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: shortness of breath and fever major surgical or invasive procedure: ercp with biliary stent placement subclavian central line picc history of present illness: 70 yo m with inoperable pancreatic cancer s/p ercp with stent placement, laparotomy with attempted whipple, h/o cholangitis, on gemcitabine (received 1st dose of his 2nd round yesterday) who presents with fever to 105 and shortness of breath. pt was in his usoh until last evening when he developed sob. he denies cp, palpitations, belly pain, n/v/d, hematochezia, dysuria. denies sick contacts or recent travel. . in the ed his o2 sat was found to be 78% on ra, cta negative for pe, cxr revealed bilateral basilar opacities and right pleural effusion. he was noted to be in aflutter with lateral st depressions and inverted t waves on ecg. trop was found to be 0.11 with a ck of 59. he was given an asa and started on a heparin gtt. he received lopresser 5 mg iv x3 and lopressor 25 mg po x1 for rate control. he also received vanco, levo, flagyl and 2 liters of normal saline. . past medical history: - inoperable pancreatic cancer diagnosed s/p ercp with stent placement, laporatomy with attempted whipple, on gemcitabine (received 3 weekly treatments starting , followed by a week off, then a fourth dose yesterday ) - h/o sbo - h/o cholangitis () with enterococcus, pseudomonas, and strep viridans - h/o bacteremia with enterococcus fecalis (vanc sensitive) and pseudomonas (sensitive to zosyn) - s/p choecystectomy tube (fell out ) - hypertension - ankylosing spondylitis - right kidney cystic lesion - moderate aortic stenosis - intermittent svt - anemia - tinea corporis . home meds: - lopressor 25 mg tid - colace - multivitamin - compazine prn . all: nkda . sh: he previously lived in city. he was an accountant from to . he then worked as a volunteer at the center. currently, he is living at facility. he has not been married and has no children. he denies past or present tobacco, alcohol, or other drug use. . fh: his sister had pancreatic cancer and is status post a whipple procedure. . physical exam: tm >104.8 tc 97.4 bp 166/85 hr 100-120 rr 20-35 sat 100% 15l nrb gen: mild respiratory distress, speaking in full sentences, appears comfortable hennt: mmm, scleral icteris neck: no lad, jvd flat cv: irregularly irregular, tachy, no m/r/g lungs: decreased at bases, crackles way up lung fields, no wheezes abd: soft, minimal ruq tenderness to deep palpation, +bs, well healed scar ext: 1+ pitting edema, strong dp/pt pulses bilaterally neuro: a&ox3, moving all extremeties . labs: . . . . . . . . . studies: ct chest : 1. no evidence of pulmonary embolism. 2. new bilateral pleural effusions. 3. new low-density low attenuating fluid seen surrounding the ascending aorta with no evidence of aortic contour abnormality, dissection, or aneurysm. 4. interval resolution of intrahepatic biliary ductal dilatation. 5. presence of intraductal air is most consistent with patient's interval stent replacement. 6. stable biapical pleural-based nodules. 7. stable calcified pulmonary nodules. 8. large right renal cyst, with rim calcifications. . cxr : 1. bilateral basilar opacities, worrisome for aspiration. 2. right pleural effusion. 3. mild congestive heart failure. . echo : 1. left ventricular systolic function is normal (lvef>55%). 2. moderate aortic valve stenosis. 3. mild (1+) aortic regurgitation is seen. 4. mild to moderate (+) mitral regurgitation is seen. 5. borderline pulmonary artery systolic hypertension. 6. no pericardial effusion. . a/p: 70 yo m with inoperable pancreatic cancer s/p ercp with stent placement, laparotomy with attempted whipple, h/o cholangitis, on gemcitabine (received first dose of 2nd round yesterday) who presents with fever to 105 and shortness of breath. . # fever/leukocytosis. likely secondary to pna seen on cxr however need to consider biliary source given pancreatic cancer with previous biliary obstruction requiring stent placement. tbili increased to 6.5 from 1.0, ap increased from 590 to 790 from yesterday. need to monitor closely for sepsis given tachycardia, tachypnea, and fever. . - s/p 3 liters ns with good bp, will hold off on additional fluid hydration given mild chf and pleural effusions seen on cxr - will obtain ct abd with oral contrast to evaluate for evidence of infection; may need ercp to evaluate biliary stent placement - will start vanco and zosyn (previous culture data from cholangitis revealed enterococcus and pseudomonas sensitive to vanco and zosyn) - control fever with tylenol - monitor blood and urine culture . # hypoxia. abg with po2 of 168 on nrb. ct negative for pe. etiology likely pna and pleural effusions. need to control hr to prevent worsening pulmonary congestion. - dilt gtt for rate control - wean o2 as tolerated . # aflutter with rapid rate. ? h/o intermittent svt. be secondary to current pulmonary process. - control rate with dilt gtt . # elevated trop of 0. depressions and twi's likely secondary