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: tetracycline attending: chief complaint: jaundice, transferred to micu for hypotension major surgical or invasive procedure: 1. right ij placed in ed 2. cholecystostomy tube placement by interventional radiology (dr. mhuircheartaigh and dr. g. sheim) history of present illness: the patient is an 81 year old male with pmh diabetes, unknown other pmh as no previous medical records here, with reported history of pancreatic mass s/p ercp and stent now transferred from for hypotension. patient is a poor historian, his medical history was obtained from ed chart, gi fellow's note and conversation with dr. , gastroenterologist at va. per records from acs discussion with dr. , pt presented to wva about 2-3 weeks ago with painless jaundice. his tbili was reported to be in the low 20s and ap ~2200 his work up including a ct pancreas protocol which showed a large pancreatic mass at the head involving that involving the sma, smv and possible portal vein. surgery was consulted but recs were unknown. patient underwent eus with biopsies which didn't yield carcinoma. however, brush biopsy (sent out) was highly suspicious for malignancy. patient underwent ercp with covered stent placement and his lfts improved. patient was either d/c home or left ama on and was brought to by his wife today given continued jaundice and was transferred to for hypotension. per the patient, he denies having any abdominal pain, and has had an appetite. he does endorse a 65lb weight loss, but cannot say over what time period. he does report -like stools and "blood" in his urine. . in the ed, initial vs 98 76 88/51 18 99% on ra. he was hypotensive to the systolic low 80s, and was bolused 3l ns without much responsive. labs were notable for wbc to 19.6 with 91% pmn's, tbili 9.7. exam notable for pt mildly confused, non-focal neuro exam otherwise. appeared comfortable, making jokes with nursing staff in ed. pt had r ij placed for access, and 2 large bore iv's. he was given zosyn x1. surgery was consulted, and recommended no surgical intervention given pt was not stable. ir was consulted, and recommedned bedside u/s with percutaneous cholecystostomy on admission. levophed was started for borderline low bp. his bp responded to systolic 140s. vs prior to transfer hr 70, v-paced, rr 17, 98% ra. . on the floor, he says that he feels well, without complaints. "i'm comfortable". denies any pain or nausea. endorses occasional chills, -colored stools, dark urine, but otherwise feels well currently. . review of systems: (+) per hpi. also notable for occasional constipation. (-) denies fever, night sweats, weight gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits, bloody or black stools. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: past medical history: per note from consult in ed who spoke with osh physician newly diagnosed pancreatic mass pancreatitis - alcohol likely dm2 mi afib gout left-sided pacer social history: lives by himself. separated from wife (who is his next of ). family history: unable to obtain physical exam: on icu admission: vitals: t: 97.4 bp: 118/71 p: 76 r: 20 o2: 99%ra general: alert, lying down in bed, appears slightly agitated, nad heent: eomi, jaundiced, icteric sclera, dry mm, op clear neck: supple, r ij in place, jvp not elevated, no lad lungs: no use of access mm, clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi chest: l-sided pacer in place cv: irregularly, irregular, + s1 s2, 2/6 systolic murmur loudest at lusb, no apparent radiation abdomen: nabs, umbilical hernia, soft, tender in ruq without sign, non-distended, no rebound tenderness or guarding, no organomegaly gu: foley in place with dark urine ext: warm, well perfused, 1+ edema to mid-ankle bilaterally neuro: alert, oriented to person, place, states "", "" (off by one day only), moving all extremities, no gross deficits, gait deferred on icu discharge: vs t 36.1??????c, hr 72, bp 89/47 mmhg, rr 16, spo2 98% ra gen: sitting up in bed in chair, resting comfortably heent: mmm, ?5 cm jvp cv: rrr iii/vi crescendo-decrescendo murmur, no s1 or s2 appreciated ch: ctab, decreased breath sounds at bases abd: soft, diffusely tender to shallow palpation, r-sided dressing with yellowish leakage at bottom of bandage, chole drain +minimal clear/yellow output ext: wwp w/bilateral le 2+ pitting edema to knees (r>l), lue 1+ nonpitting edema to elbow (known dvt), +distal pulses gu: foley in place icu re-admission: vitals: t 96.3, bp 96/53, hr77, rr 21, spo2 99% on ra general: mildly lethargic, oriented, no acute distress heent: icteric sclera, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: decreased bs at bases, otherwise clear with no wheezes, rhonchi, or rales cv: regular rate with occasional pvcs, normal s1/s2, iii/vi crescendo-decrescendo murmur, no rubs or gallops abdomen: bowel sounds present. soft, non-distended. mild tenderness in ruq, no rebound tenderness or guarding. no organomegaly. ptc site without erythema, drainage, or tenderness. evidence