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: gluten / augmentin attending: chief complaint: fever and diarrhea major surgical or invasive procedure: flexible sigmoidoscopy picc line placement and removal tunneled line placement ercp history of present illness: 85 year old man with history of refractory celiac disease, hypertension, history of pulmonary embolism, cystic pancreatic lesions, and osteoporosis who presents with abdominal pain, diarrhea, and lethargy. he was last discharged on after an admission for gallstone pancreatitis, pan sensitive e. coli bacteremia, pneumonia, bilateral pleural effusions, and new onset afib. an ercp during this admission showed a small stone and sludge was extracted and a stent was placed. the plan was for follow up with dr. for an elective outpatint cholecystectomy in months and for repeat ercp in wks for stent removal, balloon sweep, and pancreatic duct evaluation. the pt was discharged to rehab. 4 days ago later, he developed brown watery diarrhea, non bloody emesis, and inability to take pos. of note he finished a course of ceftriaxone and azithromycin on . he denies fever and is positive for abdominal pain in his left lower quadrant. per the pt's report he was started on flagyl at rehab which was discontinued due to increased liver enzymes. in the ed vitals were 98.6 112/48 101 22 98% on ra. in the ed he had tenderness in the left abdomen and was guaiac positive. ct abd showed gallstones, air in lumen of gallbladder likely related to ercp/stent placement, and no evidence of obstruction. there was no evidence of cholangitis. the pt was given iv flagyl, vanco, and zosyn as well as po vanco. surgery did not see a need for surgical intervention. cxr revealed no infiltrates. temp was 101 rectally. the patient was admitted to for concern for sepsis. review of systems: (+) per hpi. +recent weight loss (cannot quantify). +sore throat x 1 day(attributes to dryness). +mild dysuria. +visual "disorientation" recently. (-) no fever, chills. no headache. no shortness of breath or pain with inspiration. no chest pain or discomfort. no dizziness, lightheadedness, presyncope, syncope, or palpitations. no dysuria or hematuria. no joint or muscle pain. past medical history: - refractory celiac disease; currently getting tpn four nights a week, followed by dr. fib-diagnosed in -occipital embolic cva in while off ac -?lymphoma per prox ileal bx in -gallstone pancreatitis s/p recent ercp and stent placement -small bowel resection for sbo () -ulcerative ileojejunitis () & loa in for sbo - severe hypertension - iron deficiency anemia - rll pulmonary embolism - incidental finding after a ct scan was performed for evaluation of possible pancreatic mass. on coumadin x six to seven months, stopped recently. - cystic pancreatic lesions - followed with serial ct scans - kidney stone - work up of this showed possible pancreatic mass - subclinical hypothyroidism - peripheral neuropathy - osteoporosis - not on a bisphosphonate - hypogonadism - anxiety disorder social history: most recently at rehab but normally lives in . wife died in . retired comptroller of . no tobacco or etoh. family history: no known fh of celiac disease. physical exam: exam upon arrival to medicine floor : vs: t 99.4f, bp 120/58 hr 94 rr 18 96% ra general: nad heent: eomi, no scleral icterus. mmm, oropharynx clear. neck supple cardiac: rrr with ectopic beats. normal s1, s2. no murmurs, rubs or . lungs: ctab abdomen: soft, nondistended, no tenderness (previously diffusely tender), bowel sounds present extremities: no edema. warm. neuro: alert and fully oriented, fluent speech. cn 2-12 intact. ue and le strength 5/5. normal tone/decreased bulk. psych: listens and responds to questions appropriately. appropriate, slightly depressed affect. . on vitals: 98.6 132/64 74 18 96%ra 4bms/24hours pain: l upper chest over new tunneled area access: l tunneled line c/d/i gen: sitting up in chair heent: mm dry cv: irreg irreg, no m resp: ctab, no crackles or wheezing abd; soft, mild-mod distended, nontender, +bs ext; no edema neuro: a&ox3, grossly nonfocal, has difficultly remembering things at times. skin: no changes psych: flat, depressed pertinent results: wbc 16->20->20->27->19->25->21 hct 25.8-30 stable plt 417 bun/creat 43/1.2-->49/1.4->28/0.6 on lfts wnl, alk phos 126 . inr 2.4 on . tsh 1.4 hiv neg rpr nr . ua neg fena 0.6% . c-diff neg c-diff neg stool o&p neg x2 stool cx neg, including crypto/micro/cyclo cath tip cx neg all blood cx neg to date . egd biopsy a. "gastric ulcer:" 1. antral and fundic type mucosa with focal erosion, mild associated chronic active inflammation and epithelial regeneration. 2. stain is negative for h. pylori, with a satisfactory control. b. duodenum: duodenal mucosa with marked villous atrophy and increased intraepithelial lymphocytes; see note. note: the duodenal findings are consistent with involvement by the patient's known celiac disease. at the request of the clinician, slides will be sent for t-cell receptor gene rearrangement studies, and the results will be issued separately in an addendum . . . imaging/results: ct a/p with contrast : 1. new wedge-shaped hypoattenuation in the interpolar region of left kidney may represent infarct, although focal infection and neoplasm are less likely possibilities. followup contrast enhanced ct or mr when the patient's symptoms resolve recommended to exclude neoplasm. 