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 / codeine / iodine; iodine containing / darvocet-n 100 attending: chief complaint: fever, abdominal pain major surgical or invasive procedure: ercp () picc line placement () history of present illness: ms. is a 71f with stage 4 pancreatic head cancer s/p biliary stenting presenting with fevers at home. she reports that otherwise she felt ok, her ros is only notable for one episode of vomiting yesterday. she denies any chills, night sweats, abdominal pain, increase in frequency of stools, change in skin color, confusion, or increased pruritis. she also denies any new cough, dysuria, frequency or polyuria. . in the ed presenting vitals were t=98.8-102.5, bp=130/57, hr=83, rr=20, 96% on room air. notably, she had some episodes of svt in the ed to 150s, with associated hypotension to the 70s/50s. these episodes reverted spontaneously within ~30seconds before any treatments or ekgs could be initiated her exam was notable for ruq tenderness. laboratory data was notable for an increase in her transaminases and alkaline phosphatase. her tbili was at baseline, her lactate was 1.7, and she did not have a leukocytosis. urinalysis was negative, blood and urine cultures were sent. a ruq ultrasound showed expected pneumobilia with pancreatic ductal dilation. a ct abdomen and pelvis showed proper stent placement with biliarly ductal dilation, and incidental cecal thickening. ercp fellow was made aware of the admission and recommended an ercp tomorrow. renal and cardiology were asked to see the patient first thing in the am prior to this for hd and evaluation. she was given 4.5g of unasyn and 1g of tylenol. past medical history: 1. stage four pancreatic cancer: newly diagnosed in 10/. s/p biliarly stent on . oncologist is dr. . not a surgical candidate, and may have liver metastases. has seen in palliative care, however, no decisions have been made yet with regard to hospice care. per note from dr. , the patient has decided to not proceed with chemotherapy and concentrate on quality of life. 2. avnrt: managed with beta blocker therapy only per cardiology consultation given poor prognosis of other co-morbidities. has syncopized in the past secondary to this. 3. htn 4. type 2 diabetes mellitus 5. esrd on hd mwf: nephrologist is dr. 6. chronic systolic and diastolic chf 7. h/o retinal detachment 8. hyperlipidemia social history: never smoked, no etoh in 30+ years, no tobacco; lives at home independently although her daughter has been staying with her since her discharge from the hospital. family history: brother with pancreatic cancer physical exam: vital signs: t 98.8, 71, 136/41, 96% ra general: nad, lying in bed in bed. heent: normocephalic, atraumatic. no conjunctival pallor. mild icterus. surgical pupils bl. eomi, op clear. cardiac: regular rate and rhythm. normal s1, s2. ii/vi holosystolic murmur loudest at axilla. lungs: ctab, good air movement bilaterally. abdomen: non tender/non distended, hyperactive bowel sounds. extremities: no edema or calf pain, 2+ dp pulses. av fistula with bruit on left arm skin: no obvious jaundice psych: listens and responds to questions appropriately, pleasant cn intact. 5/5 strength. pertinent results: pertinent laboratory data: 3:10 pm blood culture blood culture, routine (preliminary): escherichia coli. final sensitivities. warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. tigecycline = 0.25 mcg/ml, sensitive , sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- =>64 r cefepime-------------- r ceftazidime----------- r ceftriaxone----------- =>64 r cefuroxime------------ =>64 r ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s piperacillin---------- =>128 r piperacillin/tazo----- <=4 s tobramycin------------ 4 s trimethoprim/sulfa---- =>16 r anaerobic bottle gram stain (final ): reported by phone to , r.n. on at 0500. gram negative rod(s). on admission: alt(sgpt)-331* ast(sgot)-753* ck(cpk)-25* alk phos-729* tot bili-2.5* dir bili-1.6* indir bil-0.9 glucose-221* urea n-34* creat-7.2* sodium-139 potassium-3.2* chloride-95* total co2-32 anion gap-15 wbc-5.1 rbc-3.29* hgb-9.7* hct-29.6* mcv-90 mch-29.6 mchc-32.9 rdw-17.0* pt-12.7 ptt-23.5 inr(pt)-1.1 chest radiograph, ap (): low lung volumes are present. the heart is mildly enlarged, unchanged. the aorta is unfolded with aortic knob calcifications again demonstrated. there is accentuation of the pulmonary vascular markings with crowding of vascular structures, likely due to low lung volumes. lungs are grossly clear without focal consolidation, pleural effusions, or pneumothorax. osseous structures are unremarkable. chronic thickening of the left pleura is again noted. ct abdomen/pelvis without contrast (): 1. known mass in the head of the pancreas is suboptimally evaluated in the absence of iv contrast. stent in expected location of the distal common bile duct is probably patent, given presence of pneumobilia. mild biliary ductal dilatation. adjacent duodenal wall thickening may be due to underdistention, however, inflammatory changes and/or tumor involvement is not excluded. 