of recent slight leakage. gu: no foley ext: right picc in place without erythema or drainage. left upper extremity edema. bilateral lower extremity edema (+). fingertips slightly cool. distal pulses 2+ in all extremities. pertinent results: admission labs: 03:30pm blood wbc-19.6* rbc-3.06* hgb-10.2* hct-30.4* mcv-100* mch-33.5* mchc-33.7 rdw-15.1 plt ct-171 03:30pm blood neuts-91* bands-2 lymphs-3* monos-4 eos-0 baso-0 atyps-0 metas-0 myelos-0 03:30pm blood pt-14.5* ptt-27.4 inr(pt)-1.3* 03:30pm blood glucose-128* urean-27* creat-0.7 na-134 k-3.5 cl-102 hco3-23 angap-13 03:30pm blood alt-43* ast-74* alkphos-182* totbili-9.7* 03:30pm blood albumin-2.2* calcium-8.1* phos-2.0* mg-2.0 iron-18* 03:30pm blood caltibc-143* vitb12-1493* folate-11.3 ferritn-1719* trf-110* 03:42pm blood lactate-2.6* discharge labs: hematology complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:20 8.2 2.87* 9.6* 28.8* 101* 33.4* 33.2 15.1 193 renal & glucose glucose urean creat na k cl hco3 angap 13:00 167*1 16 1.2 140 3.8 105 25 14 source: line-picc enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 05:20 14 26 110 2.7* source: line-r picc other enzymes & bilirubins lipase 03:53 14 source: line-cvc chemistry totprot albumin globuln calcium phos mg uricacd iron 05:20 2.1* 7.6* 3.0 1.9 . studies: cxr : findings: no consolidation or edema is evident. the mediastinum is unremarkable. dual-chamber pacemaker is in standard course and position from a left subclavian approach. calcified plaque is seen at the aortic arch. the cardiac silhouette is within normal limits for size. no effusion or pneumothorax is noted. the osseous structures reveal degenerative change throughout the thoracic spine. impression: no acute pulmonary process. ct torso : impression: 1. no discrete pancreatic mass. however, given given pancreatic dustal dilatation and abnormal morphology of pancreatic head, an infiltrative process cannot be excluded. correlate with ercp findings and pathology from osh. 2. gallbladder features suggest acute cholecystitis. 3. pneumobilia is related to common bile duct stent, which extends to the duodenum. 4. small ascites. 5. small bilateral pleural effusions and associated compressive atelectasis. 5. left upper lobe ground glass nodule. given suspected pancreatic malignancy, recommend follow up in no longer than 12 months with dedicated chest ct. ruq u/s : 1. linear hyperechoic foci scattered throughout the liver, presumably pneumobilia related to recent ercp, but portal venous gas can't be excluded and can be assessed on ct. 2. distended gallbladder with stones and sludge, mild circumferential wall thickening to 4mm. features suggest acute cholecystitis. 3. pancreas not well visualized. 4. mpv patent 5. cbd is 8mm, normal for age. unilateral right upper extremity ultrasound: impression: diminished flow and in one of the peroneal veins may represent a non-occlusive thrombus in the calf. unilateral left lower extremity: impression: diminished flow and in one of the peroneal veins may represent a non-occlusive thrombus in the calf. micro: blood cultures : negative urine cx : negative ucx-negative. biliary cx : gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and chains. 2+ (1-5 per 1000x field): gram negative rod(s). 3+ (5-10 per 1000x field): gram positive rod(s). fluid culture sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | staph aureus coag + | | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ 2 s <=0.5 s levofloxacin---------- =>8 r meropenem------------- 0.5 s oxacillin------------- =>4 r piperacillin/tazo----- 8 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ <=0.5 s . anaerobic culture (final ): no anaerobes isolated. . negative for malignant cells. . paucicellular sample consisting predominantly of gastrointestinal mucosal contaminant (see note). . note: it is difficult to distinguish between gastrointestinal mucosal contaminant and reactive ductal epithelium in occasional smaller groups of cells. although suboptimal sampling of a well-differentiated pancreatic adenocarcinoma is a remote possibility, there is no definitive evidence of malignancy in this sample. common bile duct brushings (rcy- a, ): atypical. atypical ductal epithelial cells, favor reactive. eus-fna, pancreatic mass (rcy- b, ): non-diagnostic. the aspirate specimen is paucicellular and consists predominantly of gastrointestinal mucosal contaminant and blood. common bile duct stricture, needle biopsy (rsp-, ): non-diagnostic. scant stromal fragment and blood. brief hospital course: pt is an 81 year old with pmh of t2dm, cad, and new history of painless jaundice with pancreatic mass on imaging, and elevated lfts suspicious for pancreatic tumor, in addition to hypotension with concerns for sepsis, requiring micu transfer.this is an 81 y/o male with dm, afib, ischemic cardiomyopathy with ef 35%, s/p pacer, with reported recent history of pancreatic mass on ct abdomen s/p ercp and eus with palliative biliary stent placement at va, initially transferred from to micu green for