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: levofloxacin / iodine / premarin / mustard / reglan attending: chief complaint: abdominal pain, fever, elevated lfts major surgical or invasive procedure: ir guided ptbd placement ptbd exchange biliary stent placement history of present illness: this is a 69 y/o woman with hx gastric cancer s/p roux-en-y gastrectomy in , with recurrent hospitalizations for malnutrition, pain, and diarrhea/constipation presents from ltac with new-onset elevated lfts, new abdominal pain, and fever. since her roux-en-y, she has had persistent nausea and vomiting and is unable to tolerate po intake, lost 15 lbs over past several months (baseline weight 130-135 lbs, weight before surgery 115 lb, weight now 99 lb). on tpn and tube jeeds through j-tube. increased diarrhea over past two weeks, describes it before as being light colored and frothy, now brown and watery. has not initiated chemotherapy due to poor nutritional status. . over the past few days at , her lfts rose to ap 1500, alt 500 and tbili 1.4. morning of she had fever to 101. she has chronic llq pain around j-tube, has new-onset ruq pain and increase abd pain diffusely. pain , relieved with dilaudid, exacerbated by eating. noncon ct abdomen at showed diffuse intrahepatic and extrahepatic ductal dilitation and distention of the gallbladder. no obvious mass lesion was identified, however contrast was not used due to hx allergy to iodine. mrcp showed dilated cbd 16mm, fullness of pancreatic head (no obvious mass), massively distended gallbladder and right hydronephrosis. . vitals prior to transfer: 111/63, 71, 97% on room air. given zosyn 2.25mg as empiric coverage for cholangitis prior to transfer. . ros otherwise negative for headache, vision changes, congestion, cough, shortness of breath, chest pain, brbpr, melena, hematochezia, dysuria, hematuria, frequency. past medical history: gastric cancer, s/p subtotal gastrectomy, roeux-en-y gastrojejunostomy, j-tube() cervical laminoplasty c2-c6 on left calcaneal fracture s/p orif hypothyroidism macular degeneration- left eye is legally blind gerd hx of pyloric channel ulcer essential tremor copd hx of left salpingo-oopherectomy-remote past appendectomy in childhood social history: lives in , is a retired professor . she lives alone in a house and is divorced. has 1 son who lives out of state. has support at home since her surgery and vna. smoking - smoked 1 pack per day since y/o, currently smokes cigarettes/day alcohol - rare illicits - none family history: father-died of cad at 84 mother-died of 54 shy- disease maternal grandmother-renal ca maternal grandfather- lung cancer physical exam: admission physical exam: vs - 100.2 138/80 82 18 96% ra general - nad, cachectic, states she is in pain heent - nc/at, perrla, eomi, mm dry, op clear neck - supple, no cervical lad or jvd lungs - cta bilat, no r/rh/wh, breath sounds distant, resp unlabored heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, tender with voluntary guarding ruq and right and left mid quadrants, nd, no appreciable ascites, no masses or hsm, j tube without exudate, no rebound or involuntary guarding extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout pertinent results: studies: ir ptbd placement - findings: 1. high-grade obstruction at the distal cbd. 2. left biliary tree was not opacified. follow-up interrogation should be performed if clinically indicated. 3.placement of 10 french internal-external drain in the right posterior ductal system. 5. satisfactory post-procedure cholangiogram demonstrating opacification of ducts and appropriate placement of catheter. . j-tube fluoroscopic study - impression: functioning j-tube. . cxr : heterogeneous pacity in right lower lobe may either represent pneumonia or aspiration pneumonitis. . abdomen s&e : decubitus and supine views of the abdomen show no evidence of free air. there is a paucity of air within the abdomen and retained enteric contrast is seen. the j-tube and biliary drains are unchanged in position. a vague opacity seen in the right lower lobe is concerning for either pneumonia or aspiration and is better characterized on the concurrent chest x-ray. a right-sided central line is noted. there are extensive degenerative changes about the lower lumbar spine . gastrograffin j tube check : impression: no leak. j-tube is directed retrograde. . ptbd check/exchange : 1. occluded existing 10 french percutaneous biliary drainage catheter. 