to demand ischemia in setting of rapid aflutter and hypoxia. ck's flat. - continue to cycle cardiac enzymes - monitor on tele - will d/c heparin gtt as likely demand ischemia - continue asa . # pancreatic cancer. pt is not a surgical candidate. last dose of gemcitabine . - will consult onc in am . # hnt. - dilt gtt as above - once off dilt gtt will restart metop 25 tid . # fen. npo for now, replete lytes prn . # ppx. sc heparin, bowel regimen . # code: full past medical history: - inoperable pancreatic cancer diagnosed s/p ercp with stent placement, laporatomy with attempted whipple, on gemcitabine (received 3 weekly treatments starting , followed by a week off, then a fourth dose yesterday ) - h/o sbo - h/o cholangitis () with enterococcus, pseudomonas, and strep viridans - h/o bacteremia with enterococcus fecalis (vanc sensitive) and pseudomonas (sensitive to zosyn) - s/p choecystectomy tube (fell out ) - hypertension - ankylosing spondylitis - right kidney cystic lesion - moderate aortic stenosis - intermittent svt - anemia - tinea corporis social history: no tobacco, alcohol, or other drug use. currently living at skilled nursing facility where his sister is also a resident. never married. no children. family history: sister with pancreatic cancer physical exam: vitals 98.3/96.5 141-170/65-82 83-107 16-20 94-100% on 3lnc gen:elderly man seated in chair heent: perrl eomi sclera yellow mmm op clear neck: supple no lad skin: warm dry no rash, l subclavian triple lumen c/d/i lungs: b/l crackles at the bases, otherwise ctab cv: rrr nl s1-s2 loud iii/vi early systolic murmur heard best at rusb abd: soft nt/nd bs+ ext: ppp no edema neuro: aox3 non-focal pertinent results: 09:39pm type-art po2-184* pco2-35 ph-7.39 total co2-22 base xs--2 intubated-not intuba 09:09pm type-art temp-37.2 o2-100 o2 flow-15 po2-33* pco2-46* ph-7.35 total co2-26 base xs-0 aado2-633 req o2-100 intubated-not intuba 09:09pm lactate-1.5 07:45pm ck(cpk)-59 07:45pm ck-mb-notdone ctropnt-0.14* 02:00pm urine color-amber appear-clear sp -1.024 02:00pm urine blood-sm nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-mod urobilngn-4* ph-6.5 leuk-neg 02:00pm urine rbc-0-2 wbc-0-2 bacteria-mod yeast-none epi-0-2 02:00pm urine hyaline-0-2 01:40pm lactate-1.5 01:37pm glucose-132* urea n-19 creat-0.9 sodium-137 potassium-3.9 chloride-101 total co2-22 anion gap-18 01:37pm alt(sgpt)-136* ast(sgot)-112* ck(cpk)-59 alk phos-791* amylase-35 tot bili-6.5* 01:37pm lipase-23 01:37pm ctropnt-0.11* 01:37pm ck-mb-notdone 01:37pm calcium-9.2 phosphate-2.9 magnesium-2.1 01:37pm wbc-18.3*# rbc-4.50* hgb-11.4* hct-34.5* mcv-77* mch-25.3* mchc-33.0 rdw-17.7* 01:37pm plt count-418 01:37pm pt-13.9* ptt-26.3 inr(pt)-1.3 10:55am glucose-75 urea n-15 creat-0.9 sodium-142 potassium-4.0 chloride-106 total co2-25 anion gap-15 10:55am alt(sgpt)-83* ast(sgot)-52* alk phos-591* tot bili-1.0 dir bili-0.3 indir bil-0.7 10:55am ggt-593* 10:55am albumin-3.5 calcium-8.6 phosphate-3.8 magnesium-2.1 10:55am cea-2.7 10:55am wbc-9.4 rbc-4.23* hgb-10.8* hct-32.5* mcv-77* mch-25.6* mchc-33.3 rdw-19.2* 10:55am plt count-401 10:55am gran 6480 _ _ _ _ _ _ ________________________________________________________________ radiology final report cta chest w&w/o c &recons 3:21 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast reason: r/o pe field of view: 38 contrast: optiray medical condition: 70 year old man with pancreatic ca & sudden onset of sob, hypoxia, & large r pleural effusion reason for this examination: r/o pe contraindications for iv contrast: none. indication: 70-year-old man with pancreatic cancer, with sudden onset of shortness of breath and hypoxia. evaluate for pulmonary embolism. comparison: ct angiogram chest dated . ap upright portable chest x-ray dated . technique: mdct imaging of the chest was performed before and after the administration of 100 cc of intravenous optiray. nonionic contrast was administered per protocol. coronal and sagittal reformatted images were obtained. ct angiogram chest: there are no filling defects within the pulmonary arteries to suggest the presence of a pulmonary embolism. prominent mediastinal lymph nodes are seen, without meeting ct criteria for pathologic enlargement. the largest lymph node is pretracheal, and measures 9 mm. there is no axillary or hilar lymphadenopathy. low-density fluid surrounds the ascending aorta, and appears new since prior exam. the aortic contour is normal, and there is no evidence of wall abnormality, intimal flap ulceration or contrast extravasation. there are dense coronary artery calcifications. the remaining great vessels are unremarkable. there is no pericardial effusion. there are new bilateral pleural effusions, right greater than left, with compressive atelectasis. there are stable pleural plaques within the right lung posteriorly. on lung windows, pleural-based nodules are seen within bilateral lung apices posteriorly, which are stable in size and appearance since prior exam. scattered calcified granulomas within the lungs are again seen. no new nodules or masses are detected. limited imaging of the abdomen reveals new air within the biliary ductal system, presumably related to patient's interval biliary stent exchange. a large right renal cyst, with rim calcifications is again seen. bone windows: there are no suspicious lytic or sclerotic osseous abnormalities. a nonaggressive-appearing sclerotic focus is again seen within the right humeral head and is stable since prior exam. degenerative changes are seen along the thoracic spine. impression: 1. no evidence of pulmonary embolism. 