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: transverse ca major surgical or invasive procedure: s/p transverse colectomy s/p ex lap, r colectomy, end ileostomy, hartmann's procedure s/p perc chole placement, drainage of subhepatic fluid collection extubated r pleural eff tap history of present illness: this was a 54-year-old woman with a several month history of intermittent hematochezia. a preoperative colonoscopy demonstrated an ulcerated mass in the mid transverse . biopsies demonstrated adenocarcinoma of uncertain depth. the patient had a substantial history of alcohol ingestion with an enlarged liver on physical examination. her preoperative liver function tests were significant only for mild elevation of her transaminases. her cea was 4.5. a preoperative ct scan of the torso demonstrated no evidence of metastasis. she did not have any findings suggestive of portal hypertension. she had no ascites or carcinomatosis. resection of her tumor was advised and accepted. past medical history: ca, oa of multiple joints, varicose veins, pad, leg cramps, emphysema, etoh fatty liver social history: smoker 44 pack years, etoh 12 pack per day 3x per week family history: maternal uncle and aunt with cancer physical exam: at d/c: gen: a and o x 2 person and place v.s: 98.6, 100, 141/79, 20, 93% 4l cv: tachycardia no m/r/g resp: faint wheezing, bilat crackles at bases abd: soft, tender at incision site, nd, stoma beefy red wound: abd, open surgical wound packed w-d. pertinent results: 07:05am blood wbc-8.1 rbc-3.16* hgb-9.9* hct-30.7* mcv-97 mch-31.3 mchc-32.2 rdw-20.2* plt ct-314 08:00am blood neuts-82* bands-0 lymphs-8* monos-7 eos-3 baso-0 atyps-0 metas-0 myelos-0 08:00am blood hypochr-1+ anisocy-2+ poiklo-normal macrocy-2+ microcy-normal polychr-occasional 07:05am blood plt ct-314 05:40am blood glucose-105 urean-3* creat-0.3* na-140 k-3.9 cl-101 hco3-31 angap-12 10:05am blood ck(cpk)-15* 10:05am blood ck-mb-3 ctropnt-0.01 05:40am blood calcium-8.2* phos-3.5 mg-1.7 05:12am blood albumin-3.4 calcium-9.1 phos-4.3 mg-2.4 04:06am blood free t4-0.90* 03:35pm pleural wbc-465* rbc-685* polys-13* lymphs-66* monos-5* eos-4* baso-1* meso-3* macro-1* other-7* 03:35pm pleural totprot-2.6 glucose-106 ld(ldh)-98 albumin-1.1 03:13pm ascites totpro-2.9 glucose-13 ld(ldh)-2170 . micro sputum: 1+ gpc, 1+ gnr - oropharyngeal flora bcx: no growth intra op cx: 4+gnr, 2+gpr, 1+gpc, cx e.coli, klebseilla-ciprosens bcx: no growth mrsa: negative 3/14,, bcx: no growth respcx: now growth wound cx: ecoli - pan subhepatic fluid ecoli - pan pleural fluid: 2+ poly, ngtd stool: c. diff positive, vre . torso ct scan: no pe, moderate bilateral pleural effusions, s/p transverse colectomy, with apparently intact anastomotic site and no large fluid collection around anastomotic site, increasing pneumoperitoneum, no evidence of obstruction or breakdown at the anastomotic site. ct abd/pelvis: rectal contrast was fills long hartmann pouch, suboptimally filling the apical region. no extravasation of contrast, though extraluminal air adjacent to the suture at the apex of the pouch has increased since , raising concern for a leak at the apex of the pouch. unchanged bilateral pleural effusions, there has been a very mild increase in fluid in the lesser sac. fluid anterior to the left lobe of liver is decreased since . ct thorax: moderate size simple bliateral effusions with associated compressive atelectasis, slightly decreased from prior. no evidence for loculations. . ct abd: contrast filling the hartmann's pouch, without definite evidence of extraluminal contrast, however, persistent air and stranding, unchanged from prior study is still noted. . b/l leni: no dvt . cxr: moderate bilateral pleural effusions larger on the left side and associated with atelectasis are unchanged. there is no pulmonary edema. cardiomediastinal contours are unchanged. there is no pneumothorax. brief hospital course: on a transverse colectomy was performed without complication. on pod#1 noted to have hct drop from 25 to 20, requiring 4uprbcs on pod#1 to pod#2. on pod#2, pt became sob, which was worse lying completely flat, and kept her from taking deep breaths. patient had increasing o2 requirement, cxr showed edema, no diuresis was done. pt also admits cough w/ occasional sputum -clear, and fevers/chills. on pod#3 (day of transfer to icu), respiratory distress worsened with increasing o2 requirements to nc and face mask to keep sats >95%. a ct of torso performed, (-) for pe, (+) pneumoperitoneum without limitated extravasation of contrast, thought likely small performation that had sealed off. patient given 20mg iv lasix for diuresis, initiated transfer to . vital signs prior to transfer: t99 (was 101.1 1hr prior to transfer), 105, 120s/70, rr24, 98% 8l, access 2pivs. . 