hypotension (sbps 70s-80s). . he initially presented to wxva about 2-3 weeks ago with painless jaundice. his t. bili was reported to be in the low 20s and ap ~2200 his work up including a ct pancreas protocol which showed a large pancreatic mass at the head involving that involving the sma, smv and possible portal vein. patient underwent eus with biopsies which did not show carcinoma. however, brush biopsy (sent out) was highly suspicious for malignancy. his lfts improved after stent placement. after being home for 2-3 days (?left ama vs. discharged), he was brought to by his wife due to continued jaundice and was transferred to for hypotension. . he was admitted to the micu for biliary sepsis and started on leveophed. he was continued on levophed for persistent hypotension, with continued poor response to ivf and low urine output. due to a question of an element of cardiogenic shock, tte was done, showing an ef of 35% and critical as. also, due to ue and le edema, ultrasounds were done which demonstrated left brachial and right peroneal dvts, so he was started on lovenox. a ptc was performed on and the drained bile grew out pseudomonas and mrsa/ vanc/zosyn initially started but switched to vanc/cefepime/flagyl due to more favorable mics. with mixed picture of sepsis and cardiogenic shock, diureses with lasix 10mg iv was started with mild improvement of sbps to 90s-100s and improved uop. the pathology slides from the eus biopsies were obtained and there is no confirmation of malignancy, but ca-19-9 is very elevated. ercp service was consulted for ercp vs. eus and asked for transfer to the for consideration of ercp in the am for replacement of the stent, which they believe may be occluded. he was transferred to the on . . in the , he was continued on leveophed, which was weaned off at 3 am ; and was continued on vanc/cefepime/flagyl. ercp felt stent was still viable per data, continued to have drainage from ptc. went for eus on that showed 2cm pancreatic head mass, but not biopsied given recent plavix use. onc spoke with pt and family re: mass, however the family was not interested in surgical treatment nor would he likely be a surgical candidate given critical as and other medical comorbidities. med onc saw patient on floor and felt that cancer was likely, but not definitive diagnosis without actual tissue. pt initially refused medical oncologic treatment, as he was not interested in chemo and xrt. abx d/c;d on after 14d course. plavix d'c'd on given goc and risk of bleeding while on lovenox, aspirin and with likely malignancy. dr. spoke with wife of 55 years (now seperated, but still current rn) about overall condition and she agreed that given co-morbidities of malnutrition, poor functional status, critical as and chf, worsening renal function, and likely cancer which he most likely wouldn't be a candidate for chemo and his wishes of pursuing least medical treatments as possible, that goals of care should be comfort focused/hospice. pt also defers all medical decision making to his wife. letter written to his pcp, , .d. va in ma ext.5050 updating him about the clinical course and change to hospice. . by problem: #pancreatic mass-see above . #cholangitis/cholecystitis/s/p septic shock- s/p abx tx course 14d with vanco/cipro/flagyl for mrsa/pseudomonas. s/p icu course see above. ptc drain was placed by ir and reevaluated on . drained appeared occluded in ir, however, it was recommended to keep this drain in place given risk of recurrent infection. therefore, upon discharge, will plan on keeping ptc drain in place. if causing discomfort and not within goals of care, can remove. in addition, if drainage were found to be decreasing, consider ir cholangiography evaluation for patency. . # acute on chronic schf- pt volume overloaded on exam with edema. however, given critical as, recent sepsis, and borderline bps (sbp 90's), attempt at diuresis was challenging. as urine output steady and patient on ra, did not give additional lasix on the floor. however, can consider gentle doses of iv lasix for goal -500cc/day. pt was not hypoxic, but did report occasional sob while eating or lying flat. pt was given oxycodone and trialed ativan for symptomatic management. however, if this were to fail or patient actually became dyspneic, hypoxic would consider gentle diuresis. pt was given gentle diuresis in the icu. . # dvt, acute- pt started on lovenox . likely due to suspected malignancy, will will continue for now, as large pe would likley not be comfort care. . # unclear of exact cardiac history leading to pacemaker, ?arrhythmia and heart failure given his depressed ef, ?due to critical as vs. ischemic cardiomyopathy. pt did not report chest pain during admission. cardiac medications appear to have been discontinued per goc conversation by prior provider. had been on asa 81mg daily, plavix 75mg daily. bb and acei initially avoided due to hypotension/low bp and statin held given elevated lfts. pt requested to continue his aspirin therapy. therefore, will continue this, but