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: monocular right visual loss major surgical or invasive procedure: none history of present illness: the pt is a 76 year-old right-handed, with history of hypertension, rheumatic heart, ra, dyslipidemia, who presented with a history of right eye pain at 11:30am today. patient had been in her usoh, when she was working at home, when she began to experience a sudden onset of right eye pain after she leaned forward. she denies any headache, weakness, numbness, loc, nausea/vomiting. following her right eye pain, within minutes, she reportedly began to have blurring of vision and then double vision. she called her eye doctor, who saw her. on examination, she was noted to have right nasal visual half field loss. rest of the ophthalmological exam was unremarkable. patient denies any similar symptoms in the past. she denies any recent illness or bowel/bladder problems. stroke was activated at 3:32 pm and she was evaluated per neurologist including stroke fellow at 3:35pm who found her reporting ~50% improvement in blurry vision and pain but complete abatement of diplopia. nihss: at : 3:30 pm () total score 1 f/u nihss 0 she was admitted to stroke service for evaluation and treatment including esr, mri/a, optho consult, tte and carotid ultrasound plus asa 325mg. she had no issues overnight and had normal exam during morning rounds except for rapid and irregular hr. however at 12:05, she developed l hemiplegia and neglect with conjugated eye deviation to the right hence another code stroke code was called. repeat cta showed r ica occlusion seen previously but also a clot in r mca in m1 division. because her symptoms were improving, heparin drip was started rather than iv tpa but another hour later at 1:05 pm, she again developed l hemiplegia with neglect plus slurred speech which improved within minutes. although she again improved, given fluctuating symtpoms, iv tpa (0.9mg/kg) was started at 1:52 pm with 10% as bolus over 1 minute and 90% over the next hour and she was transferred to the icu. additionally given that she seems more symptomatic when bp decreases, she received ns bolus and orders were put into start pressor if sbp < 140. after arriving in the icu, she had another 5~10 minutes of l hemiplegia with neglect with sbp ~120~130's which resolved. past medical history: 1. htn - well controlled with meds per patient 2. hyperlipidemia 3. rheumatic heart disease 4. rheumatoid arthritis social history: lives with husband with 6 grown children. remote 30 pack years and drinks 2 glasses of wine/night. family history: non-contributory physical exam: neurological examination on admission : t 97.3 bp 131/87 hr 120 rr 19 o2sat 96% with 2l nc gen: lying supine in bed - hob flat heent: nc/at, moist oral mucosa cv: irregularly irregular, no murmurs/gallops/rubs appreciated lung: clear abd: +bs, soft, nontender ext: 2+ symmetruc dorsalis pedis and no edema. neurologic examination: mse: awake and alert, cooperative with exam, normal affect. oriented to person, place, and date. attentive. speech is fluent with normal comprehension and repetition; naming intact.no dysarthria. intact recent and remote recall. no right left confusion. no evidence of apraxia or neglect. cranial nerves: ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. l inferior quadranopsia. fundoscopic exam normal with sharp disc margins. iii, iv & vi: extraocular movements intact bilaterally, no nystagmus. v: sensation intact to lt and pp. vii: facial movement symmetric. viii: hearing intact to finger rub bilaterally. x: palate elevation symmetrical. : sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline, movements intact motor: normal bulk and tone bilaterally. no observed myoclonus or tremor. slight drift upward of l arm when testing pronator drift. tri we fe ff ip h q df pf r 5 5 5 5 5 5 5 5 5 5 5 l 5 5 5 5 5 5 4 4+ 5 5 5 sensation: intact to light touch, pinprick, vibration, and cold throughout. reflexes: +2 and symmetric throughout except for achilles. toes downgoing bilaterally coordination: intact ftn bilaterally. gait: deferred discharge physical exam:no-neurological deficits noted, gait was slow but narrow based. pertinent results: labs results: from latest to early during admission. 