54yof pod #3 from transverse colectomy, hx pad, emphysema, ethanol abuse, transferred for hypoxemic respiratory failure. . in the icu: 1. hypoxemic respiratory failure- started pod#2, with hypoxia on nc. ddx includes pe, but cta is negative and pt is on sqh. pt may have become fluid overloaded s/p 4u prbc. pt shows moderate pleural effusions that were not present on the ct scan on . trali syndrome also a possiblity, which has been known to occur upto 6 hours after blood transfusion. infection unlikely w/o wbc and infiltrate on ct. pt also shows atalectasis that may be contributing. - o2 on nc/facemask - check serial abgs - bnp and echo . 2. pt??????s hr 130s, in sinus tach on ekg. also pt??????s bp dropped to 80/60. - bolus with imporvement . # leukopenia- may show early sepsis. pt beginning to become hypotensive, . # pneumoperitoneum- surgery. - vanco/zosyn - serial lactates - serial abd exams . # etoh withdrawl - valium 5 q4, ciwa >10 . # copd- none at home - alb/ipratrop nebs ___________________________________________ anastomotic bleed then leak >> returned to or for ex lap, r colectomy, end ileostomy, hartmann's procedure - pt given colloid- albumin 25g after uop near 30-40cc, w/o signifcant change - restarted vasopresin, then later levophed - f/u hct 25.6 stable ______________________________________ - u/o excellent with lasix 10 iv - off pressors - goal u/o per is 100cc/h, redose lasix when u/o drops below 100cc/h - ngt in right place _________________________________________ - diuresed - tachypneic - checked abg _________________________________________ - pt was not on pressure support of 12, stayed on 15, when turned down to 12 (around mn)pt's rr incr 40s. pt also became agitated and given sedative, and needed to be on assist, now back on pressure support at 15. - lasix 10mg iv x1 tapered off around 10pm, given lasix 20mg iv x1 around 10pm. at 6am pt was -1.2l and given another 10 iv lasix at 6am - swab from fluid- speciation back: growing e.coli, klebsiella - pan-sensitive - tbili coming down ________________________________________ - started lasix gtt because the pt was hypotensive this am in the setting of sedation and bolused lasix - got 50ml albumin for hypotension - started fentanyl gtt in order to get the pt off benzos as there is some concern for worsening ms in the setting of versed ________________________________________ - repeatedly febrile, although bp and hr stable. - resited cvl to r ij as site appeared erythematous and not fully covered by dressing. line sent for culture - surgery opened surgical site and drained some purulent material. - considered thoracentesis but held off given other potential etiologies. - diuresing well, pm lytes stable ________________________________________ - around 4pm pt became febrile to 101.2 and tachycardic to 120s (previously never tachycardic). also rr increased to 40s. surgery wanted to try precedex, started. - pt??????s abg prior to this (in am) was 7.46 / 43/ 96 / 32, and the new abg at 5pm was similar 7.45 / 37 / 81 / 27 ?????? but pt??????s minute venilation was significantly increased from then and would expect pc02 lower ?????? suggesting incr dead spacing, and pt was concerning for pe. - pt??????s pressure support was inc to 25 w/o benefit on rr, - pt??????s 02 sat dropped to 90%, and pt??????s fi02 was increased from 40 to 70% and started back on ac vt 450, fio2 70, peep 8, rr 32. given hypoxia and tachycardia w/ new dead spacing decision was made to attempt cta for pe. - also around this time from pt??????s lasix gtt she was already -2l,. also considered pt??????s tachycardia. - new cxr showed no new infiltrates and was unchanged. - leni was negative - blood cx sent, more tylenol given - pt was to get 25g albumin, but surgery decided to give 2 u prbc instead, hct stable at 25 at the time. - around 6pm ?????? pt??????s wbc increased from 13 earlier that day to 24 (hct stable at 25.4) cdiff was sent. and a new lactate was sent and was 4.1 - spoke to surgery