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: tetracycline / benadryl / methotrexate attending: chief complaint: abdominal pain major surgical or invasive procedure: drain placement into intra-abdominal abscess subclavian line placement (left) , removed diagnostic and therapeutic paracentesis with removal of 500cc picc placement history of present illness: ms. is a 75 yo female with long history of crohn's disease in the terminal ileum and colon s/p partial colectomy and ileostomy which was reversed in at and more recently s/p small bowel resection, partial colectomy and ventral hernia repair at hospital in for a crohn's associated bowel perforation who was admitted to the sicu for sepsis from an abdominal abscess. of note she had just arrived from at and was sent directly to the ed as she was felt to require higher level of care given her abdominal pain and fevers. ct abdomen and pelvis on revealed an intraperitoneal abscess, areas of peritoneal enhancement and an enhancing mass in the liver worrisome for a malignancy. she was admitted to the sicu and had ct guided drainage of the abscess on . she was initially treated with vancomycin, levofloxacin and zosyn. coverage was narrowed to vancomycin alone on when cultures from the fluid grew vancomycin sensitive enterococcus. . her present illness dates back to . she had been having low grade fevers. a ct scan showed ti inflammation c/w crohn's flare. her remicade was increased but fevers continued. in . , she had a ct abdomen in to evaluate fever, which showed an abcess in her pelvic area and thickening of the distal small bowel extending into the large bowel. she was taken to the or and was found to have perforated colon from crohn's disease with pelvic abcess and complex ventral incision hernia. she had resection of distal small bowel, partial colectomy, ileosigmoidostomy and liver biopsy and primary repair ventral incision hernia. the skin was not closed and a wound vac was placed. she had prolonged ileus and ngt placed and she was transferred to rehab in (her son lives here) as above with subsequent transfer to . . on , she was transferred to the medical liver service for further evaluation of her liver lesions with general surgery following. past medical history: crohn's disease --s/p ilectomy and partial colectomy in 's with colostomy reversed in --s/p small bowel resection and colectomy in uti cryptogenic cirrhosis with ascites from unclear etiology (negative for hep a,b,or c) osteoporosis iron deficiency anemia ventral hernia pancreatic cyst cholecystectomy s/p tah social history: patient is widowed with 3 children, drinks alcohol occasionally and denies tobacco abuse. she is retired and worked as a secretary to a software company. independent with adl's and iadl's prior to recent hospitalization. family history: non contributory physical exam: exam on admission : t 97.1 bp 87/47 hr 66 sao2 98% ra gen: anxious, cachectic cv: regular rhythm pulm: symmetric expansion, roncherous at bases b/l abd: soft, distended, minimally tender, abd wound open extrem: 2+ edema b/l; diminished dp skin: jaundice, granulation over abd wound neuro: aox 2, follows simple commands, moves all extremities exam on transfer to liver service : vs: 99.3 96 118/46 22 95% ra gen: a&o x3, comfortable, no distress, able to state months of year backward heent: perrl, eomi neck: supple chest: left sided subclavian line, rrr, 2/6 systolic murmur throughout the precordium lungs: slight basilar crackles anteriorly otherwise cta abd: wound vac in place over abdominal surgical incision, right sided jp drain from rl quadrant, abdomen somewhat distended, some tenderness to palpation in the right lower quadrant, otherwise nontender ext: 1+ pitting edema of le's bilaterally, warm, bruising no rash exam on discharge *** pertinent results: labs on admission: wbc-9.9 rbc-3.83* hgb-10.7* hct-32.6* mcv-85 mch-27.8 mchc-32.7 rdw-17.1* plt ct-215 neuts-86.8* lymphs-6.3* monos-5.2 eos-1.6 baso-0.2 pt-14.0* ptt-29.6 inr(pt)-1.2* glucose-137* urean-28* creat-0.4 na-140 k-3.7 cl-108 hco3-27 angap-9 alt-23 ast-37 alkphos-245* totbili-1.8* lipase-33 albumin-1.8* calcium-6.9* phos-2.7 mg-1.6 iron-16* ammonia-44 other labs: ggt-93* vitb12-1071* folate-13.5 caltibc-66* ferritn-504* trf-51* triglyc-45 tsh-11* free t4-1.0 hbsag-negative hbsab-borderline hbcab-negative hav ab-negative hcv ab-negative ama-negative -positive * titer-1:160 afp-3.5 crp-80.4* igg-1748* iga-325 igm-280* alpha-1-antitrypsin-test 233 h 83-199 mg/dl zinc level 136 (normal) hereditary hemochromatosis mutation analysis result: negative interpretation: dna testing indicates that this individual is negative for the c282y and h63d mutations in the hfe gene. this negative result significantly reduces the likelihood of hereditary hemochromatosis (hh) in this individual. however, it does not rule out the presence of other mutations within the hfe gene or a diagnosis of hh. the risk of this individual carrying a hfe mutation other than those tested in this assay depends greatly on family and clinical history as well as ethnicity. this assay does not test for other primary or secondary iron overload disorders. discharge lab studies: . 