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: patient recorded as having no known allergies to drugs attending: chief complaint: fevers s/p ercp major surgical or invasive procedure: elective ercp: stent removal, spincterotomy & balloon sweep history of present illness: 80 yo male who initially presented to for elective ercp. patient had an ercp done back in which showed a dilated cbd and intrahepatic bile ducts with multiple filling defects in the distal cbd, consistent with stones, and a stent was placed at that time. the patient then underwent a lap cholecystectomy in without any complications. he returned to on the day of admission for repeat ercp, stent was removed, a sphincterotomy was performed, and a balloon sweep was also done. following the procedure, the patient spiked a temperature to 101, which then climbed to 103. he was started on unasyn, labs and blood cultures were sent. he was transferred to the for closer monitoring. he defervesced and was transferred to the floor the following day. past medical history: dm ii chf diastolic dysfunction afib copd hyperlipidemia lung ca s/p l lobectomy bph esophagitis h/o arf social history: - lives in , retired - lives with his wife family history: non-contributary physical exam: pe: vitals: 103.8/ bp 130/70/hr 76/rr 22/ 97% on 1l gen: appears ill, sitting semi-upright, awake, alert heent: atraumatic, anicteric, eomi, dry mucosa neck: no lad, no jvd cv: irregular rhythm, normal s1/s2, no murmurs lungs: mild bibasilar crackles, good inspiratory effort abd: non-tender, non-distended, nabs, no rebound or guarding ext: warm, dry. dp pulses full b/l, no skin: diaphoretic, no rashes noted neuro: a/ox 3, able to follow commands, moves all extremities spontaneously, no focal deficits pertinent results: admission labs: 08:45pm wbc-9.3 rbc-3.47* hgb-10.7* hct-30.5* mcv-88 mch-30.8 mchc-35.2* rdw-15.7* 08:45pm neuts-88.5* bands-0 lymphs-6.1* monos-4.3 eos-0.8 basos-0.3 08:45pm plt count-258 08:45pm pt-12.7 ptt-23.9 inr(pt)-1.1 08:45pm alt(sgpt)-154* ast(sgot)-248* alk phos-357* amylase-51 tot bili-1.3 08:45pm lipase-25 08:45pm glucose-71 urea n-19 creat-1.1 sodium-140 potassium-3.3 chloride-100 total co2-29 anion gap-14 discharge labs: 06:45am blood wbc-6.4 rbc-3.40* hgb-10.0* hct-29.8* mcv-88 mch-29.5 mchc-33.7 rdw-16.5* plt ct-295 07:15am blood neuts-76.6* lymphs-16.4* monos-5.0 eos-1.5 baso-0.5 06:45am blood plt ct-295 06:45am blood glucose-122* urean-15 creat-1.2 na-139 k-4.1 cl-102 hco3-28 angap-13 07:15am blood alt-30 ast-13 totbili-0.7 06:45am blood mg-2.1 imaging: ercp reportprocedures: 1. the previously placed plastic stent was removed with a snare. 2. a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire 3. the stones were extracted successfully using a 15 mm balloon. impression: 1. a previously placed plastic stent was found in the major papilla and was removed using snare 2. cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique 3. cholangiogram showed dilated cbd to 1.5 cm and multiple filling defects suggestive of stones 4. a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire 5. the stones were extracted successfully using a 15 mm balloon. recommendations: 1. admit for observation 2. npo tonight and start clears in am 3. advance diet if tolerated in am 4. ciprofloxacin 500 mg for 7 -10 days 5. iv fluids and analgesia 6. follow up with dr and . pathology: stent returned negative for malignant cells. . cxr one view. comparison with . there is blunting of the left costophrenic sulcus. the lungs appear otherwise clear. the left hemidiaphragm is mildly elevated, as before. the cardiac silhouette remains prominent. the aorta is mildly tortuous and calcified. mediastinal structures are otherwise unremarkable. a single surgical clip is projected over the left pulmonary hilum as before. the bony thorax is grossly intact. impression: blunting of the left costophrenic sulcus which may represent pleural thickening or fluid. the lungs appear clear. cxr pa and lateral: heart is enlarged and central pulmonary vascularity appears engorged. previously reported asymmetric hazy opacities in the right perihilar region have slightly progressed, and there are new subtle interstitial opacities within the left lung, but distribution remains asymmetric. there has been previous partial