06:00am blood wbc-9.7 rbc-3.53* hgb-12.7 hct-35.1* mcv-99* mch-36.1* mchc-36.3* rdw-13.1 plt ct-399 05:50am blood wbc-11.6*# rbc-3.52* hgb-12.6 hct-34.8* mcv-99* mch-35.7* mchc-36.1* rdw-13.1 plt ct-334 06:45am blood wbc-7.5 rbc-3.47* hgb-12.2 hct-34.8* mcv-100* mch-35.1* mchc-35.0 rdw-13.2 plt ct-327 03:50pm blood wbc-11.4* rbc-4.16* hgb-14.6 hct-41.6 mcv-100* mch-35.1* mchc-35.1* rdw-12.5 plt ct-330 05:50am blood neuts-73.4* lymphs-18.7 monos-4.5 eos-3.0 baso-0.5 06:50am blood neuts-72.4* lymphs-18.7 monos-5.6 eos-2.6 baso-0.6 03:50pm blood neuts-85.8* lymphs-10.7* monos-2.8 eos-0.4 baso-0.3 06:00am blood plt ct-399 06:00am blood pt-31.7* ptt-38.6* inr(pt)-3.3* 05:50am blood plt ct-334 05:50am blood pt-29.0* ptt-39.0* inr(pt)-2.9* 06:45am blood plt ct-327 12:40pm blood pt-21.7* ptt-65.4* inr(pt)-2.1* 06:00am blood pt-20.1* ptt-69.2* inr(pt)-1.9* 03:50pm blood esr-6 06:00am blood glucose-87 urean-8 creat-0.7 na-140 k-3.4 cl-106 hco3-25 angap-12 05:50am blood glucose-82 urean-4* creat-0.7 na-139 k-3.4 cl-106 hco3-26 angap-10 06:35am blood glucose-84 urean-9 creat-0.7 na-137 k-3.4 cl-102 hco3-28 angap-10 03:50pm blood glucose-158* urean-10 creat-0.7 na-132* k-4.2 cl-96 hco3-23 angap-17 05:50am blood alt-18 ast-32 alkphos-83 totbili-0.6 07:17pm blood ck(cpk)-44 06:50am blood lipase-31 06:00am blood calcium-8.9 phos-4.5 mg-1.7 05:50am blood calcium-8.9 phos-4.6* mg-1.7 06:35am blood calcium-9.1 phos-3.9 mg-1.8 cholest-238* 06:35am blood triglyc-88 hdl-81 chol/hd-2.9 ldlcalc-139* 07:17pm blood tsh-1.7 07:17pm blood t4-5.4 03:50pm blood crp-3.2 12:38pm blood type- ph-7.43 12:38pm blood freeca-1.19 other results: cardiology ekg atrial fibrillation with rapid ventricular response. no previous tracing available for comparison. ekg atrial fibrillation with rapid ventricular response. possible prior inferior myocardial infarction. non-specific st-t wave changes. compared to the previous tracing of no significant change. echo: tte the left atrium is mildly dilated. the right atrium is moderately dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets (3) are moderately thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. minimal aortic stenosis. mild aortic regurgitation. mild to moderate mitral regurgitation. moderate to severe tricuspid regurgitation. moderate pulmonary hypertension. chest rx patient positioning is severely kyphotic. moderate bilateral pleural effusion is new. moderate cardiomegaly unchanged. upper lungs clear. no pneumothorax. carotid series () findings: there are findings consistent with right ica occlusion and substantial atherosclerotic disease of the external carotid artery on the right with intimal thickening. this can be clinically significant in the setting of ica occlusion. peak systolic flow velocity of the cca on the right was measured as 0.27 m/sec. on the left side, there is intimal thickening consistent with atherosclerotic plaque formation, but no evidence of significant stenosis. the following peak systolic flow velocities were obtained on the left in m/sec. cca 0.55, proximal ica 0.52, mid ica 0.72 and distal ica 0.75. the ica/cca ratio on the left is 0.9. antegrade flow was noticed in both vertebral arteries. impression: 1. findings compatible with right-sided ica occlusion and external carotid artery atherosclerotic plaque formation that can be clinically significant in the setting of ica occlusion. 2. no significant ica stenosis on the left, which is patent. 3. antegrade flow in both vertebral arteries. neuroimagings: head and neck cta: there is calcified plaque at the origins of the innominate, both common carotid, and both subclavian arteries, without evidence of hemodynamically significant stenoses. the proximal common carotid and vertebral arteries are tortuous. there is plaque at the origin of the left vertebral artery, without evidence of hemodynamically significant stenosis. calcified plaque is present at the origin of the left internal carotid artery, spanning less than 1 cm, with approximately 30% to 40% stenosis. the distal cervical left internal carotid artery measures 5 mm in greatest diameter. calcified atherosclerotic plaque is present within the cavernous and supraclinoid portions of the left internal carotid