130 | 102 | 20 5.1 | pnd | 0.7 . ca: 7.9 mg: pnd p: 3.5 . alt: 16 ap: 313 tbili: 0.7 alb: 2.3 ast: 28 ldh: 180 . wbc 6.8 plt 150 hct 26.6 . pt: 13.9 ptt: 32.7 inr: 1.2 . . . . micro: : u cx pending : u cx- 2 strains pan-sensitive klebsiella c diff negative x 4 during hospital course subclavian tip culture: no significant growth vre swab: negative bcx: ngtd peritoneal fluid: cultures no growth , urine culture: >100,000 yeast sputum: mssa ________________________________________________________ staph aureus coag + | clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- 2 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s fungal culture (preliminary): yeast. abscess: vancomycin sensitive enterococcus enterococcus sp. | ampicillin------------ <=2 s penicillin g----------<=0.12 s vancomycin------------ <=0.5 s blood cultures x2: no growth (final) imaging: ct abdomen/pelvis: 1. rim-enhancing fluid collection within the pelvis, consistent with abscess. 2. moderate amount of ascites with areas of peritoneal enhancement. while the enhancement could be due to recent surgery, bacterial peritonitis cannot be excluded. 3. nodular liver with massive splenomegaly and collaterals, most consistent with cirrhosis and portal hypertension. foci of enhancement within the liver, incompletely evaluated on this single-phase study, but concerning for underlying multifocal hepatic cellular carcinoma. metastatic disease is an alternative differential. futher evaluation with mri is recommended. 4. small left ventral hernia containing bowel, but no obstruction. 5. cystic changes in pancreas, suggestive of ipmn. abdominal ultrasound: 1. hepatic vasculature patent. 2. cirrhotic liver 3. limited assessment of liver demonstrates 1.7 cm hyperechoic lesion at the right dome of the liver corresponding to hypodense lesion seen on single phase ct abdomen. this and other liver lesions seen on ct are non-specific in appearance and incompletely characterized; mri of the liver is recommended for further assessment to exclude hepatocellular carcinoma. 4. moderate ascites. 5. right pleural effusion with right lower lobe atelectasis. cxr: removal of right internal jugular catheter with no visible pneumothorax. heart size is normal and unchanged. slight improvement in left retrocardiac opacity and persistent small left effusion. possible increase in layering moderate right pleural effusion. adjacent right basilar lung opacity favors atelectasis, but coexisting pneumonia is not excluded. mri abdomen: 1. multiple lesions in the cirrhotic liver remain indeterminate, as delineated above. 13 mm lesion in segment v/viii is most concerning and may represent dysplastic nodule although hepatoma cannot be excluded. close continued follow up is recommended; consider multiphase ct for next assessment due to the limitations of mr in the non-breathhold setting. 2. 14 mm hypoenhancing lesion in segment vii is indeterminate, but given the reported history (obtained from careweb) of percutaneously drained liver abscess, resolving abscess could have this appearance; comparison with prior outside hospital imaging would be extremely helpful to help make this diagnosis. other hypoenhancing lesion such as metastasis is not excluded. 3. multiple t2 hyperintense foci in the l1 and l5 vertebral bodies demonstrate enhancement. also hyperintense signal in the right l3 pedicle on t2-weighted images. bone scan is recommended to assess for possibility of metastatic disease. 4. splenomegaly, perisplenic varices, and ascites redemonstrated. bilateral pleural effusions with adjacent atelectasis. anasarca. 5. multiple pancreatic cystic lesions, the largest measuring 13 x 17 mm, appearing to communicate with main pancreatic duct, and with no abnormal enhancement nor dilatation of main pancreatic duct. as differential considerations include side branch ipmt, followup in six months is recommended by mri. again, bone scan is recommended to evaluate for possibility of metastatic disease. comparison with prior imaging is recommended for liver lesions, particularly lesion in segment vii. if ultrasound-guided targeted liver biopsy is contemplated, targeted feasibility ultrasound should be performed first (with ultrasound attending present). ct /pelvis: 1. decrease in size of the central abdominal collection which is partially drained with a new enhancing collection in the right flank. 2. liver cirrhosis with splenomegaly consistent with portal hypertension. 