneumonia and sepsis. your kidneys failed during your low blood pressure states and you continue to need dialysis. you became confused which seemed to clear. . your medications have changed: -stop captopril -stop glyburide -stop neurontin -stop trifluoperazine -stop celexa -stop trazodone -stop zantac -start albuterol and ipratropium nebulizers -start cipro and flagyl (antibiotics) -start antifungal creams and powders -start lansoprazole -start nephrocaps followup instructions: you do not need followup with the ercp team. you should followup with your primary care doctor after rehab. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis endoscopic removal of stone(s) from biliary tract endoscopic sphincterotomy and papillotomy arterial catheterization endoscopic insertion of stent (tube) into bile duct removal of t-tube, other bile duct tube, or liver tube removal of t-tube, other bile duct tube, or liver tube other cholangiogram other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract percutaneous hepatic cholangiogram percutaneous hepatic cholangiogram replacement of stent (tube) in biliary or pancreatic duct injection or infusion of oxazolidinone class of antibiotics pancreatic sphincteroplasty diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified end stage renal disease anemia, unspecified mitral valve disorders acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis acute on chronic diastolic heart failure other chronic pulmonary heart diseases personal history of tobacco use atrial flutter other persistent mental disorders due to conditions classified elsewhere other and unspecified hyperlipidemia acute respiratory failure other specified cardiac dysrhythmias septic shock morbid obesity pressure ulcer, lower back other ascites diarrhea accidents occurring in residential institution streptococcal septicemia cholangitis other and unspecified coagulation defects other specified antibiotics causing adverse effects in therapeutic use delirium due to conditions classified elsewhere candidiasis of skin and nails peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction pressure ulcer, stage ii nutritional marasmus calculus of bile duct without mention of cholecystitis, with obstruction unspecified schizophrenia, chronic other specified aplastic anemias 

Answer: The patient is high likely exposed to