artery, without evidence of hemodynamically significant stenosis there is complete occlusion of the right internal carotid artery from its origin through its intracranial bifurcation. the right anterior and middle cerebral arteries are patent. fetal origin of the right posterior cerebral artery is noted, a normal variant. there is no evidence of an aneurysm. there is mild focal narrowing in the p2 segment of the left posterior cerebral artery. there is mild emphysema within the lung apices. the right submandibular gland is atrophic. degenerative changes are present in the cervical spine. a developmental venous anomaly is present in the right frontal lobe. impression: 1. right internal carotid artery demonstrates complete occlusion from the origin to the supraclinoid portion, which is likely chronic given patency of the anterior and middle cerebral arteries. 2. 30% to 40% stenosis at the origin of the internal carotid artery, spanning less than 1 cm. 3. fluid and aerosolized secretions in the left maxillary sinus, which may be seen in acute sinusitis. 4. right frontal lobe developmental venous anomaly. 5. mild emphysema. mri head: there is no evidence of hemorrhage, edema, masses, mass effect or infarction. no diffusion abnormalities are detected. mild prominence of the sulci and ventricles is consistent with cerebral atrophy. there is no flow void in the right internal carotid artery, corresponding to the occlusion demonstrated on the concurrent cta. a right frontal developmental venous anomaly is noted. foci of high t2 signal in the subcortical, deep and periventricular white matter of the cerebral hemispheres, and in the right pons, likely correspond to chronic microvascular ischemic disease in a patient of this age. fluid and aerosolized secretions are present in the left maxillary sinus. mri orbits: coronal postcontrast images are limited by motion, but axial postcontrast images are diagnostic in quality. no abnormalities are detected in the orbits or cavernous sinuses. the optic nerves are normal in morphology and signal intensity. impression: 1. occlusion of the right internal carotid artery, better demonstrated on the concurrent cta. no evidence of acute infarction. 2. chronic small vessel ischemic disease. 3. right frontal lobe developmental venous anomaly. 4. fluid and aerosolized secretions in the left maxillary sinus, which may indicate acute sinusitis. 5. normal appearance of the orbits. carotid series findings: there are findings consistent with right ica occlusion and substantial atherosclerotic disease of the external carotid artery on the right with intimal thickening. this can be clinically significant in the setting of ica occlusion. peak systolic flow velocity of the cca on the right was measured as 0.27 m/sec. on the left side, there is intimal thickening consistent with atherosclerotic plaque formation, but no evidence of significant stenosis. the following peak systolic flow velocities were obtained on the left in m/sec. cca 0.55, proximal ica 0.52, mid ica 0.72 and distal ica 0.75. the ica/cca ratio on the left is 0.9. antegrade flow was noticed in both vertebral arteries. impression: 1. findings compatible with right-sided ica occlusion and external carotid artery atherosclerotic plaque formation that can be clinically significant in the setting of ica occlusion. 2. no significant ica stenosis on the left, which is patent. 3. antegrade flow in both vertebral arteries. head ct: there is subtle loss of the normal -white matter differentiation in the territory of the right mca. mild sulcal effacement is present in the right hemisphere (2b:50). new foci of hyperattenuation are present within the right m1 segment of the mca both proximally and distally (2b:44), which were not present on comparison from one day previous. there is no intracranial hemorrhage, hydrocephalus, or midline shift. an air fluid level with aerosolized secretions is again noted in the left maxillary sinus. the remaining visualized paranasal sinuses and mastoid air cells are clear. head cta: new abrupt cutoff is present within the m1 segment of the right mca (3:64). abrupt cutoff is also present with regard to the right fetal pca (3:59). the remaining carotid and vertebral arteries and their major