3. suspicious liver lesion, recently examined by mr. cxr: a left subclavian central line is present, tip in distal svc near svc/ra junction. there are bilateral pleural effusions, small to moderate on the right and small on the left, with underlying collapse and/or consolidation. these are improved compared with . no chf, focal infiltrate or effusion is identified. doubt pneumothorax. bone scan: the lumbar vertebral lesions seen on mri demonstrate no definite correlative increased tracer uptake on this study. however, there is asymmetric uptake in the right sacrum adjacent to the sacroiliac joint, which may correlate with a t2 hyperintense lesion retrospectively seen on mri. cxr for dobhoff placement: dobhoff in lower stomach multiphasic ct /pelvis: 1. multiple arterially enhancing lesions within the liver are concerning for hepatomas. 2. interval decrease in anterior, posterior pelvic and right iliac crest fluid collections. osh liver path (prelim per discussion with path): the findings of this biopsy are mild and non-specific. minimal portal and lobular mononuclear inflammation, sinusoidal and mild portal fibrosis (however the biopsy was small and subcapsular so evaluation of fibrosis was limited). there was no steatosis, balloon cell degeneration, or intracytoplasmic hyaline, and by report no significant iron deposition. no explanation for a mass lesion. tumor board evaluation/action plan of liver lesions - they do not look ominous and do not demonstrate washout. some lesions are very bright and show enhancement, c/w hemangiomas. others noted appear c/w focal nodular hyperplasia or adenomas. no further action necessary. abdomen ct with iv and po contrast indication: 75-year-old female with crohn's post-partial colectomy and ileosigmoid anastomosis, ct-guided drainage of intra-abdominal abscesses, increased diarrhea. comparison: ct from and mr from . technique: helical mdct images were acquired from the lung bases through the greater trochanters with intravenous and oral contrast. coronal and sagittal multiplanar reformations were generated. findings: bibasilar atelectasis is noted, right greater than left. a moderate right pleural effusion is present. abdomen: the liver enhances heterogeneously and has a nodular contour, consistent with cirrhosis. multiple cysts are present, the largest measuring 2.5 cm in segment iv (2:11). indeterminate masses include a 1.3-cm peripherally enhancing lesion in segment v (2:14) and 1-cm hyperenhancing lesion in segment viii (2:21). overall, these appear unchanged, but are better characterized on recent mr. the gallbladder is surgically absent. mild common bile duct dilatation up to 12 mm (2:26) is unchanged. the pancreas is mildly atrophic, with multiple cysts reflecting known intraductal papillary mucinous tumor. the largest cyst in the mid-pancreatic body measures 2 x 1.2 cm (2:23). the spleen is again markedly enlarged at 19 cm, with multiple portosystemic collateral vessels reflecting portal hypertension. the adrenals and kidneys are unremarkable. scattered renal hypodensities are too small to characterize. there is no hydronephrosis. pelvis: the bladder is distended. the uterus and adnexae are unremarkable. a 2.2 cm rounded hyperdense lesion in the right posterolateral vulva (2:85) is stable since , and likely represents a hemorrhagic bartholin cyst. gastrointestinal: nasogastric tube coils in the stomach. again seen are multiple large duodenal diverticula. oral contrast opacifies the small bowel and proximal colon. the rectal vault is distended with fecal material. there are no signs of bowel inflammation, obstruction, or fistulization. diffuse ascites has almost completely resolved. percutaneous drainage catheter in the anterior pelvis has been removed. remaining fluid collections are markedly decreased in size, measuring 3.8 x 2 cm in the posterior pelvis (2:62), previously 5.6 x 1.9 cm; 2.2 x 1.4 cm in the infrahepatic region (2:51), previously 3.5 x 1.7 cm; and 1.7 x 1.1 cm in the left psoas muscle, previously 1.9 x 1.3 cm (2:34). these collections demonstrate continued peripheral enhancement, consistent with phlegmonous changes. diffuse mesenteric stranding persists. multiple retroperitoneal, mesenteric, and inguinal lymph nodes measure up to 7-8 mm in short axis, and are likely reactive. surgical changes are noted in the ventral abdominal wall. diffuse subcutaneous edema has improved. impression: 1. improvement in multiple fluid collections. 