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: sepsis major surgical or invasive procedure: ercp picc line placement history of present illness: 83 year old female with a history of biliary obstruction due to tumor with metal stents presenting to an osh on with an episode of weakness/incontinence found to have polymicrobial bacteremia/sepsis. the patient was treated for a uti on with macrobid. on she was being assisted to the bathroom by her husband and became acutely weak and incontinent of urine. she was taken to the osh ed where she had a fever of 104 and a sbp in the 70s (per report). full ros at osh was negative. patient does not remember the episode and cannot provide further history at this time. no discharge summary or hospital course was provided by the osh. from the provided data, her blood cultures from the osh are positive for e. coli, klebsiella a 3rd gnr and gpc. she was treated initially with levofloxacin, but changed to imipenim and gentamicin with improvement in her clinical status. a ct of the abdomen demonstrated persistent biliary dilatation concerning for stent obstruction. there were also questionable liver lesions with decreased enhancement surrounded by increased enhancement concerning for abscess. she also developed af with rvr necessitating a diltiazem gtt. the patient was transferred to on for ercp evaluation of her metal biliary stents given ct findings. she is afebrile and clinically stable on transfer. currently, she complains of irritation by the foley, but denies headache, blurry vision, dry mouth, thirst, difficulty/pain with swallowing, chest pain, shortness of breath, palpitations, nausea, heartburn, vomiting, abdominal pain, diarrhea, constipation (though notes no bm in 1 week), new weakness, numbness or tingling. past medical history: -biliary obstruction/malignant stricture s/p ercp x 2 and 2 metal stents--last placed in . thought to be cholangiocarcinoma, no clear pathologic diagnosis made. by report, evaluated by surgical team, thought not to be a surgical candidate. -diabetes mellitus, type 2 -hypertension -coronary artery disease -parkinson's disease -diastolic chf -vaginal carcinoma -s/p cholecystectomy -urosepsis d/t e. coli and proteus -bacteremia due to vre in treated with 2 week course of linezolid -bacteremia due to e. coli in treated with 2 week course of ceftriaxone. -atrial fibrillation -hyperlipidemia social history: lives with husband in no children. dependent for adls--has vna and husband cares for her, no tobacco or drugs, occassional alcohol. retired tax examiner for the state. family history: mother died of heart disease physical exam: vs: 98.3 136/63 p67 r20 99ra gen: elderly female, non-toxic. heent: perrl, op clear, mmm neck: no jvp car: rrr. no mrg. resp: cta-ant/lat abd: soft, nontender, nondistended + bs ext: + le edema b. neuro: cn ii-xii intact. masked facies. non-focal. skin: warm/well perfused, several dry patches, no rash, no jaundice. area l hip bandaged for superficial pressure ulcer. pertinent results: admission labs: 06:04pm wbc-25.6*# rbc-4.26 hgb-11.5* hct-35.4* mcv-83 mch-27.1 mchc-32.6 rdw-17.7* 06:04pm neuts-91.3* lymphs-6.0* monos-2.5 eos-0 basos-0.1 06:04pm plt count-120*# 06:04pm pt-14.0* ptt-20.6* inr(pt)-1.2* 06:04pm alt(sgpt)-8 ast(sgot)-27 ld(ldh)-152 alk phos-139* tot bili-1.1 06:04pm glucose-111* urea n-36* creat-0.8 sodium-142 potassium-4.4 chloride-110* total co2-25 anion gap-11 06:04pm albumin-2.8* calcium-9.8 phosphate-2.7 magnesium-1.9 osh (-) labs wbc 26.6(87p,8b)->33.7(84p,6b)->30.1(87p,7b)->25.2 hct 37.6->28.7->30.5->31.8 plt 245->201->109->93 pt/inr () 11.4/1.1 cr 1.44->1.32->1.08->0.75 alb 1.9 tuberculosis 1.9->1.5->1.2 ap 198->134->128 ast 46->35->30 alt <5->24->7 tni 0.12 () bnp 733 ()->1508 () ua: neg le, neg nit, 1+ gluc, trace acetone, 1.015 osh micro: : blood culture-e. coli (amp r, cipro r, augmentin, aztreonam, cefazolin, cefoxitin, ceftriaxone, fent, imipenem, zosyn) : urine culture-negative : blood cluture: k. pneumonia, other gnr : blood culture: gnr, gpc : blood culture: gpc : sputum culture: yeast osh studies: 1. cxr: vascular congestion in right upper lung, unchanged since without active lung disease. 2. ct abd/pelvis (): double biliary stent catheter in place with evidence of continued biliary obstruction throught the liver--not improved. liver shows areas of decreased enhancement in posterior right lobe and in the anterior left lobe with no definite mass effect seen suspicious for possibility of infections at that site. in the anteriormost portion of the left lobe, a low area of decreased enhancement surrounded by increaseed enhancement extend over a diameter of 2 cm which could represent early formation of an abscess even though no clear-cut abscess is definitely identified. spleen is unremarkable. large amount of retained stools in rectum compatible with fecal impaction. 