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: no known allergies / adverse drug reactions attending: chief complaint: fevers, malaise major surgical or invasive procedure: ir guided biliary tube exchange history of present illness: patient is a 52f with history of pancreatic cancer metastatic to the liver on hospice who presents with a several day history of fever and malaise. she has a history of prior cholangitis with biliary drain in place, which has had decreased output over the past several days. the plan was for scheduled cholangiogram as an outpatient tomorrow. her vna noted drainage around the stent site. she has been febrile to 101 at home per vna and notes cough, but denies any chest pain, dyspnea, abdominal pain, vomiting, or diarrhea. blood cultures were drawn by vna at and were positive for gnrs. she was brought to ed for evaluation. in the ed, initial vs were 98 109/70 29. she was hypoxic to 85% on ra, but sats came up to 100% on nrb. labs notable for leukocytosis of 22.2, na 127, k 5.2, cr 2.1, anion gap 15, lactate 2.5, alt 146, ast 71, tbili 6.4, dbili 4.4, and alkphos 256. she received vanc, cefepime, and flagyl, and repeat blood cultures were sent. cxr showed right lower lobe collapse vs. consolidation. ir was consulted, and patient underwent replacement of biliary catheter. she was intubated for the procedure then extubated and transferred to the icu. on arrival to the micu, patient's vs t98.9, hr84, bp100/68, rr21, o2sat: 100%. patient states that she feels better after the procedure and that she is no longer in pain. she states that she feels weak and exhausted. review of systems: (+) per hpi (-) denies denies shortness of breath, cough, or wheezing. denies chest pain, chest pressure, palpitations. denies constipation, abdominal pain denies dysuria, frequency, or urgency. denies other pain past medical history: pancreatic cancer diagnosed egd on disclosed a pancreatic head mass s/p whipple t3n1 (stage iib) adenocarcinoma of the pancreas adjuvant chemotherapy and chemoradiation therapy completed on 09/. multiple low-attenuation lesions were noted in the liver. eus/fna on disclosed a local recurrence liver biopsy on disclosed metastatic recurrence gemcitabine chemotherapy . - per outpatient visit, does not wish to undergo further chemotherapy initiated hospice services at home past medical history: increased intraocular pressure t3n1 (stage iib) pancreatic adenocarcinoma (see above history) pshx: tubal ligation, hysteroscopy, bilateral knee arthroscopies, breast biopsy social history: she lives with her husband. she has never smoked and drinks socially. she works as a secretary. family history: mother with dm and "everything"."bone cancer" in her father per . physical exam: on admission: vitals: t98.9, hr84, bp100/68, rr21, o2sat: 100% general: alert, oriented, cachectic heent: sclera mildly icteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, biliary drainage catheter in place draining bilious, blood-tinged fluid gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 4/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. discharge physical exam vs tc 99.2 tm 99.2 bp 96-107/56-70 hr 91-99 rr 18 spo2 95-96%ra general: alert, oriented, cachectic heent: sclera mildly icteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, biliary drainage catheter in place draining bilious, blood-tinged fluid gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 4/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. pertinent results: on admission: 06:08pm blood wbc-22.2*# rbc-4.04* hgb-11.7* hct-36.5 mcv-90 mch-29.0 mchc-32.1 rdw-15.9* plt ct-347 06:08pm blood neuts-90.0* lymphs-6.0* monos-3.4 eos-0.1 baso-0.4 06:08pm blood pt-17.4* ptt-34.0 inr(pt)-1.6* 06:08pm blood glucose-165* urean-107* creat-2.1*# na-127* k-5.2* cl-88* hco3-24 angap-20 06:08pm blood alt-146* ast-71* alkphos-256* totbili-6.4* dirbili-4.4* indbili-2.0 06:08pm blood albumin-2.9* 11:58pm blood calcium-7.3* phos-3.4 mg-2.6 06:12pm blood type- po2-41* pco2-35 ph-7.47* caltco2-26 base xs-1 comment-green top 06:12pm blood lactate-2.5* portable cxr : right basilar opacification with elevation of the right hemidiaphragm suggests atelectasis or an infectious process. small bilateral pleural effusions. percutaneous biliary catheter cholangiogram/exchange : findings: 1. existing 10 french modified pigtail drain patent in its intrahepatic component, but obstructed distally with no contrast drainage noted into the hepaticojejunostomy. 