not plavix given that pt is on lovenox for dvt and triple therapy will increase bleeding risk especially with suspected malignancy. restarted low dose bb, metoprolol 6.25mg if bp allows to prevent discomfort from possible angina, tachycardias. . #acute renal failure-cr 0.7 to 1.2. likely prerenal from poor po intake and possible chf. pt not given iv fluids as has chf/critical as and would likely cause flash pulmonary edema/hypoxia. . #dm2- continued hiss with finger sticks. conservative insulin coverage in order to avert symptomatic hyperglycemia. this can be discontinued, if becomes painful for patient. . fen: regular diet as tolerated . access: picc dc'd prior to discharge. . #goals of care-please note. pt had been cmo/dnr/dni per prior discussions in icu and goals of care conversations. however, pt decided day of discharge that he would not sign the dnr/dni comfort care form for the ambulance ride to hospital. he stated that he does not make decisions during emergencies and would want his wife called during an emergency to determine goals of care. explained that this is not feasible during an emergency and that a quick decision would have to be made. pt stated that we have to "talk to his wife" and that he would not sign the form at this time. . medications on admission: medications on discharge from va in chart medications from asa 81mg daily calcium 250mg qhs docusate 100mg daily glyburide 5mg po daily metformin 500mg simvastatin 80mg daily omeprazole 20mg daily metoprolol 25mg po daily camphor prn itching clopidogrel 75mg daily loratidine 10mg daily discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 3. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q6h (every 6 hours) as needed for wheeze. 6. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for indigestion. 7. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 8. enoxaparin 60 mg/0.6 ml syringe sig: one (1) subcutaneous q12h (every 12 hours). 9. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 10. oxycodone 5 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for severe pain: prn pain/dyspnea. 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for sob. 13. insulin lispro 100 unit/ml solution sig: as directed subcutaneous asdir (as directed): for blood sugar >200-in order to prevent symptomatic hyperglycemia if within goals of care. (. 14. metoprolol tartrate 25 mg tablet sig: 0.25 tablet po bid (2 times a day). discharge disposition: extended care facility: hospital discharge diagnosis: pancreatic mass-elevated ca19-9 sepsis/cholangitis acute on chronic systolic chf critical aortic stenosis dvt discharge condition: alert confused at times, level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were initially admitted to the icu with a severe infection of your bile ducts (cholangitis). you were given antibiotics and had a gallbladder drain placed. this should remain in place to prevent future infection. your symptoms improved from an infection standpoint and you were transferred to the regular medical floor. you likely have pancreatic cancer. a surgery would be too risky and you expressed that you would not want any therapies, such as chemotherapy and radiation, that would not be curative. therefore, a discussion was had between you and your hcp, your wife, to transition your care to comfort oriented/hospice care. . medication changes: 1.start oxycodone 2.5 mg q6hrs for pain 2.start senna/colace to prevent constipation 3.start ativan 0.25-0.5mg for anxiety 4.start zofran for nausea 5.start lovenox for blood clots . please take all of your medications as prescribed and follow up with the appointments below. followup instructions: department: gastroenterology when: wednesday at 10:00 am with: , md building: ra (/ complex) campus: east best parking: main garage procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified other endoscopy of small intestine percutaneous aspiration of gallbladder other cholangiogram other cholangiogram diagnostic ultrasound of digestive system diagnostic ultrasound of digestive system diagnoses: coronary atherosclerosis of native coronary artery congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified unspecified septicemia severe sepsis aortic valve disorders other specified cardiac dysrhythmias other and unspecified angina pectoris cardiogenic shock septic shock other specified disorders of biliary tract cardiac pacemaker in situ methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site do not resuscitate status chronic pancreatitis acute cholecystitis acute on chronic systolic heart failure cholangitis pseudomonas infection in conditions classified elsewhere and of unspecified site unspecified deficiency anemia unspecified disease of pancreas acute venous embolism and thrombosis of deep vessels of distal lower extremity malnutrition of moderate degree cholecystitis, unspecified acute venous embolism and thrombosis of deep veins of upper extremity body mass index between 19-24, adult 

Answer: The patient is high likely exposed to