2. cirrhosis and splenomegaly, reflecting portal hypertension. multiple liver lesions are better characterized on recent mr. 3. pancreatic ipmn. 4. stable right vulvar lesion, likely hemorrhagic bartholin cyst. clinical correlation is recommended. brief hospital course: ms. is a 75 yo f with crohn's disease and history of prior partial colectomy admitted to hospital in with fevers and abdominal pain found to have perforated colon s/p resection in , now with admission here for intraabdominal abscess s/p ir drainage also found to have multiple liver lesions. # intraabdominal abscess - recent colon perforation and colectomy. wound vac from abdominal incision was removed and incision dressed with wet to dry dressings . s/p ct guided drainage with jp drain placed. vanc sensitive enterococcus in micro. pt continued on vancomycin. para negative for sbp. repeat imaging demonstrated that abscesses were smaller and radiology stated that they would not move drains based on this. over the next few days, jp drain did not drain any significant amount of fluid. drain was pulled , and patient was monitored. she remained afebrile, hemodynamically stable. repeat ct scan showed further decrease in size of abscesses, and ir did not feel that any further intervention was required. patient will continue vancomycin (day 1= )until id follow up. she will also follow up with general surgery. she will have weekly safety labs (cbc with differential, bun, cr, vanco trough) faxed to the infectious disease r.ns. at (. a vancomycin trough should be checked on saturday after increasing her dosing to 750mg q12 from 1250 q 24 on . ** please have pharmacy mix vancomycin in normal saline rather than d5w to avoid free water administration given hyponatremia. # loose bloody stools/crohn's disease - pt had frequent large volume watery stools which were bloody on x3 episodes only. hct remained stable. bloody stools resolved spontaneously, however pt continued to have frequent loose stools (up to q 1hr). ddx included crohn's flare (off remicaid for 8 weeks prior to admission, and it continued to be held this admission given active infection), malabsorption recent bowel resection (s/p resection of 1.5 foot of small bowel), vancomycin-associated, or tube feed associated. stool culture negative and c. diff negative on multiple specimens. diarrhea was treated empirically with mesalamine and rifaximin for crohns, cholestyramine for bile salt malabsorption, and psyllium. diarrhea had improved upon discharge. patient will follow up in clinic. she may need to restart remicade when infection is resolved. . # hyponatremia - na 144 on admission but decreased to as low as 119 during hospital course. renal team was consulted. picture was consistent with post-op siadh, worsened iatrogenically with maintenance fluids. she was started on 1000ml fluid restriction. when sodium continued to decrease, patient was given tolvaptan x 2. timing of decreased sodium also correlated with starting celexa, so this was stopped. she will require electrolyte monitoring as outpatient and adjustment of free water intake. . # liver lesions - per discussion with radiology, the lesions were present in , and appear stable on current ct and mri. afp negative. per pt, they have been present for 20 years. path findings are non-specific given small sample and subcapsular specimen. on multiphasic ct , the lesions are concerning for hepatomas. however, per tumor conference, liver lesions do not look ominous and do not demonstrate washout. some lesions are very bright and show enhancement, c/w hemangiomas. other lesions noted appear c/w focal nodular hyperplasia or adenomas. no further action necessary. # hepatic cirrhosis - with ascites. unclear etiology. hep b,c negative. alpha 1 antitrypsin, (1:360) are both elevated. hh labs negative. smooth muscle negative. para negative for sbp. path findings non-specific and demonstrate increased fibrosis because they are sucapsular and small specimen and may not represent liver tissue as whole. she was not started on lactulose given loose stools due to crohn's. lfts, t bili and coags remained stable throughout her hospitalization. # normocytic anemia - likely anemia of chronic disease given elevated crp and ferritin with component of blood loss from recent surgery. b12 and folate normal. hct stable after bloody stools. she did not require transfusions. # malnutrition - likely crohn's and recent infections/surgery. dobhoff placed with tip in lower stomach. despite her crohn's flare/bloody stools, her tube feeds were continued as team felt that pt needed nutrition to help healing/immunity. #stage i pressure ulcer- treated with pressure relief, mepelex for protection. it did not become infected or require increased management during this hospitalization. # positive ua - noted , after foley removal. pt started on bactrim ds 1 tab (day 1 = pm) for 3 day course for positive ua. urine culture showed 2 strains of pan-sensitive klebsiella. given that pt was asymptomatic and cx had been in setting of foley which was subsequently removed, abx were stopped after 3 days. repeat uas were negative. of note, patient