2. cecal wall thickening is nonspecific and could be due to inflammatory or infectious reasons. 3. unchanged splenic lesions. stable appearance of the prominent left adrenal gland. abdominal ultrasound (): 1. redemonstration of a known pancreatic head mass with distal pancreatic atrophy and pancreatic duct dilatation. 2. cbd stent not visualized, however, presence of pneumobilia suggests patency of the stent. 3. mild biliary ductal dilatation. left lobe hepatic hyperechoic lesion measures slightly larger today, and may be due the technical reasons; this probably represents hemangioma, however, a metastatic lesion not excluded in the setting of malignancy. ercp (): eight intraprocedural spot radiographs of the right upper quadrant from an ercp show a pre-existing metallic stent in the common bile duct. subsequent images show cannulation and opacification of the common bile duct with a mild diffuse dilatation. irregular filling defects are seen in the common bile duct during its course through the metallic stent. there are no other filling defects and there are no strictures. further details can be found in the ercp report in the patient's online medical record. tte (): the left atrial volume is markedly increased (>32ml/m2). the interatrial septum is aneurysmal. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the mid inferior and inferolateral segments. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no vegetation, abscess or significant valvular regurgitation seen. moderate symmetric lvh with mild focal lv systolic dysfunction. biatrial enlargement. chest radiograph (): in comparison with the study of , there has been placement of a right subclavian picc line that extends to the lower portion of the svc. no evidence of acute pneumonia or other cardiopulmonary abnormality. brief hospital course: 71 year old female with stage 4 pancreatic cancer presented with fevers, vomiting, and abdominal pain on . hospital course was as follows: 1. bacteremia: on admission, patient was febrile to 102.5 found to have ruq tenderness. did not appear jaundiced and bilirubin was elevated but below baseline. given known pancreatic head mass and evidence of ductal dilatation on ct, concern for ascending cholangitis. blood cultures ( set) grew out gnr within first 24 hours. patient reportedly received unasyn in emergency department; antibiotic regimen was changed to ciprofloxacin and flagyl given reported history of allergy to penicillins in past. on day 1 of admission, patient underwent ercp with debris extraction from major papilla stent. she continued to be febrile post-procedure. sensitivities revealed e coli sensitive to only zosyn; further antibiotic sensitivities are pending. given history of pencillin allergy (anaphylaxis) in and unclear history regarding whether patient has received penicillins since that time, patient was transferred to micu for pencillin desensitization. zosyn desensitization was completed in micu with decreased beta-blocker dosing (beta-blockers lower threshold for anaphylaxis reaction). on readmission to medicine floor, antibiotic regimen was changed to meropenem given identification of e coli as an extended-spectrum beta-lactamase (esbl) producer. patient tolerated therapy well. tte was conducted to assess for seeding on valve; no vegetations were seen. picc line was placed on . antibiotic course to continue for total 14 days. 2. pancreatic cancer, stage 4: the patient is no longer a surgical candidate, nor would she benefit from chemotherapy, and has decided not to go forward with aggressive management. palliative care was contact during admission, and patient elected to have home hospice with continuation of hemodialysis and antibiotics. 