2. several separate areas of stricturing identified within the intrahepatic ducts in segments not directly accessed by the existing tube. these do demonstrate some partial drainage of contrast at the end of the procedure. impression: occluded existing indwelling modified biliary drain, successfully replaced. ct abd/pelvis : impression: 1. multiple large liver and smaller uterine abscesses, likely secondary to hematogenous spread of pathogen. 2. possible bilateral lower lobe pneumonia, concerning for aspiration etiology. correlate clinically. 3. biliary drainage catheter in unchanged position, surrounded by a locally recurrent mass at the whipple resection bed. brief hospital course: assessment and plan: this is a 52yo female with pmh of pancreatic cancer s/p whipple and with metastases to the liver who presents from home with fever, malaise, and leakage of fluid from around her biliary drain site. this is concerning for cholangitis with report of bc positive for gnr at outside lab facility. # biliary drainage: patient presented from home with blockage of external drainage from biliary drain and leakage of fluid from around the tube. ir exchanged the drain on presentation with good effect. her bilirubin was elevated on presentation likely from acute biliary drainage blockage and improved after the exchange. however, following the tube exchange, she was noted to have decreased drainage. ct abdomen was performed which revealed her biliary tube to be in good positions, however there are also multiple hepatic and uterine abscesses which may be due to hematogenous spread of pathogen or possibly superinfection of necrotic metasteses. she will continue to use her biliary catheter at home as she did previously. # gnr/gpc/gnc bacteremia: patient reportedly has positive bc from outside lab for gnr. she was empirically started on vancomycin, cefepime, flagyl. was contact and reported that blood culture grew enterobacter cloacae, to cefepime, levofloxacin, cipro. 1 blood culture in hospital also grew gnrs and gpcs. preliminary gram stain of bile culture grew gpcs and gnrs. the likely source is biliary given the acute blockage of the drain associated with onset of symptoms. subsequent organisms grown from culture include gnc as well. she was continued on cefepime and flagyl in house with vancomycin stopped on hd#3. because she did not worsen clinically, it was decided that was less likely. as such, the decision was made to simplify her regimen to once daily ertapenem to provide adequate coverage for her polymicrobial bacteremia, as the only organism this would miss . her bacteremia is likely biliary in origin, with hematogenous spread to her liver, resulting in these abscesses. the possibility of drainage was discussed with ir, and it was decided that to do so would require 1 or 2 more drains to be placed, and it would be unlikely to be curative. the etiology of her bacteremia being these multiple hepatic abscesses was discussed with the patient and her family, and a decision was reached to forgoe ir intervention, and to continue just with iv antibiotics and her home hospice care. as such a picc line was placed, confirmed via cxr to be in good position, and she was discharged to home with home hospice care. # pancreatic carcinoma: patient has pancreatic adenocarcinoma with metastases to the liver. she has undergone surgery with adjuvant chemotherapy and has decided to pursue no further chemotherapy but has initiated hospice care. her ct scan after biliary stent replacement showed likely superinfection of necrotic metasteses in her liver, which is a very poor prognostic sign. this was communicated with her primary oncologist. she will continue with her prior pain and nausea regimen consisting of hydromorphone and morphine prn, as well as ondansetron, compazine and lorazepam. she will continue creon for pancreatic enzyme repletion. # iddm: the patient was maintained on her home glargine plus ss insulin in-house. # arf: cr was elevated to 2.1 on admission, likely pre-renal azotemia. she was given ivfs and cr returned to 1.1. #hypoxemia: pt's oxygen saturation was reportedly 85% on ra at the ed and improved to 100% on nrb. she had no further episodes of hypoxia. cxr was clear. she did not require supplemental oxygen at the time of discharge and does not experience any shortness of breath of dyspnea. medications on