about expanding abx ?????? agreed to adding flagyl 500 iv q8, and surgery contd to want to r/o pe - bladder pressure 19 - stable - pt became hypotensive to sbp 70s, map 40s, and gave 1l bolus, w/ 1unit prbc being transfused during that time. pt still required levophed 0.3, and then added vasopresin 1.2 then 2.4. - pt??????s map stabalized > 65 lactate came down to 3.8, pt went to ct -> cta neg prelim read. pt weaned from levophed. - pt stayed stable until 4am, fever of 103.5, new blood cx sent. lactate back to 4.0 restarted on levophed, now 0.12, and vasopresin 2.4, map stable , at 7am lactate 3.8 ____________________________________________ - per id recs added po vanc - per recs added iv cipro - on flagyl added - percutaneous cholecystostomy by ir at bedside, drain in place draining bilious fluid. fluid sent for gs and cx - perc drain of loculated subdiaphragmatic fluid (luq), fluid sent for gs and cx - per dr plan for ex lap on , pt's family consented by and anesthesia - repeat hct 25, asked for transfusion - d/c'ed left art line, placed new right radial art line ________________________________________ - repeat ct scan with rectal, po and iv contrast without significant change in air collection near hartmanns pouch - culture of peritoneal fluid drained on growing gnr - deferred surgery today, reconsider tomorrow. - failed pressure support - tachypneic into 50s, agitated - weaned off pressors and sedation, consider haldol in am. - face becoming purple when lying flat _______________________________________________ - initially decreased pt's peep and pressure support. surgery wanted pt on precedex - later that day around 1pm surgery decided to extubate pt. pt's tolerated extuabtion for 45min, then pt's 02 sat began to drop -> 90%, cpap and neb did not help -> reintubated and put on ac. - many attempts to get a-line unsuccesful, surgery even tried - id: narrow abx when sensitivies return to cipro/flagyl or ctx/flagyl - haldol prn started, continuing fentanyl - standing nebs put on - lasix 10, then 20 iv given prior to extubation - after reintubated put on lasix drip 1-3mg/hr ________________________________________________ - on lasix gtt, then bp's dropped to 70s systolic. per give 25% albumin, hold lasix gtt, pt's pressures went to 80's systolic - id rec'd stopping zosyn as cx growing pan sensi e coli, but couldn't reach , still on zosyn - off lasix gtt overnight ________________________________________________ - ct chest to eval pleural effusions unremarkable - present but not huge, unlikely to fix the problem but if no other ideas, can tap prior to trach - increasing peep as bp and airway pressures allow to recruit more lung and assist with extubation - changed antibiotics to po - overbreathing the vent, becoming alkalotic - tried pressure support to decrease minute volume but pt became tachypneic to 40s/50s and with very shallow breaths. restarted ac and increased sedation. - restarted lasix gtt ____________________________________________ - ip tapped the effusion, right side - maroon stool - febrile->tylenol ___________________________________________ - tried to go down on peep, pt thrashing, returned peep to - pt tachycardic to 130's, stopped lasix gtt, then pt's bp in 70's systolic with temp of 104, gave 1l bolus, ordered albumin per - ct showed ? new consolidation on chest aspiration v pna - started vanc zosyn - at mn had ~500 cc brbpr ____________________________________________ - self extubated at 1:30 pm (had been planned for extubation or trach at 3pm) and started saying "i don't need this tube" continued to sat high 90s with supplemental oxygen (nc and shovel mask). was oob to chair sitting up, asking for coffee. - no more fevers but bandemia from am concerning so kept on antibiotics. potentially planned for ct guided drainage of abdominal collections tomorrow. - respiratory distress o/n with sat's to 70's, responded to bolus of lasix gtt, nebs, repositionning - 7:15 am (), tachy to 130's, hypertensive to 160's, sat's in 70's. got 50 iv lasix (10 bolus gtt then 40 iv), total 4 mg morphine, placed on bipap, abg 7.38/50/55, after 45 minutes finally tolerating bipap and sats up to mid 90's (very agitated and sob, mottled, would not tolerate mask). lasix gtt had been held for marked hypokalemia (2.8) but was still putting out 80cc/hr urine. surgery at bedside and did not want re-intubation ________ - pt negative 