resection of the left lung with associated volume loss and mild pleural thickening, unchanged. impression: worsening asymmetrical opacities involving the right lung to a much greater degree than the left. although potentially related to asymmetrical edema, underlying pneumonia in the right lung is suspected given the history of persistent fever. micro: 7:19 am sputum source: expectorated. **final report ** gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): budding yeast. quality of specimen cannot be assessed. respiratory culture (final ): oropharyngeal flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. extended workup requested by dr. . enterobacter cloacae. sparse growth. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. staph aureus coag +. sparse growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. trimethoprim/sulfa sensitivity testing performed by . yeast. sparse growth. escherichia coli. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterobacter cloacae | staph aureus coag + | | escherichia coli | | | ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ 4 s ciprofloxacin---------<=0.25 s =>4 r clindamycin----------- =>8 r erythromycin---------- =>8 r gentamicin------------ <=1 s <=0.5 s <=1 s imipenem-------------- <=1 s <=1 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s <=0.25 s oxacillin------------- =>4 r penicillin------------ =>0.5 r piperacillin---------- <=4 s 64 i piperacillin/tazo----- <=4 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s s <=1 s vancomycin------------ <=1 s brief hospital course: 80 yo male s/p ercp with stent removal and sphincterotomy who developed transient sepsis, fevers, and rml pna. following issues addressed on this admission: 1. id, pneumonia, ?cholangitis--patient developed fever to 103 in the pacu after ercp stent removal and there was a concern for sepsis/bacteremia with the source being biliary, subsequently meeting the criteria for sirs. he was started on unasyn iv for antibiotic coverage and pan cultured. he was monitored overnight in the icu and then transferred to the floor. on hd#3 () the patient had oxygen desaturation down to the 80s and a subsequent cxr showed a likely rml pna. his antibiotic coverage was broadened to cover mrsa with vancomycin on and a sputum culture was obtained. the patient defervesced by on vancomycin and unasyn. on his antibiotics were switched to vancomycin and levaquin, awaiting culture data. by he was requiring no further supplemental oxygen (had been on liters in the days following decompensation on ). on his sputum cultured showed sparse growth of mrsa and resistant enterobacter and e. coli. of note, he defervesced of antibiotics to which enterobacter and e. coli were reported resistant (to both unasyn and quinolones). therefore, significance of culture data showing only sparse growth of multiple organisms in question. given patient's clinical improvement, patient will be discharged on levaquin and bactrim. linezolid was considered, but given patient got 5 days of vancomycin and mrsa was only sparse growth, will treat with bactrim and cover for gnr with levaquin. satting in high 90's on room air both at rest and with ambulation on discharge. other possibility is that fever after ercp, along with decompensation was related to biliary obstruction. above antibiotics should cover. will need 6 more days of levaquin and bactrim for total 10 day course starting from when vancomycin was initiated. all blood cultures negative to date, still some pending at time of discharge. 2. atrial fibrillation--chronic afib, however rate controlled by beta blocker. patient was on coumadin in the past but taken off of it by his pcp. the discussion of anticoagulation was had with the patient, he refused future treatment with coumadin. the risks and benefits were discussed in detail with him. initially patient on lopressor which was transitioned to his outpatient toprol dosing of 200mg daily on which he was discharged. recommend re-discussion with pcp about . 