admission: hydromorphone - 2 mg tablet - tablet(s) by mouth every 3-4 hours as needed for pain insulin glargine - (prescribed by other provider) - 100 unit/ml (3 ml) insulin pen - 10 insulin(s) at bedtime insulin lispro - (prescribed by other provider) - 100 unit/ml solution - as directed solution(s) qac according to sliding scale provided by clinic lactulose - 20 gram/30 ml solution - 30 ml by mouth qd if no bm in the am lipase-protease-amylase - 12,000 unit-,000 unit-,000 unit capsule,delayed release(dr/ec) - capsule(s) by mouth qac lorazepam - 1 mg tablet - 1 tablet(s) by mouth every six (6) hours as needed for mild nausea, insomnia, anxiety morphine concentrate - 100 mg/5 ml (20 mg/ml) solution - 0.5 ml ( 10 mg) by mouth every 1 hour as needed for pain omeprazole - 40 mg capsule,delayed release(dr/ec) - 1 capsule(s) by mouth twice a day ondansetron - 8 mg tablet,disintegrating - 1 tablet(s) by mouth three times a day as needed for severe nausea may alternate with compazine prochlorperazine maleate - 10 mg tablet - 1 tablet(s) by mouth q8 as needed for moderate nausea alternate with zofran medications - otc cholecalciferol (vitamin d3) - (prescribed by other provider) - 1,000 unit capsule - 1 capsule(s) by mouth docusate sodium - (otc) - 100 mg capsule - 1 capsule(s) by mouth twice a day multivitamin - (otc) - tablet - 1 tablet(s) by mouth sennosides - (otc) - dosage uncertain preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. hydromorphone (dilaudid) 2-4 mg po q4h:prn pain 2. lactulose 30 ml po daily constipation 3. lorazepam 1 mg po q6h:prn mild nausea, anxiety 4. mirtazapine 30 mg po hs 5. morphine sulfate (concentrated oral soln) 10 mg po q1h:prn pain 6. omeprazole 40 mg po daily 7. ondansetron 8 mg po tid:prn severe nausea 8. prochlorperazine 10 mg po q8h:prn moderate nausea 9. vitamin d 800 unit po daily 10. docusate sodium 100 mg po bid 11. multivitamins 1 tab po daily 12. senna 1 tab po bid discharge medications: 1. docusate sodium 100 mg po bid 2. hydromorphone (dilaudid) 2-4 mg po q4h:prn pain 3. lactulose 30 ml po daily constipation 4. lorazepam 1 mg po q6h:prn mild nausea, anxiety 5. morphine sulfate (concentrated oral soln) 10 mg po q1h:prn pain 6. multivitamins 1 tab po daily 7. omeprazole 40 mg po daily 8. ondansetron 8 mg po tid:prn severe nausea 9. prochlorperazine 10 mg po q8h:prn moderate nausea 10. senna 1 tab po bid 11. vitamin d 800 unit po daily 12. ertapenem *nf* 1 gram injection daily 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. rx *heparin lock flush (porcine) 10 unit/ml one flush as directed once a day disp #*30 syringe refills:*2 14. creon 12 caps po tid w/meals rx *lipase-protease-amylase 3,000 unit-,500 unit-,000 unit capsule(s) by mouth three times a day with meals disp #*60 capsule refills:*0 15. sodium chloride 0.9% flush 10 ml iv daily picc - please flush your picc line as directed rx *sodium chloride 0.9 % 0.9 % one flush as directed once a day disp #*30 syringe refills:*2 16. mirtazapine 30 mg po hs discharge disposition: home discharge diagnosis: biliary catheter obstruction polymicrobial bacteremia pancreatic carcinoma discharge condition: mental status: clear and coherent. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mrs. , it was a pleasure caring for you at medical center. as you know, you were hospitalized when your biliary drainage tube became clogged. our interventional radiology team exchanged your tube which appears now to be draining properly. you were found to have a serious bloodstream infection, which we started antibiotics to treat. you should continue these antibiotics at home to help treat your infection. you should also resume your home hospice care. we made the following changes to your medications: start ertapenem (invanz) heparin flush normal saline flush followup instructions: you should follow up with your oncologist on an as-needed basis. procedure: other percutaneous procedures on biliary tract diagnoses: malignant neoplasm of liver, secondary acute kidney failure, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure bacteremia long-term (current) use of insulin mechanical complication due to other implant and internal device, not elsewhere classified hypoxemia personal history of malignant neoplasm of other gastrointestinal tract personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria postsurgical hypoinsulinemia 

Answer: The patient is high likely exposed to