2. unchanged mildly dilated small bowel loops around anastomotic site. 3. unchanged renal and hepatic hypodensities, and likely left lobe hemangioma. 4. pancreatic cystic lesions, one of which represents ipmn based on prior ercp stable from , but both slightly increased since . 5. cholelithiasis without evidence of cholecystitis. 6. atherosclerotic disease of the abdominal aorta and its branches. . . egd : a few small ulcers were found in the antrum and body of the stomach. cold forceps biopsies were performed for histology at the stomach antrum. duodenum: : diffuse blunting of the villi was noted throughout the duodenum. cold forceps biopsies were performed for histology at the duodenal bulb. impression: gastric ulcer (biopsy) normal mucosa in the duodenum (biopsy) otherwise normal egd to third part of the duodenum . tte the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. ct abd 1. there is a question of intramural edema involving the descending and sigmoid colons; however, this appearance may simply be due to nondistention and intraluminal fluid as the adjacent fat shows no definite inflammatory change. please correlate clinically. 2. no change in pancreatic lesions as described, expected pneumobilia, cholelithiasis, probable liver hemangiomas. 3. small wedge-shaped area of absent contrast enhancement within the inferior pole of the right kidney, likely representing a small infarct, relatively acute or subacute given lack of renal capsular retraction. this area could not be appreciated on the most recent prior study due to lack of intravenous contrast. . colonic mucosal biopsies: a. proximal descending: colonic mucosa with focal acute inflammation and crypt regeneration, suggestive of adjacent injury. b. distal sigmoid: 1. colonic mucosa with focal, mildly active colitis and erosion; see note. 2. immunostain for cmv is negative for viral inclusions, with satisfactory controls. . ercp: impression: a plastic stent placed in the biliary duct was found in the major papilla. the plastic stent was removed via snare. evidence of a previous biliary sphincterotomy was noted in the major papilla. cannulation of the biliary and pancreatic ducts was successful and deep with a sphincterotome using a free-hand wire guided technique. a single 5 mm stone that was causing partial obstruction was seen at the lower third of the common bile duct. a biliary sphincterotomy was successfully extended in the 12 o'clock position using a sphincterotome over an existing guidewire. one stone and sludge/debris was extracted successfully using a balloon catheter. repeat balloon sweeps were negative and occlusion cholangiogram revealed no residual filling defects. a segmental dilation of the side branches of the pancreatic duct was seen at the head of the pancreas. this was consistent with side-branch ipmn. the main duct was without filling defects. . brief hospital course: mr. is an 85 year old man with history of celiac disease, hypertension, history of pulmonary embolism, a fib, osteoporosis, and gallstone pancreatitis who presented with elevated wbc/fever/elevated lactate/diarrhea/arf. each of the problems addressed during this hospitalization are described in detail below: . # colitis/gi bleeding: pt admitted to icu with sepsis (febrile, tachycardic, leukocytosis, bandemia (bands 37 on admission), elevated lactate). based on the clinical presentation, recent abx course, there was a high suspicion of c. diff colitis, although other etiologies such as other infectious etilogies, ischemic colitis given atrial fibrillation, cholangitis, refractory celiac disease were considered. no evidence of colitis was present on abd ct scan, although this was a noncontrast study. the patient was pan-cultured and started on antibiotic regimen including po vanco, flagyl, and zosyn. a number of other studies were sent including fecal culture, ova and parasites, c. diff, yersenia, shigella, campylobacter, microsporidia, giardia, cryptosporidium were sent and were negative. the patient was kept npo, put on tpn. aggressive fluid resuscitation was given. c. diff toxins were negative x 4 and po vancomycin was discontinued on . the patient was seen by gi service, who recommended continuing abx treatment with iv vanc, zosyn, flagyl and contacting ercp to discuss follow-up of the biliary stent placed on . on transfer to the floor, the pt continued to have persistent leukocytosis and diarrhea. the id team was consulted to discontinue zosyn given that his picture was consistent with colitis. on , the pt underwent a flexible sigmoidoscopy which revealed a friable, ulcerative colonic mucosa which was concerning for viral pathologies such as cmv. he was empirically changed to po vancomycin for concern of severe c diff and started on