2. new bilateral pleural effusions. 3. new low attenuating fluid seen surrounding the ascending aorta , of uncertain cause in the absence of evidence of aortic contour abnormality, dissection, or aneurysm. correlate clinically to determine if further evaluation by mr exam (or intra-esophageal ultrasound) should be considered. 4. interval resolution of intrahepatic biliary ductal dilatation. 5. presence of intraductal air is most consistent with patient's interval stent replacement. 6. stable biapical pleural-based nodules. 7. stable calcified pulmonary nodules. 8. large right renal cyst, with rim calcifications. these findings were enterred into the emergency department dashboard, and discussed with dr. at 4:15 pm . the study and the report were reviewed by the staff radiologist. dr. . dr. approved: 3:29 pm _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ cardiology report ecg study date of 4:01:30 pm compared to the previous tracing of the rhythm is now probbaly atrial flutter with 2:1 a-v block, atrial rate, 260, ventricular rate 130. non-specific repolarization changes consistent with ischemia and/or tachycardia persist. tracing #3 read by: , s. intervals axes rate pr qrs qt/qtc p qrs t 132 0 96 326/404 0 -6 168 () _ _ _ _ _ _ _ _ _ ________________________________________________________________ radiology final report ct abdomen w/o contrast 1:03 am ct abdomen w/o contrast; ct pelvis w/o contrast reason: please eval for evidence of cholangitis, obstruction medical condition: 70 year old man with pancreatic cancer, t to 105, tachycardia, hx of cholangitis and bacteremia, indwelling stent reason for this examination: please eval for evidence of cholangitis, obstruction contraindications for iv contrast: none. indication: pancreatic cancer with febrile to 105. technique: multidetector ct images were obtained from the lung bases to the pubic symphysis without intravenous contrast. coronal and sagittal reformatted images were obtained. the lung bases show large bilateral pleural effusions with associated compressive atelectasis. the heart shows coronary artery calcifications. otherwise, the heart and pericardium are unremarkable. the non-contrast-enhanced liver demonstrates diffuse intrahepatic biliary ductal dilatation extending into the extrahepatic biliary ductal system. a plastic stent is seen coursing from the common hepatic duct to the ampulla of vater. the gallbladder is nondistended. there is no gallbladder wall thickening or gallstones identified. the non-contrast-enhanced pancreas is unremarkable. the spleen is normal. the left kidney is unremarkable. the right kidney contains a large unchanged simple renal cyst at the upper pole. both kidneys excrete contrast symmetrically from a prior contrast-enhanced examination. the adrenal glands are normal. the opacified stomach and intra-abdominal loops of small bowel are unremarkable. diverticulosis without evidence for diverticulitis is seen throughout the large bowel, most predominantly within the sigmoid colon. there are no focal fluid collections. there is a small amount of ascites. there is no pathologically enlarged mesenteric or retroperitoneal lymphadenopathy. there is no free air. ct of the pelvis without contrast: the rectum is unremarkable. the sigmoid colon contains extensive diverticula without evidence for diverticulitis. the distal ureters are unremarkable. the bladder contains a foley catheter. there is no free air. there is a small amount of free fluid. the seminal vesicles and prostate are unremarkable. there is no pathologically enlarged inguinal, pelvic, retroperitoneal, or mesenteric lymphadenopathy. the aorta contains calcifications. bone windows: there are no suspicious lytic or sclerotic osseous lesions. ct reformats: coronal and sagittal reformatted images confirm the axial findings. value grade 1. impression: 1. diffusely dilated intrahepatic biliary ducts extending into the extrahepatic biliary ductal system. plastic stent extending from the common hepatic duct to the ampulla of vater. no focal fluid collections or abscesses are identified. there is no free air. 2. large bilateral pleural effusions with associated compressive atelectasis at the bilateral lung bases. 