branches are patent without evidence of stenosis. attenuated filling of the sylvian branches of the right mca are possibly secondary to retrograde leptomeningeal filling. incidental note is made of a right frontal lobe developmental venous anomaly (3:78). impression: 1. new occlusion of the distal m1 segment of the right mca and a segment of the right fetal posterior cerebral artery. associated subtle edema and sulcal effacement present in the right mca distribution. mra/mri brain and neck findings: on the diffusion-weighted sequence, there are areas of restricted diffusion in the vascular territory of the right mca, also some scattered hyperintense foci noted on the right occipital lobe, right basal ganglia and distally on the right temporal lobe suggesting thromboembolic ischemic changes. hyperintensity signal is also demonstrated on the right insular region and tip of the right temporal lobe. no significant mass effect is noted, on the left cerebral hemisphere also multiple areas of hyperintensity signal are noted on t2 and flair consistent with chronic microvascular ischemic changes. there is no evidence of hemorrhagic transformation. the orbits, the paranasal sinuses and the mastoid air cells are unremarkable. there is persistent mucosal thickening with fluid level on the left maxillary sinus. impression: acute/subacute ischemic changes are visualized on the vascular territory of the right mca with heterogeneous distribution raising the possibility of thrombolytic ischemic event as described above. mra of the circle of there is evidence of vascular flow in both internal carotids, narrowing of the distal branches of the right mca at the level of the m2, m3 segments, hypoplasia of the a1 segment is noted on the right with fetal pattern, the right posterior communicating artery apparently is arising from the right internal carotid. the anterior communicating artery appears prominent. no definite aneurysmatic formation is identified. the previously described right frontal developmental venous anomaly is not demonstrated in this examination. mra of the neck: in these follow examination apparently there is recanalization or reconstitution of the right internal carotid artery and narrowing at the origin of the right external carotid artery. the left cervical carotid bifurcation appear within normal limits. both vertebral arteries are patent. impression: findings compatible with recanalization of the right internal carotid on the right with narrowing of the cervical carotid bifurcation. acute/subacute ischemic changes possibly thromboembolic on the right mca as described in detail above. brief hospital course: briefly, 76 year old woman with a h/o ra developed sudden onset of visual loss accompanied with a right orbital pain yesterday. ophthalmology evaluation showed a left nasal field cut only in the right visual filed but no optic disc abnormalities. initial neck cta showed a r-ica occlusion in neck. overnight she developed tachycardia with af. around noon today, while walking to the bathroom with daughter developed left sided weakness (face, arm, leg) with right gaze deviation. dr. (neurology resident) promptly saw the patient within five minutes of symptom onset and noted her to be awake but somewhat lethargic but oriented to date, locale. she was unaware of deficits. within 15-20 minutes she beacme more alert and had full strength in her left sided extremities but continued to show some left sided field cut and sensory extinction. she was taken for an emergent head ct/cta which showed a possible in-situ thrombus at r-m1 and r-m2 occlusion. since her deficits had largely resolved, the team initially elected not to use iv tpa beacuse of a probable recent retinal infarction and low nihss (2). the option of ia tpa was discussed with dr. from neurosurgery but the stroke team decided against it because of technical difficulty accessing the r-mca via an occluded r-ica and beacuse of a concern for causing disruption of the carotid thrombus with distal embolization. at 1:25 her deficits returned. her bp~ 130/80s. her nihss was 15. within the next 15 minutes her deficits improved again (nihss 3).after discusiing the pros and cons of treatment with family it was decided to proceed with iv