ganciclovir for empiric cmv coverage. a serum cmv viral load was sent and was negative. pathology of colon biopsies was consistent with colitis, inflammation. cmv stains on path were negative as well. . though all c diff and cmv studies have returned negative, a decision was made with gi and id teams' input to continue both oral vanco and ganciclovir treatment, though vancomycin po was d/c'd on as cdiff was negative x6. though his clinical picture seemed to fit c diff (colitis, diarrhea, leukocytosis) his diarrhea seemed to improve when ganciclovir was initiated. with the completely negative infectious results, there was also some strong concern that this event may have been ischemic colitis as the patint also has evidence of embolic infarcts in his brain and has atrial fibrillation, so the decision was made to restart the patient on coumadin with a heparin bridge. . . patient then had approximately 5 bowel movements from 0300 to 0600 passing marroon stools with clots. his hct was 21.1 on morning labs on and was transferred to the icu. . while in the icu he receieved 3u of blood and had a negative bleeding scan. he was started on iv ppi and changed back to home medication on . his hct remained stable and he had a brown stool the morning of transfer back to the floor. a repeat flex sig showed good healing of the colonic lesions so anticoagulation was restarted. . on his diarrhea began to worsen again. id and gi were called back to re-examine and another infectious w/u was initiated, but was again unrevealing. an egd was performed and 2 gastric ulcers were found and biopsies of the small intestine were done in multiple places to r/o malt. these results showed celiac sprue, with malt stain pending at the time of discharge. he was started on loperamide for symptomatic improvement which worked well and should be titrated to bm's per day. . at the time of discharge the patient had been receiving loperamide and was down to 1-2 bm per day, but was having some increasing abd distention. plan is to hold all loperamide and restart if bm frequencies increase. need pathology f/u as well. need f/u hct checks and monitoring for s/s of significant bleeding. require intermittant transfusion if hct drifts down as it has been slowly decreasing over last 2 weeks with blood draws and possibly slow loss from gi source. would consider transfusion for hct<24. . # mrsa bacteremia - on /2 blood culture bottles grew mrsa. iv vanco started and picc line discontinued for suspicion that it was the source of the infection. id was consulted and recommended ordering a tte which was negative for valvular vegetations. he had a new picc line placed on the right ue on . after further review of his case (hx endocarditis , as well as possible renal infarcts on ct scan). . picc removed on and surveillance blood cultures since admission have been without growth. picc tip was sent for culture on and has final result of no growth. tte on was negative for valvular vegetations; however, could not rule out small vegetations. patient has a past history of endocarditis in , which increases his risk for recurrent endocarditis and id consult recommending tee, which was negative for vegetations on . he received a total of 4 weeks of vancomycin per the id team, and completed this on . at the time of discharge he has a left tunnelled catheter. his discharge was held for a day b/c of a clogged line which cleared with tpa held in the line for 2 hours then drawn out. there has never been any problems flushing the line, just drawing labs back. patient is a difficult peripheral stick, but can be done if needed. . # uti - urinalysis and culture was drawn on due to concern for low grade temperatures and a rising leukocytosis at that time. as u/a was unimpressive, treatment decision hinged on a urine culture that was positive for enterobacter on . ciprofloxacin iv was started at that time on . repeat urine cultures 11/30 and were negative for enterobacter, but positive for enterococcus. per id a repeat ua was performed and was negative for nitrites and leuk esterase. the id recommended discontinuing ciprofloxacin since the enterbacter had cleared and did not want to treat the enterococcus (vre), since this is likely now a colonizer (ua was negative). . # rue swelling - pt noted to have some rue edema approximately . a rue us revealed no flow in a portion of cephalic vein, likely representing a superficial vein clot. due to the ongoing need for picc line for tpn as well as other indications for anticoagulation (afib with hx embolic strokes), heparin gtt was entertained, but was not started given his falling hct and guaiac positive stools. on , the pt went for an ir guided tunnelled line and had his picc removed. his rue swelling is slowly resolving. however, the tunneled line had to be removed (see below). . * biliary stent - the inpatient gi service recommended that ercp be contact in order to determine how to manage his biliary stent in the setting of a rising lipase. the team felt that the stent had not migrated, but did agree that the stent would need to