2. high-grade stricture of the distal common bile duct, 1-2 cm distal to the cystic duct insertion. 3. uncomplicated replacement of a 10 french internal-external biliary drainage catheter . picc placement cxr : 1. left picc tip in mid-to-low svc. 2. bibasilar atelectasis with developing right apical opacity, compatible with pneumonia . biliary stent placement : 1. reocclusion of a 10 french internal-external biliary drainage catheter. 2. successful deployment of 12 mm x 90 mm wallstent across the high-grade stricture of the distal common bile duct. 3. pre-stenting and post-stenting balloon dilatation of the high-grade stricture of the distal common bile duct using a 12 x 40 mm balloon. 4. temporary placement of a 10 french amplatz anchor drain into the common hepatic duct anticipated to be removed within 24-48 hours. . . biliary stent check 1. occlusion of the metallic stent by the soft intraluminal debris after recent metallic stent deployment and balloon dilatation. 2. 10 french amplatz anchor drain was left in place and connected to the bag for external drainage. 3. anticipated recanalization of the stent/sweeping and dilatation will be performed with the assistance of department of anesthesiology, either under monitored anesthesia care or general anesthesia at the earliest available time. . biliary dilation 1. pre-procedure occlusion of mid and distal portions of cbd wallstent. 2. successful balloon dilatation and sweeping of cbd stent, with post-procedure demonstration of stent patency. 8 french amplatz anchor drain left with tip in proximal cbd with orders to cap at 1800 on . 3. j-tube injection showing probable antegrade orientation and no leak around jejunostomy site. . biliary dilation: 1. complete obstruction of the stent distal to this cystic duct towards the duodenum. 2. balloon dilatation with 12 mm x 40 mm balloon and balloon sweep towards the duodenum. 3. placement of a 12 french internal-external biliary drain, which was capped f exchanged pr internal drainage. this drain needs to be changed every 3 months. . microbiology. negative except where otherwise indicated stool clostridium difficile toxin a & b test-pending inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient catheter tip-iv wound culture-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient stool clostridium difficile toxin a & b test-final inpatient urine urine culture-final inpatient mrsa screen mrsa screen-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {enterococcus faecium, vancomycin sensitive}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final urine urine culture-final inpatient bile gram stain-final; fluid culture-final {enterococcus sp. vancomycin sensitive}; anaerobic culture-final urine urine culture-final {enterococcus sp. vancomycin sensitive, corynebacterium species (diphtheroids)} blood culture blood culture, routine-final inpatient pertinent chemistry results: 11:40pm blood wbc-6.8 rbc-3.57* hgb-9.8* hct-32.3* mcv-91 mch-27.5 mchc-30.4* rdw-16.4* plt ct-367 05:28am blood wbc-4.7 rbc-3.37* hgb-9.2* hct-30.5* mcv-91 mch-27.2 mchc-30.1* rdw-16.5* plt ct-420 05:56am blood wbc-10.5# rbc-3.37* hgb-9.3* hct-29.8* mcv-88 mch-27.6 mchc-31.2 rdw-17.4* plt ct-399 06:30am blood wbc-7.9 rbc-3.30* hgb-9.1* hct-28.7* mcv-87 mch-27.6 mchc-31.7 rdw-17.9* plt ct-377 04:26am blood wbc-11.3* rbc-3.61* hgb-9.9* hct-32.0* mcv-89 mch-27.3 mchc-30.8* rdw-17.7* plt ct-596* 07:40am blood wbc-11.9* rbc-3.18* hgb-8.7* hct-27.3* mcv-86# mch-27.3 mchc-31.8 rdw-18.3* plt ct-334 11:40pm blood pt-13.5* ptt-36.9* inr(pt)-1.3* 05:28am blood pt-14.3* ptt-41.1* inr(pt)-1.3* 11:40pm blood glucose-81 urean-12 creat-0.6 na-136 k-4.2 cl-97 hco3-31 angap-12 05:13am blood glucose-131* urean-13 creat-0.6 na-138 k-4.0 cl-103 hco3-28 angap-11 05:27am blood glucose-102* urean-16 creat-0.4 na-137 k-3.6 cl-106 hco3-27 angap-8 06:38am blood glucose-139* urean-14 creat-0.6 na-138 k-4.5 cl-103 hco3-31 angap-9 05:32am blood glucose-165* urean-24* creat-0.5 na-134 k-4.7 cl-98 hco3-31 angap-10 07:40am blood glucose-96 urean-21* creat-0.6 na-132* k-4.1 cl-96 hco3-30 angap-10 11:40pm blood alt-657* ast-512* ld(ldh)-211 alkphos-* amylase-40 totbili-2.0* 02:09pm blood alt-605* ast-494* alkphos-1847* totbili-2.4* 11:00am blood alt-467* ast-296* alkphos-1821* totbili-2.2* 05:13am blood alt-212* ast-51* alkphos-1107* totbili-0.8 05:56am blood alt-147* ast-27 ld(ldh)-121 alkphos-924* amylase-386* totbili-1.6* 05:43am blood alt-82* ast-20 alkphos-614* totbili-0.9 06:45am