tpa. she recieved iv tpa bolus at 1:52 pm followed by an infusion. she will be monitored in the neuro-ice for 24 hours. we will aim to keep her bp~140/80 mm to 180-100 mmhg range. a f/u head ct will be obtained in the am. on she had an episode on confusion, which was attributed to a urinary tract infection, which was treated with ciprofloxacin. on mrs was transferred out of icu to the floor. cardiology recommended cardizem and metropolol for her atrial fibrillation. in addition, she was started on coumadin for her af and stroke. she required a couple of doses of lasix for lvf which was seen in the cxr. incidentally, she had an inflammed sebaceous cyst, which could not be lanced due to the fact that she was on coumadin. medications on admission: 1. plaquenil 2. atenolol 3. lisinopril discharge medications: 1. outpatient lab work inr (please send results to -myshkin ) 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily). 4. diltiazem hcl 180 mg capsule, sustained release sig: two (2) capsule, sustained release po daily (daily). disp:*60 capsule, sustained release(s)* refills:*2* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 6. warfarin 2.5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*0* 7. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: 1. cerebral infarction 2. hyperlipidemia 3. rheumatic heart disease 4. rheumatoid arthritis 5. htn discharge condition: the neurological examination prior to discharge was completely normal. please discuss your sebaceous cyst with your primary care physician. discharge instructions: you were admitted to this hospital because you were experiencing visual changes, and you have multiple risk for stroke this diagnosis was considered in the first place. while you were in the hospital you had three events of subtle left side weakness and neglect. you need to have your blood drawn for your inr (coumadin level) on monday. management of dietary interactions and vitamin k: dietary consistency is the key to maintaining a sustained, stable response during warfarin therapy. you should be aware of vitamin k content in common foods, particularly foods high in vitamin k (green leafy vegetables (broccoli, sprouts, turnip greens, kale, spinach, beet greens), cauliflower , legumes, mayonnaise, canola and soybean oils), and should maintain a consistent amount of these foods in their diet. the following foods should be avoided or limited, since they also can effect warfarin therapy: caffeinated beverages (cola, coffee, tea, hot chocolate, chocolate milk). alcohol intake greater than 3 drinks daily can increase the effect of coumadin. as long as alcohol intake does not exceed 3 drinks daily, clotting times should not be affected. this amount of alcohol is present in 12 ounces of table wine or three 12 ounce beers. (acute binges can raise inr. chronic alcohol ingestion may decrease inr. ) herbal supplements can affect bleeding time. coenzyme q10 is an herbal supplement whose chemical structure is similar to vitamin k, so it has the potential to affect bleeding time. herbal teas: green tea, , horsechestnut, tonka, bean, meliot, and . other examples include: feverfew, garlic, and ginseng. herbal medications should either be avoided or used consistently while on warfarin therapy. followup instructions: you need to call dr. at on monday to get set up in the coumadin clinic and arrange for your blood test. neurology: , md phone: date/time: 4:30 cardiology: , md phone: date/time: 1:00 the appointment could only be made for 9am or 1pm with drs. and - if you would like to make an appointment for a different time, please call and ask to have an appointment with a different provider. if you would like a primary care provider within the system, you can call to arrange it. md, procedure: injection or infusion of thrombolytic agent diagnoses: urinary tract infection, site not specified unspecified essential hypertension atrial fibrillation other and unspecified hyperlipidemia long-term (current) use of anticoagulants other constipation rheumatoid arthritis cerebral embolism with cerebral infarction rheumatic heart disease, unspecified occlusion and stenosis of carotid artery with cerebral infarction sebaceous cyst 

Answer: The patient is high likely exposed to