3. avnrt: in emergency department, patient was noted to be tachycardic with concurrent hypotension. episodes were short-lived (~30 seconds). on floor patient with stable vital signs; on review of telemetry patient had few episodes of sinus tachycardia to 150s. home beta-blocker regimen was changed from metoprolol tartate 150mg po daily to 75mg po bid. cardiology was consulted in emergency department; on floor recommended rate control. on day 1 of admission patient triggered for tachycardia to 130s; by ekg, she was found to be in atrial fibrillation with rvr. patient received metoprolol 5mg iv x4, diltiazem 10mg iv x1, metoprolol 50mg po, and diltiazem 30mg po with improvement in heart rate. for remainder of hospital course heart rate well-maintained with metoprolol and diltiazem po. 4. esrd: continued mwf hd sessions, nephrocaps, and sevelamer. nephrology involved. 5. dm: held glipizide. on sliding scale insulin while inpatient. **code status: dnr/dni, confirmed with patient medications on admission: amlodipine 10mg daily nephrocaps glipizide 2.5mg daily hydroxyline 25mg daily metoprolol tartrate 150mg daily sevelamer 800mg daily discharge medications: 1. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 4. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 5. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 6. heparin, porcine (pf) 10 unit/ml syringe sig: 3-5 mls intravenous daily and prn as needed for line flush. disp:*2 week supply* refills:*0* 7. saline flush 0.9 % syringe sig: injection daily and prn as needed for line flush. disp:*2 week supply* refills:*0* 8. meropenem 500 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours) for 11 days. disp:*11 recon soln(s)* refills:*0* 9. diltiazem hcl 120 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po once a day. disp:*30 capsule, sust. release 24 hr(s)* refills:*2* 10. glipizide 2.5 mg tab,sust rel osmotic push 24hr sig: one (1) tab,sust rel osmotic push 24hr po once a day. 11. morphine 15 mg tablet sig: as directed tablet po every four (4) hours as needed for pain: take to 1 tablet every 4 hours as needed for pain. please be aware this medication causes drowsiness. do not drive or operate any equipment or machinery while taking. hold for respirations < 10/minute or oversedation. disp:*180 tablet(s)* refills:*0* 12. iv morphine instructions please continue to take morphine sulfate 1-2 mg iv q4h:prn for pain relief hold for oversedation discharge disposition: home with service facility: hospice discharge diagnosis: primary: - ascending cholangitis - e. coli bacteremia - penicillin desensitization secondary: - av nodal re-entrant tachycardia - end stage renal disease, on hemodialysis discharge condition: ambulatory. hemodynamically stable. discharge instructions: you were admitted on with abdominal pain and a fever. during your hospitalization, you were found to have bacteria in your blood, likely coming from your abdomen. you underwent ercp, a procedure to visualize that stent that was placed in your bile duct; this area was cleaned. you also received iv antibiotics; this required a brief stay in the icu to allow you to take penicillins given that you have a pencillin allergy. you had a picc line placed to allow for a total 14 day course of iv antibiotics. your medication regimen has changed. please review the medication list closely. changes include: - adding diltiazem (by mouth), a medication to help control your heart rhythm - adding meropenem (by iv), an antibiotic - stopping amlodipine - taking metoprolol at a different dose three times daily rather than at the current dose once daily. during the hospital course you and your family had discussions regarding your care with the palliative care team. a hospice organization will be working with you at home. please be sure to follow-up with your appointments as listed below. please call your physician or return to the emergency department if you have any concerns. the hospice organization will work with you and your family to make you comfortable at home. followup instructions: dr. at 1:10pm phone: ( provider: , m.d. (ophthalmology) phone: date/time: 1:45 provider: , md phone: date/time: 2:00 provider: . (oncology) phone: date/time: 2:00 procedure: venous catheterization, not elsewhere classified endoscopic retrograde cholangiopancreatography [ercp] diagnoses: end stage renal disease congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other specified cardiac dysrhythmias mechanical complication due to other implant and internal device, not elsewhere classified septicemia due to escherichia coli [e. coli] cholangitis malignant neoplasm of other specified sites of pancreas chronic combined systolic and diastolic heart failure 

Answer: The patient is high likely exposed to