3. ct head without contrast: no actue abnormality identified, sinus disease and left mastoiditis. small vessel disease ecgs: : sinus tachycardia at 112 bpm with pacs, twi in iii, no st changes. q waves in ii/iii/avf : nsr, axis change from : af with rvr, maintained axis change from : nsr, normal axis (same as ), normal intervals, twi v1-v4 (new), biphasic t waves v5-v6, poor baseline d/t parkinson's tremor but otherwise, no st changes. . cardiac echo : impression: normal left and right ventricular systolic function. mild mitral regurgitation. evidence of elevated left sided filling pressures. . ercp : biliary tree: there were multiple filling defect that appeared like sludge in the upper third of the common bile duct, right main hepatic duct and left main hepatic duct,within the metallic wallstents. procedures: multiple stone fragments and sludge were extracted successfully using a 11 mm balloon. impression: stent obstruction by stones and sludge was found - stents were dredged using a balloon. (stone extraction) . cxr for picc placement: portable upright chest radiograph: the left picc terminates over the mid right atrium and can be pulled back 4 to 5 cm to the lower svc. the nasogastric tube has been removed. the cardiomediastinal is stable and within normal limits. the lungs are clear. . le dopplers : impression: 1. no dvt of the right lower extremity. 2. probable thrombus of a deep vein of the left calf, likely one of the paired posterior tibial veins. . ct abd : impression: 1. intrahepatic biliary ductal dilatation with peri-biliary enhancement consistent with cholangitis. anteriorly in the left lobe, multiple hypodense collections with enhancing rims, consistent with multiple abscesses. the largest measures approximately 2 cm and may be amenable to percutaneous sampling if desired, but is not likely amenable to catheter drainage at its present size. 2. vague region of parenchymal enhancement at the apex of dilated ducts could represent obstructive tumor mass, but its margins are difficult to define. 3. interval increase in small bilateral pleural effusions, small pericardial effusion, and small amount of ascites. 4. interval increase in size of enhancing pericardial lymph node. 5. evidence of thrombosis of the posterior right portal vein, resulting in heterogeneous perfusion of the posterior right lobe of the liver. 6. 9-mm pancreatic hypodensity, not previously visualized. while it is too small to characterize, findings suggest a cystic lesion such as a dilated side branch or an isolated cystic lesion. if desired, this can be further evaluated with mrcp. . micro: clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. . blood culture (multiple bottles): enterococcus faecium | ampicillin------------ =>32 r linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ =>32 r . blood cultures : continued positive with above. blood cultures : results still pending; please follow up final results. . urine culture: negative mrsa screen: negative . discharge labs: wbc 11.3 hgb 9.8 hct 29 plt 340 na 142 k 3.9 cl 105 hco3 32 bun 7 cr 0.5 glu 84 pt 20 ptt 38.5 inr 1.9 . cpk 10 ast 26 alt 6 alkph 135 tuberculosis 1.4 brief hospital course: 83 year old female with history of biliary obstruction, polymicrobial bacteremia from cholangitis presented with biliary sepsis. patient was transferred from in , ma. . # sepsis/biliary obstruction/liver abscesses: at the osh she was hypotensive with leukocytosis and polymicrobial bacteremia, with e. coli, klebsiella, gpc, and vre from blood cultures. had negative ua/urine culture and cxr for pneumonia. source is biliary, with additional concern for liver abscess on ct scan. culture data was faxed from the osh and showed: 1) enterococcus sensitive to gent and streptomycin, 2) e.coli sensitive to gent, imipenem, and cephalosporins, and 3) klebsiella pansensitive except to amp. on transfer to the floor from , she was transitioned to linezolid and gentamicin alone. . the repeat ct abd/pelvis showed multiple abscesses in the liver adjacent to where the stents are placed in the anterior portion of the left lobe. the largest collection is 1.5 cm; additionally there are a couple of subcm foci. also seen is intrahepatic ductal dilation/cholangitis. the radiologist also suspects a mass centrally at the porta hepatis as intrahepatic ductal dilation is present (but no mass is visualized). per radiology none of the collections would be amenable to drainage. she underwent ercp on and had both sides of her stents flushed with sludge removed. . id was consulted, and antibiotics were changed from linezolid and gent to ceftriaxone and daptomycin on due to the duration of treatment that will be required. patient will follow up with clinic and have repeat imaging of her liver to ensure clearance of infection/abscesses. **she will also need weekly lab monitoring on daptomycin:** cbc, lft's, cpk, bun/cr please fax results to dr. of infectious disease at . at the time of discharge, several blood cultures remain pending, please follow up final results. . # diarrhea patient was noted to have ongoing loose stools for which patient has a flexiseal. patient has been tested and resulted c-diff negative x 1. . # cholangiocarcinoma: discussion with family to clarify goals of care revealed that patient is not planning on surgery or chemo/xrt given extremely poor prognosis of cancer. . # atrial fibrillation: paroxysmal. she was continued on digoxin. the patient has remained in normal sinus rhythm. chads score is 4, and she was placed on lovenox with transition to coumadin. - resumed lovenox s/p picc placement for coumadin bridge - inr 1.9 at