blood alt-50* ast-31 alkphos-626* totbili-2.3* 05:38pm blood alkphos-543* totbili-2.6* 06:50am blood alt-50* ast-32 alkphos-525* totbili-1.7* 06:30am blood alt-34 ast-16 alkphos-420* totbili-1.2 03:45am blood alt-61* ast-33 alkphos-258* totbili-0.7 05:49am blood alt-41* ast-43* alkphos-191* totbili-0.6 07:40am blood alt-45* ast-30 alkphos-220* totbili-0.7 11:40pm blood albumin-3.1* calcium-8.8 phos-3.5 mg-1.9 05:56am blood calcium-8.4 phos-2.0* mg-1.8 06:50am blood calcium-7.4* phos-2.8 mg-1.9 07:40am blood calcium-8.3* phos-3.5# mg-2.0 05:52am blood albumin-2.8* calcium-8.7 phos-3.1 mg-2.0 06:30am blood triglyc-195* 06:50am blood vanco-22.2* 06:50pm blood vanco-19.2 12:03pm blood type-art temp-38.1 po2-77* pco2-39 ph-7.46* caltco2-29 base xs-3 intubat-not intuba 12:03pm blood lactate-1.1 12:06pm blood lactate-1.2 09:06pm blood glucose-greater th lactate-1.0 urine chemistry: 11:58am urine color-yellow appear-hazy sp -1.018 08:57pm urine color-yellow appear-clear sp -1.009 10:45am urine color-dkamb appear-hazy sp -1.015 08:58pm urine color-red appear-hazy sp -1.017 08:57pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-tr 10:45am urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirub-sm urobiln-neg ph-5.5 leuks-sm 08:58pm urine blood-lg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-tr 11:58am urine rbc-2 wbc-7* bacteri-mod yeast-none epi-1 08:57pm urine rbc-2 wbc-1 bacteri-few yeast-none epi-0 10:45am urine rbc-28* wbc-7* bacteri-few yeast-none epi-0 08:58pm urine rbc-135* wbc-24* bacteri-few yeast-none epi-0 brief hospital course: principle reason for admission: 69 year old female with gastric cancer s/p roux-en-y gastrectomy admitted with cholangitis s/p ptbd placement and failed biliary stent placement across malignant stricture. active problems # pain control/nausea/anxiety/agitation/palliation - patient with chronic abdominal pain, acutely worsened with cholangitis. she has a significant narcotic requirement, and palliative care was consulted to provide guidance with narcotic use. regimen initially included dilaudid and methadone. patient was ultimately continued on methadone and switched to dilaudid pca. patient had difficult to control nausea and emesis. nausea was controlled with ondansetron, promethazine, and lorazepam. additional prochlorperazine was also used occasionally. patient was also started haldol with good effect. later she was transitioned to thorazine for nausea with the intent of providing relief from nausea and also for sedation as patient was very agitated and restless. she continued to suffer even on the regimen of standing and prn thorazine, dilaudid, methadone, decadron. she received ativan for sedation with paradoxical agitation. she remained delerious likely secondary to pain and steroids. patient and her son/health care proxy both expressed wishes that she receive palliative sedation as she was restless and intermittently agitated on multiple regimens. the palliative care service recommended palliative sedation, which was consistent with the patient's wishes. on , there was a meeting with the primary medical team, palliative care, ethics service, social work, nursing, hospice, and hospital administration. as all other palliative measures had been exhausted, it was felt that palliateive sedation was the most appropriate and medically necessary treatment. please see omr notes by ethics service, palliative care, and medicine from for further details. patient was started on a pentobarbital infusion and was able to rest peacefully with marked improvement in agitation. on at 16:48, patient expired. #) cholangitis: patient presented from ltac with increased ruq pain, fever, and rising t.bili givng concern for cholangitis. she was treated empirically for cholangitis with ciprofloxacin and flagyl. ptbd drain was placed on with initial resolution of fevers and t. bili began to downtrend. of note, cholangiogram during procedure revealed high grade obstruction of the distal cbd. on the morning of she re-developed fever and blood pressures began to drop to 90'/50's initially unresponsive to ivf bolus on the floor necessitating transfer to the micu. antibiotics were broadened to vancomycin and zosyn and patient underwent further aggressive fluid resuscitation. fevers and hypotension resolved and patient was transferred back to the floor on . microbiology cultures of blood, urine, and bile were notable for ampicillin-resistant enterococcus sensitive to vancomycin. patient remained