500ml by 5pm, then uop tapering off to 30cc/h. surgery at that point began lasix bolus on top of gtt, 20 iv, and acetazolamide 250 iv x6 x4doses, and 25g albumin. - pt alert but very agitated, tried ativan 1mg, then haldol 4mg pox1 which helped - around 11pm, bt became tachycardic to 120s, rr 40, changed from facemask to bipap, but still 02 sat decr 90%. neb tx given, and additional 40 iv lasix. pt was given morphine 2mg iv x2 (since this helped w/ similar episode at 7am), ativan 1mg, abg 7.37 /50/ 86/ 30. did not reintubate. pt eventually calmed down, and went to sleep. ____________________ - pt on bipap most of day - stopped lasix gtt in am as pt hypotensive in 70's and symptomatic (improved in trendelenberg), did not end up getting fluid bolus. - placed dobhoff to start feeding - picc placed but ended up in rij, so pulled back to make a midline - started tf at dr goal of 20cc/h - per recs got lasix 20 iv x1 in afternoon _______________________ - surgery goal to reeval sunday evening after 48 hrs of steroid re tube/trach or improving. want to optimize with diuresis as well. - today on bipap except 2 short bursts of 2h and 45min on facemask. becomes confused and agitated, wanting to take off masks (likely hypoxic/hypercarbic, abgs not checked) - starting to have nasal skin breakdown - attempting diuresis with lasix boluses - dobhoff did not advance with reglan, likely because bipap mask holding it in place. continuing reglan and surgery will try to manually advance it on morning rounds tomorrow. - did not sleep overnight, no response to haldol or trazadone, delirius, trying to crawl out of bed. ______________________________ - anxiety much better controlled w/ ativan 2mg alternating w/ haldol - decreased solumedrol 40mg q12 now - leni reordered this am, not done - lasix 20 iv x1 at mn (got 40 in am), pt neg 300, goal neg 500 __________________________________ - hct stable despite hartmann bleeding - leni negative -negative 1650, got 40 iv lasix x2 yesterday, k=repleated -tried chest pt but pt kept slipping down in bed - check to see if pt came -did require going back on bipap as had increased rr, oxygen sat was in low 90s, and she pulled out dubhoff... concern could have aspirated. on face mask 1:30-3:45 -dubhoff replaced, tf to start in am -middle of night bipap came off and pt in 2:1 block, ekg checked continues to have inverted t waves -ck and mb neg x2, third set to be drawn -alb nebs changed to xopenex nebs given pt tachycardic diuresed about 2.4l per surgery ok to optimize med mgmt of cad: bb, asa, statin-started tte- poor quality but slightly decreased ef, global hypokinesis of rv with mod pulm htn switched to nc/shovel for short time maintained sats cardiac enzymes negative ------------- per surgery, patient to continue fwb. would like to see if iv meds can go in with 1/2ns. - continue diuresis - at 4:30 in atfernoon had a fib with rvr got lopressor 2.5 iv x2 and then back in sinus -nausea not responsive to zofran but was to compazine, tf stopped because of nausea -10pm i/os -231 -pt weaned down to 60s during early afternoon, then a fib with rvr so back up to 90s -increased free water boluses (may have gotten held when tf held) restarted tf decreased free water boluses switched xopenex back to albuterol took sips of water po still on shovel mask for o2 - weaned to 5l nc - advanced tfs - patient ao x3, coherent - d/c diamox - increased sch to tid - decreased vanco enemas to -a fib with rvr did not respond to metoprolol 5 iv x3, converted to sinus on dilt gtt, then switched to po dilt and po metoprolol discontinued -surgery did not want to diurese, just wanted pt to settle out on her own -3 pm lytes repleted k+. mg came back > 12 and then repeated was > 11. no signs of cardiac toxicity. pt hyperreflexive not hyporeflexive. repeated again (drawn peripherally) and came back as 2.4. -had nausea in pm -tf at 50 then turned off (a fib with rvr) then 20 -> increased to 30 = = = = = ================================================================ diuresed 2100cc weaned to 6l nc surgery considering calling out patient about even i/o for los abd discomfort improved surgery considering calling out on -a fib with rvr got metoprolol 5iv x2 then started dilt drip and gave 10 iv dilt bolus -morphine for pain -did not go to surgery b/c of a fib with rvr no afib w/ rvr cardiac consult - last updated by , b. on @ 1540 patient location: 4i-404-01 54yo s/p transverse colectomy, long icu stay w/ resp failure. intermittent min-hrs; sinus. af 120-150s. dilt po 30 qid + metoprolol 12.5mg . w/ occ bb iv. 1x day. c.diff. . pt transferred to 5. she was screened for rehab, family aware. pt has altered mental status at times but reoriented easily. the patient will be d/c'd to acute rehab and will f/u with dr. on at 9:30 am. medications on admission: none discharge medications: 1. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed. 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 4. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. 5. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 7. hydrocodone-acetaminophen 5-500 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed: please give tylenol first. . 8. diltiazem hcl 30 mg tablet sig: 2.5 tablets po qid (4 times a day). 9. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 10. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed. 11. insulin insulin sc sliding scale breakfast lunch dinner bedtime regular regular regular regular glucose insulin dose insulin dose insulin dose insulin dose 0-60 mg/dl amp d50 amp d50 amp d50 amp d50 61-159 mg/dl 0 units 0 units 0 units 0 units 160-199 mg/dl 2 units 2 units 2 units 2 units 200-239 mg/dl 4 units 4 units 4 units 4 units 240-279 mg/dl 6 units 6 units 6 units 6 units 280-319 mg/dl 8 units 8 units 8 units 8 units 12. heparin flush 10 unit/ml kit sig: two (2) ml intravenous once a day: mid-line, heparin dependent: flush with 10 ml normal saline followed by heparin as above, daily and prn per lumen. 13. saline flush 0.9 % syringe sig: one (1) injection once a day: flush with 10ml normal saline daily and prn. discharge disposition: extended care facility: - discharge diagnosis: primary: transverse ca post-op: hypoxemic respiratory failure tachycardia a-fib leukopenia pneumoperitoneum etoh withdrawl copd anastomotic bleed then leak fevers malnutrition . secondary: ca, oa of multiple joints, varicose veins, pad, leg cramps, emphysema, etoh fatty liver discharge condition: stable. tolerating regular diet pain well controlled with oral medications. discharge instructions: rehab: please contact md if pt * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomiting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomiting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *avoid driving or operating heavy machinery while taking pain medications. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to ambulate several times per day. . incision care: -mid-line incision healed with distal part open and packed w-d twice a day. . monitoring ostomy output/prevention of dehydration: -keep well hydrated. -replace fluid loss from ostomy daily. -avoid only drinking plain water. include gatorade and/or other vitamin drinks to replace fluid. -try to maintain ostomy output between 1000ml to 1500ml per day. -if ostomy output >1 liter, take 4mg of imodium, repeat 2mg with each episode of loose stool. do not exceed 16mg/24 hours . telemetry: -please continue to assess pt's heart rate. -pt had new onset a-fib while in hospital. followup instructions: 1. please follow up with dr. on at 9:30. 2. please follow up with your pcp, , , in one week or as needed. . scheduled appointments provider: mammography phone: date/time: 10:40 md, procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube thoracentesis percutaneous abdominal drainage colostomy, not otherwise specified open and other right hemicolectomy open and other resection of transverse colon percutaneous aspiration of gallbladder diagnoses: tobacco use disorder acute kidney failure with lesion of tubular necrosis other postoperative infection unspecified pleural effusion acute posthemorrhagic anemia alcoholic cirrhosis of liver unspecified septicemia severe sepsis atrial fibrillation obstructive chronic bronchitis with (acute) exacerbation hypopotassemia pulmonary collapse hemorrhage complicating a procedure acute and chronic respiratory failure alkalosis surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation other and unspecified alcohol dependence, unspecified delirium due to conditions classified elsewhere alcohol withdrawal other suppurative peritonitis alcoholic fatty liver malignant neoplasm of transverse colon other protein-calorie malnutrition 

Answer: The patient is high likely exposed to