be removed. the ercp team removed the stent on without complication. . * acute on chronic kidney disease (stage ii): on admission, creatinine was noted to be 3.8 up from baseline of 0.6. it was believed to be prerenal and secondary to severe dehydration. with aggressive hydration, his cr declined back to normal. . * anion gap acidosis lactic acidosis and uremia - this was thought secondary to his severe colitis and mrsa bacteremia. his anion gap was resolved at the time of transfer to the floor. . * supratherapeutic inr on admission - secondary to both coumadin and poor po intake. vitamin k given in icu and coumadin/asa was held given diarrhea and guaiac positive stools. the patient received additional iv vitamin k as inr on the day of callout was 4.5. his inr improved and was 1.5 on the . given his atrial fibrillation and subacute strokes and renal infarct, asa was restarted on and then stopped in the setting of gib. there is strong indication for re-anticoagulation to be initiated at lower dose and carefully monitored. discussion undertaken with patient, daughter and pcp after careful review of outside neurology consult report. pros and cons presented to patient. anticoag held until repeat flex sig was done , and tunnel line placed then restarted. his goal inr should be with ideal range 2-2.5 given his high bleeding risk. * atrial fibrillation with hx embolic strokes: on admission, his asa and coumadin were held. at , he had complained of visual changes and he had a neurology consultation and was found to have subacute strokes - bilateral posterior infarcts (right side affecting posterior temporal and occipital lobes; left side involving medial right occipital lobe). he was restarted on coumadin at at 5mg qhs but had supratherapeutic inrt. on admission, asa and coumadin were both held. his ct abd revealed a new renal infarct, may be related to embolic phenomenon from afib vs. endocarditis. his asa was restarted on then held in the setting of gib, which was felt to be due to ischemic colitis (other evidence for embolization). he was started on diltiazem on then changed to his home metoprolol on . neurology consult was cancelled in light of pt refusal, and fact that there is strong indication to anticaogulate with careful monitoring. full discussion with pt and his daughter and he agreed. as above, coumadin restarted and inr should be check frequently. would no restart aspirin at this time. . * transaminitis - likely related to hypoperfusion from severe diarrhea. had resolved at time of transfer to the floor. of note, pt had biliary stent placed and after further discussion with ercp was removed. . * celiac disease: has refractory disease and had been on tpn for the past 4 years per his outpatient gi attending. held intermittant with above complication, but has been restarted without event. the patient will require that all medications be confirmed with the manufacturing company that they are gluten free before he will agree to take them. he has some of his own meds to take that he know is gluten free. . * benign hypertension: some of his bp medications were held in the setting of septicemia picture in the icu. he slowly was restarted on his home metoprolol. the calcium channel blocker and acei was no longer needed. . * hypothyroidism: continued levothyroxine. thyroid labs checked. . * history of pe: s/p course of coumadin in past, but now back on anyway for afib reasons and h/o embolic phenomenon. . * osteoporosis: home d2 50,000 units on mon and thursday, citracal + d 315-200 units were continued. . * anxiety disorder: stable medications on admission: metoprolol 100 mg po bid captopril 50 mg po tid felodipin 5 mg daily levothyroxine 125 mg po daily coumadin ?dose ondansetron 4 mg iv q6h prn omeprazole 20 mg po daily vitamin e 800 units daily vitamin a b12 1000 mcg daily vit d2 50,000 units mon/thurs citracal +d 315-200 units aspirin 81 mg daily albuterol 1-2 puffs q6h prn folic acid 1 mg daily discharge medications: 1. cyanocobalamin 500 mcg tablet sig: two (2) tablet po daily (). 2. folic acid 1 mg tablet sig: one (1) tablet po daily (). 3. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po twice weekly (monday, thursday) (). 4. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (). 5. vitamin a 10,000 unit capsule sig: one (1) capsule po daily (). 6. citracal + d 315-200 mg-unit tablet sig: one (1) tablet po bid (2 times a day). 7. metoprolol tartrate 50 mg tablet sig: three (3) tablet po bid (2 times a day). 8. omeprazole 20 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po every twelve (12) hours: continue high dose for 4 weeks, then 40 mg qdaily. 9. simethicone 80 mg tablet, chewable sig: 0.5 tablet, chewable po qid (4 times a day) as needed for gas. 10. zofran 4 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. 11. sucralfate 1 gram tablet sig: one (1) tablet po qid (4 times a day). 12. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarrhea: titrate to bm's per day. hold if any abdominal distention. 13. budesonide 3 mg capsule, sust. release 24 hr sig: three (3) capsule, sust. release 24 hr po daily (daily). 14. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for anxiety. 15. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 16. acetylcysteine 20 % (200 mg/ml) solution sig: one (1) neb miscellaneous q6h (every 6 hours) as needed for congestion. 17. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for shortness of breath. 18. petrolatum ointment sig: one (1) appl topical tid (3 times a day) as needed for to buttocks . 19. phenol 1.4 % aerosol, spray sig: one (1) spray mucous membrane q4h (every 4 hours) as needed for sore throat. 20. ondansetron hcl (pf) 4 mg/2 ml solution sig: four (4) mg injection q8h (every 8 hours) as needed for nausea. 21. coumadin 2 mg tablet sig: one (1) tablet po once a day: last inr 2.4 on . dose was 4 mg a day, now down to 2mg with ideal dose in that range. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: gib due to colonic ulcerations mrsa bacteremia of unclear source celiac sprue, refractory pud atrial fibrillation c/b embolic cvas hypertension, benign recent occipital stroke () renal infarct discharge condition: stable discharge instructions: the patient is being discharge to a facility with the following active problems: 1. diarrhea: has improved some with entercort and loperamide, both at the recommendation of dr. . still may need some medication titration, but he's down to 2-4 bm's a day, which is a significant improvement. he still has path pending on the duodenal biopsies to see whether he has malt lymphoma causing his worsening symptoms. of note, the patient has significant abdominal distention that is normal for him. it comes and goes depending on his current symptoms. would hold loperamide anytime there is significant distention. 2. titration of coumadin: inr is 2.4 today, but we'd like to keep it between 2-2.5 if possible. please monitor frequently as he is a very high bleeding risk, but unfortunately for emoblic events as well. see dc summary for h/o bleeding issues. suspect coumadin dose to be between 2-4 mg daily 3. wbc's: he still has a high white count despite all our interventions. id is very confident that this is not an infection, but we believe it should be monitored closely for bandemia or significant increase. last wbc count was 21 without any bands. 4. advancing his diet: as of yesterday he was still only drinking occasional water. we have started advancing his diet a bit, which will hopefully improve. he is ok to advance to a gluten free diet as tolerated. 5. anemia:the patient is at high risk of bleeding his last hct is 25.8. his hct level has been varying between 25-30 during his stay. he does have colon ulcers and has guiac + stools, but without any s/s of gross bleeding and stable hct. require intermittant transfusion if hct drifts down as it has been slowly decreasing over last 2 weeks with blood draws and possibly slow loss from gi source. would consider transfusion for hct<24 and transfer back to for any s/s of significant bleeding. for changes in his condition, would discuss with dr. (gi) and dr. (pcp) who are actively involved in his case. he has f/u with dr. in , but earlier f/u can arranged if needed. they can be reached at and with any questions. the patient's daughter, , is exceptional at coordinating the day to day care of her father. she knows him well. followup instructions: 02:10p , b. lm , liver center (sb) 10:30a , n. sc clinical ctr, bone & mineral-cc7 (sb) procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances injection or infusion of thrombolytic agent injection or infusion of thrombolytic agent endoscopic removal of stone(s) from biliary tract esophagogastroduodenoscopy [egd] with closed biopsy removal of t-tube, other bile duct tube, or liver tube closed [endoscopic] biopsy of large intestine closed [endoscopic] biopsy of large intestine diagnoses: acidosis urinary tract infection, site not specified acute kidney failure, unspecified iron deficiency anemia secondary to blood loss (chronic) atherosclerosis of aorta hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure bacteremia osteoporosis, unspecified other complications due to other vascular device, implant, and graft long-term (current) use of anticoagulants celiac disease calculus of gallbladder without mention of cholecystitis, without mention of obstruction personal history of venous thrombosis and embolism carrier or suspected carrier of methicillin resistant staphylococcus aureus streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site dehydration other and unspecified infection due to central venous catheter accidents occurring in residential institution cholangitis other specified hypotension infectious colitis, enteritis, and gastroenteritis other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms calculus of bile duct without mention of cholecystitis, with obstruction chronic kidney disease, stage ii (mild) ulceration of intestine chronic gastric ulcer without mention of hemorrhage or perforation, without mention of obstruction other ulcerative colitis 

Answer: The patient is high likely exposed to