time of discharge - coumadin dosing: 5 mg po q 1600 since . please follow inr and titrate coumadin dosing as appropriate. . # left lower extremity dvt: the patient was noted to have right>left lower extremity swelling so lower extremity dopplers were obtained which showed a probable thrombus of a deep vein of the left calf, likely one of the paired posterior tibial veins. the patient was started on a heparin gtt with a goal ptt of 50-70, and then transitioned to lovenox/coumadin. - on lovenox/coumadin . # diastolic chf/ecg changes: the patient had a positive single troponin value at the osh and 2 measured/elevated bnp levels. has le edema and is on chronic lasix at home. ecg from to demonstrated a change in axis and co-incides with chills/rigors/shortness of breath noted in one of the consultant notes. ecg here with new twi v1-v4 and maintainance of new axis since --cycled enzymes; trp 0.05 but ck-mb remained negative. she was continued on aspirin and a statin. a tte was obtained which showed an ef of >55%, but elevated pcwp. - currently appears euvolemic and bun/cr stable - restarted lasix . # concern for aspiration: there was concern that the patient aspirated her pm meds so her meds were changed to iv and speech and swallow c/s was requested. she had an ngt placed, which she self-d/c'd. she remained npo until when speech and swallow cleared patient for modified diet. s+s recommendations: regular diabetic/consistent carbohydrate consistency: ground; nectar prethickened liquids 1. po intake of nectar thick liquids and ground solids. 2. pills crushed with puree. 3. 1:1 supervision with all pos. 4. continue q8 oral care. . # parkinson's disease: she was continued on sinemet. . . code: dnr/dni access: picc dispo: d/c'd to center, . medications on admission: medications at home: simvastatin 10 mg daily, lasix 40 mg daily, omeprazole 40 mg daily, albuterol 2 puffs/4x day, singulair 10 mg daily, mvi, prazosin 2 mg , mirapex 0.375 mg tid, carbidopa/levodopa 25/100 mg three times per day medications at transfer from rehab: albuterol neb q4h, ssi, lovenox, protonix 40 mg iv daily, simvastatin 10 mg qhs, singulair 10 mg daily, mvi, aspirin 81 mg daily, gentamicin 120 mg iv daily since , nystatin, imipenim/cilastin 250 mg iv q6h, pramipexole 0.375 mg tid, sinemet 25/100 mg three times/day, digoxin 0.25 mg iv q4h x 4 doses (received x 4), vancomycin 1 gm iv q24h, digoxin 0.125 mg po daily, propafenone. diltiazem gtt stopped at 12 am. phenylephrine ordered, unclear if received. discharge medications: 1. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po tid (3 times a day). 2. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed. 4. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 5. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 6. ipratropium bromide 0.02 % solution sig: one (1) nebs inhalation q6h (every 6 hours) as needed for wheezing. 7. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 9. enoxaparin 80 mg/0.8 ml syringe sig: one (1) inj subcutaneous q12h (every 12 hours) for until inr >2 days. 10. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: please follow inr and titrate dose accordingly. 11. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 12. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 13. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 14. ceftriaxone 1 g iv q24h start: in am 15. daptomycin 500 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours). 16. insulin regular human 100 unit/ml solution sig: one (1) per sliding scale injection asdir (as directed). discharge disposition: extended care facility: center discharge diagnosis: # biliary sepsis # biliary obstruction # liver abscesses # cholangiocarcinoma # paroxysmal atrial fibrillation # left lower extremity dvt # chronic diastolic chf # parkinson's disease discharge condition: stable discharge instructions: please seek medical attention if you develop fevers, chills, changes in mental status, abdominal pain, or any other concerns. followup instructions: please continue to take antibiotics as prescribed. you will need to follow up with infectious disease doctors and have repeat imaging to determine the total duration of antibiotics. . patient will need weekly lab monitoring on daptomycin: cbc, lft's, cpk, bun/cr please fax results to dr. of infectious disease at . . appointment: provider: , md phone: date/time: 10:00 procedure: venous catheterization, not elsewhere classified endoscopic removal of stone(s) from biliary tract injection or infusion of oxazolidinone class of antibiotics diagnoses: thrombocytopenia, unspecified congestive heart failure, unspecified severe sepsis atrial fibrillation paralysis agitans other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure abscess of liver mechanical complication due to other implant and internal device, not elsewhere classified accidents occurring in other specified places streptococcal septicemia cholangitis chronic diastolic heart failure personal history of malignant neoplasm of other female genital organs pressure ulcer, stage ii calculus of bile duct without mention of cholecystitis, with obstruction malignant neoplasm of intrahepatic bile ducts pressure ulcer, hip 

Answer: The patient is high likely exposed to