3. diverticulosis without evidence for diverticulitis. the study and the report were reviewed by the staff radiologist. dr. . dr. approved: 1:29 pm _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ ercp report date: thursday, endoscopist(s): , md , md (fellow) patient: ref.phys.: , md; , md birth date: (70 years) instrument: tjf indications: 70 year old with inoperable pancreatic cancer. presents with stent in situ and cholangitis. medications: midazolam 8 mg fentanyl 100 micrograms asa class: p3 procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. the patient was placed in the prone position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. careful visualization was performed. the procedure was not difficult. the quality of the preparation was good. the patient tolerated the procedure well. there were no complications. findings: esophagus: limited exam of the esophagus was normal stomach: limited exam of the stomach was normal other multiple elevated erosions suspicious for malignant involvement of the duodenum. major papilla: a plastic stent placed in the biliary duct was found in the major papilla. evidence of a previous sphincterotomy was noted in the major papilla. cannulation: cannulation of the biliary duct was successful and deep with a cannula using a free-hand technique. contrast medium was injected resulting in partial opacification. the procedure was not difficult. biliary tree: dilated cbd with filling defects and distal stricture. note c arm used in icu. procedures: a plastic stent was removed from the lower third of the common bile duct. a 6 cm by 10 mm covered wall stent biliary stent was placed successfully in the common bile duct. 3 'diamond' spaces of the stent extended into the duodenum. impression: multiple elevated erosions suspicious for malignant involvement of the duodenum. plastic stent removal - evidence of prior sphincterotomy biliary dilation with distal cbd stricture 6 cm wallflex stent placed - pus, bile and sludge evident following stent placment. recommendations: continue iv anti-biotics remain in icu _________________________________ , md _________________________________ , md (fellow) case documented on 9:15:08 pm patient: () brief hospital course: this is a 70 yom with known pancreatic ca with biliary stent placement who presented to the ed with fever and sob. # cholangitis - found by ct scan, blood cultures negative. s/p ercp and stent placement. puss seen on ercp but no culture data. hx of cholangitis with enterococcus fecalis (vanc sensitive) and pseudomonas (sensitive to zosyn).treated initally with vancomycin and zosyn. remained afebrile. switched to augmentin. pt remained afebrile and was discharged on 2 weeks of po augmentin. #elevated lfts - elevated during acute illness after ercp. trending of enzymes showed graduall decrease back to baseline. likely secondary to acute infection. # hypoxia -related to small b/l effusions, atelectasis and rll pna. initial require intubated due to increased work of breathing. extubated after one day in the icu. maintianied on supplemental oxygen for a few days post -extubation. given insentive spirometer. now stable on room air. # aflutter with rapid rate. ? h/o intermittent svt. seen on telemetry in icy. treated with metoprolol. dose titrated up to 100 mg po tid. now in normal sinus rhythm. . # pancreatic cancer. pt is not a surgical candidate. last dose of gemcitabine . holding further treatment until resolution of this acute illness. . #aortic stenosis - heard on exam and seen on echo in . no symptoms at this point. must be careful with bb. . . # elevated trop of 0. depressions and twi's likely secondary to demand ischemia in setting of rapid aflutter and hypoxia. ck's flat. has now resolved. . medications on admission: - lopressor 25 mg tid - colace - multivitamin - compazine prn discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 7. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 8. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 2 weeks. discharge disposition: home with service facility: home health, discharge diagnosis: pancreatic cancer cholangitis pneumonia discharge condition: good discharge instructions: please call dr. at( or return to the emergency department if you have fever, chills, nausea, vomitting, shortness of breath, or chest pain. followup instructions: please call dr. at( to arrange a follow up appointment for next week. provider: , rn phone: date/time: 11:30 provider: 17 date/time: 11:30 provider: scan phone: date/time: 11:00 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube enteral infusion of concentrated nutritional substances endoscopic insertion of stent (tube) into bile duct removal of t-tube, other bile duct tube, or liver tube diagnoses: pneumonia, organism unspecified anemia, unspecified congestive heart failure, unspecified unspecified essential hypertension aortic valve disorders atrial flutter acute respiratory failure cholangitis external hemorrhoids without mention of complication family history of malignant neoplasm of gastrointestinal tract malignant neoplasm of other specified sites of pancreas secondary malignant neoplasm of small intestine including duodenum 

Answer: The patient is high likely exposed to