3. choledocholithiasis, s/p ercp with stent removal and sphincterotomy: ercp team followed post procedure and the patient's lfts normalized with no further abdominal pain, nausea or emesis. as above under #1, recommend antibiotics for 6 more days. 4. diabetes type ii--patient's oral hypoglycemics were initially held and then restarted with adequate po intake. his bg was monitored qac with a sliding scale. on had hypoglycemia with bs of 55. likely due to combination of quinolone with metformin and glimiperide. both metformin and glimperide have been discontinued and should be held until the patient has completed his antibiotic regimen. can re-start in 7 days. 5. chf--per prior discharge summary, patient has a history of diastolic dysfunction. no echo report on file here. pt on beta-blocker, lasix at home. lasix was held initially and then titrated back to his outpatient regimen. patient euvolemic on discharge. . 6. anxiety: patient maintained on lorazepam. . 7. bph: flomax held with decompensation, but re-started , no acute issues . 8. depression: continued on zoloft. . 9. copd: advair initiated, patient should continue as outpatient. . 10. insomnia: trazadone continued with variable effect. code status - full throughout. patient has follow up with np on at 9am. phone number is . fax is . copy of this discharge summary to be faxed and copy given to patient. . . medications on admission: sertraline 100 mg daily flomax .4 mg daily lasix 80 mg daily toprol xl 200 mg daily protonix 40 mg daily metformin 500 mg daily lorazepam 2 mg qhs trazodone 150 mg qhs discharge medications: 1. sertraline 100 mg tablet sig: one (1) tablet po daily (daily). 2. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 3. trazodone 150 mg tablet sig: one (1) tablet po at bedtime. 4. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 5. klor-con 10 10 meq tablet sustained release sig: one (1) tablet sustained release po twice a day. 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) puff inhalation (2 times a day). disp:*1 disk with device* refills:*2* 8. lorazepam 2 mg tablet sig: one (1) tablet po qid (4 times a day). 9. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 6 days. disp:*6 tablet(s)* refills:*0* 10. bactrim ds 160-800 mg tablet sig: one (1) tablet po twice a day for 6 days. disp:*12 tablet(s)* refills:*0* 11. toprol xl 200 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. discharge disposition: home discharge diagnosis: 1. choledocholithiasis 2. pneumonia 3. sepsis secondary: 1. copd 2. heart failure, diastolic 3. depression 4. bph 5. dm type ii, controlled 6. atrial fibrillation 7. esophagitis discharge condition: stable, ambulating, taking good po, afebrile>48 hours. discharge instructions: continue to take all your medications as prescribed. you should take all the medications you were before coming into the hospital except for the following. we have made the following changes: 1)we have added advair inhaler. this is for your history of copd/smoking. you should use this twice a day and let your doctor know you are using it. 2)you should not take your metformin or glimperide (diabetic medications) for the next 6 days until your antibiotics are completed. once the antibiotics are done, you can re-start these 3) in addition, you will need to take the antibiotics as prescribed. you will take levoquin and bactrim. the levoquin is once a day and the bactrim is twice a day. follow up as below. if you develop fevers, cough, chest pain, shortness of breath, abdominal pain or any other new concerning symptoms contact your doctor or go to the emergency room. bring a copy of your discharge paperwork to dr. office when you see np on . followup instructions: you must follow up with your primary care doctor, dr. and np . i have scheduled an appointment for you with for , at 9am with np . bring a copy of your discharge paperwork there. you should also follow up with dr. , surgery, his number is . np and dr. can help you set up this follow up. procedure: endoscopic removal of stone(s) from biliary tract endoscopic sphincterotomy and papillotomy diagnoses: pneumonia, organism unspecified other postoperative infection congestive heart failure, unspecified unspecified septicemia chronic airway obstruction, not elsewhere classified atrial fibrillation personal history of malignant neoplasm of bronchus and lung diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled diastolic heart failure, unspecified calculus of bile duct without mention of cholecystitis, without mention of obstruction 

Answer: The patient is high likely exposed to