did complain of dysuria day prior to discharge. ua was contaminated and urine cx was pending. . #hypothyroid - levothyroxine initially started, then stopped as it appears to be sick euthyroid by labs. she will need repeat tsh as outpatient once recovers from acute illness. #anxiety/depression - takes prn ativan at home, c/w depression per geriatrics consult. pt was started on citalopram but had hyponatremia. she was switched to mirtazapine qhs. she was also given ativan 0.25mg : prn (0.5mg made her sedated) with close monitoring for delirium. #pancreatic cyts - c/w ipmn. per radiology report f/u mri recommended to evaluate for stability in 6 months; however per surgical note from dr. , no need for repeat mri as patient is not a surgical candidate should there be any change in her lesions. # l1,3,5 lesions seen on mri - worrisome for potential metastatic disease, but lesions not noted on bone scan. however, there is area of uptake on r sacrum that is not well visualized on mri. per discussion with msk radiology, corresponding area on mri is not significant (possibly subchondral cyst) and they did not feel that dedicated imaging was warranted at this time. pt will likely need further imaging in the further for abdominal processes and imaging should include pelvis. #code status - full (confirmed) #contact - son or patient was discharged to rehab macu. medications on admission: home medications: albuterol qid dulcolax cepacol tpn dilaudid prn atrovent ativan 0.25 - takes very infrequently protonix 80 daily remicade was stopped 8 weeks ago and in the meantime she was being treated with enterocort. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: intra-abdominal abscesses after perforated bowel crohn's diease liver lesions, benign anxiety, depression urinary tract infection cryptogenic cirrhosis anemia osteoporosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: ms. , it was a pleasure taking care of you. you were admitted to for evaluation of fevers and abominal pain. you have an infection in your belly after your recent surgery in . a drain was placed and scans have shown that it is improving. you were started on antibiotics for this. you are very malnourished and were started on tube feeds via a tube that goes to your stomach. there are some lesions on your liver, but they are benign and no further action is required. you also had problems with low sodium, and were treated with special medication called tolvaptan to increase your salt levels. you were started on a new medication for depression and anxiety called remeron (mirtazapine). changes to your medications: continue 1. albuterol inhaler 1-2 puffs every 4-6 hours if needed for shortness of breath or wheezing 2. atrovent inhaler 2 puffs four times a day if needed for shortness of breath or wheezing 3. ativan 0.25mg twice a day if needed for anxiety stop: 1. dulcolax as you are having loose stools due to your crohn's 2. cepacol as you no longer need this medication 3. tpn - you are getting tube feeds 4. dilaudid prn 5. enterocort - you are on different medications for your crohn's decrease: 1. pantoprazole to 40mg daily start: 1. remeron (mirtazapine) 15 mg at night for depression and anxiety 2. mesalamine 500 mg 4 times daily for crohn's 3. rifaximin 200 mg 3 times daily for crohn's 4. vancomycin 750 mg every 12 hours for the abscess. this will be continued until you are seen in clinic and they will determine how long your course will be. 5. saline nasal spray for dryness with feeding tube 6. cholestyramine 4g twice daily for loose stools followup instructions: provider: , md (geriatrics) phone: date/time: 3:00 infectious disease , md phone: date/time: 10:10 gastroenterology for crohn's: dr. thursday 9:20 am **note: dr. had no appointments until , you can make appointment with him if preferred after this initial follow-up general surgery (dr. for abscess and abdominal incision thursday :30 am procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances percutaneous abdominal drainage percutaneous abdominal drainage removal of other device from thorax diagnoses: anemia of other chronic disease unspecified pleural effusion urinary tract infection, site not specified friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site cirrhosis of liver without mention of alcohol unspecified protein-calorie malnutrition portal hypertension unspecified acquired hypothyroidism perforation of intestine candidiasis of mouth osteoporosis, unspecified pressure ulcer, lower back iron deficiency anemia, unspecified streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] other disorders of neurohypophysis peritoneal abscess cyst and pseudocyst of pancreas pressure ulcer, stage i regional enteritis of small intestine with large intestine 

Answer: The patient is high likely exposed to