afebrile, although did require ptbd drain exchange on for rising t. bilirubin. patient underwent biliary stent placement on . repeat ptca showed occlusion of stent. she returned to ir for recanulization of stent, which unfortunately failed. an internal drain was placed through stent to drain into the duodenum and external drain also placed. patient completed 14 day course of vancomycin and zosyn on . #) nutrition: patient was chronically malnourished with 30 lb recent weight loss, and has been on tube feeds and tpn concurrently prior to admission. tf's were initially held as to not exacerbate abdominal pain and tpn was continued. upon reinstitution of tf's, there was concern for malfuction of j-tube due to apparent leakage. fluoroscopic and gastrograffin studies of the j-tube revealed functioning, but retroverted positioning of j-tube. further evaluation of j-tube revealed anterograde, funtioning tube. following development of vse bacteremia, tpn was held as picc line was removed. picc was replaced on following >72 hours of negative blood cultures and tpn was resumed on . tpn was discontinued on given patient's goals of care. #) right hydronephrosis: has evidence of ureteralpelvic junction obstruction on mrcp. no stone seen, renal function is normal. urology was , and recommended scan. given transition of goals of care, no further action was taken. chronic problems #) gastric adenocarcinoma s/p surgical resection: originally diagnosed after subtotal gastrectomy with roux-en-y ansatomosis on for presumed gastric outlet obstruction. lymph nodes and omental margins were positive, but duodenal and gastric margins were negative. patient did not receive additional treatment due to complicated post-operative involving severe pain, nausea and malnutrition. patient was deemed to be a poor candidate for chemotherapy, palliative or otherwise. #) anemia: stable, baseline low and variable. normocytic anemia, likely acd, however had iron studies which were normal. stable and no signs of active bleed. medications on admission: tylenol 325-650mg q6h prn albuterol inhaler prn arixtra 2.5mg daily fluticasone 220mcg hydromorphone 4mg q4h prn through jtube jevity 1.2 full strength at 30ml/hour and 55ml/hour is target levothyroxine 100mg iv daily (just increased on from 50mcg daily) lorazepam 0.5mg q4h prn nausea through jtube methadone 7.5mg q6h through jtube nicoderm patch 14mg daily oil retention enema pr daily prn zofran 4mg iv q4h prn nausea pantoprazole 40mg iv daily zosyn 2.25mg iv q6h (started on for possible cholangitis) compazine 5mg iv q6h or 25mg pr q12h prn nausea promote with fiber at 30ml and hour with goal of 55ml/hr and tp cycled starting at 7pm discharge medications: not applicable discharge disposition: expired discharge diagnosis: primary: cholangitis, gastric adenocarcinoma discharge condition: patient expired discharge instructions: not applicable. followup instructions: not applicable. md procedure: venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract other percutaneous procedures on biliary tract percutaneous hepatic cholangiogram percutaneous hepatic cholangiogram percutaneous hepatic cholangiogram diagnoses: esophageal reflux tobacco use disorder urinary tract infection, site not specified unspecified acquired hypothyroidism chronic airway obstruction, not elsewhere classified nausea with vomiting anxiety state, unspecified bacteremia macular degeneration (senile), unspecified other specified disorders of biliary tract iron deficiency anemia, unspecified other and unspecified special symptoms or syndromes, not elsewhere classified fever, unspecified abdominal pain, other specified site other postprocedural status streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] encounter for palliative care do not resuscitate status hydronephrosis cholangitis obstruction of bile duct legal blindness, as defined in u.s.a. other alteration of consciousness secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes neoplasm related pain (acute) (chronic) personal history of peptic ulcer disease nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] other specified disorders of gallbladder other severe protein-calorie malnutrition other ureteric obstruction attention to other artificial opening of digestive tract essential and other specified forms of tremor infection with microorganisms with resistance to multiple drugs malignant neoplasm of pyloric antrum 

Answer: The patient is high likely exposed to