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: no known allergies / adverse drug reactions attending: chief complaint: unresponsiveness and left-sided weakness major surgical or invasive procedure: peg tube insertion history of present illness: 79rhf with paroxysmal atrial flutter/af previously well controlled on sotalol and on dabigatran for anticoagulation, cad, mild to moderate mitral regurgitation, diastolic chf, htn, hld, ckd presents with unresponsiveness and left-sided weakness. patient was apparently at her usual state of health other than feeling tired when her son spoke to her on the phone at 8pm on . no-one sw her in the interim on and on a son saw her in bed at 10am, asked if she was ok and she did not respond but he did not think much of it and attributed this to her being tired. however, when her other son came to check on her at 19:00 today (), he found her to be unresponsive, had been incontinent of urine and had her right leg hanging onto the floor and the other leg in bed. son gave her a small amount of water and apparently managed this as she was motioning that she wanted water and appeared dry. she was not moving her left side and was very drowsy and not talking. ems were called and she was noted to be in fast aflutter in 150s and in the ambulance they administered iv diltiazem which brought her hr to the low 100s. bp was stable throughout and on arrival at the ed bp was 120s-130s/70s and she had been incontinent of stool. there was initial concern regarding whether she would need to be intubated as she was obtunded and not opening her eyes. her respiratory status remained stable save requirement for suctioning and sats maintained at 100s and rr ranged from 20s when unstimulated to 30s when stimulated. she had clear left hemiparesis and right gaze deviation. patient does not feel in pain or shortness of breath but more expanded ros not possible due to difficulties communicating and conscious level. patient is oriented partially and does not appear to be aphasic but is very dysarthric. patient had persistent tachycardia and had a further 10mg iv diltiazem prior to transfer to the icu. patient thirsty and saying she wants water. past medical history: pmh: - paroxysmal atrial flutter/atrial fibrillation previously well controlled on sotalol and on dabigatran for anticoagulation s/p failed tee cardioversion - cad-single vessel (80% avg) per cath - mild to moderate mitral regurgitation - diastolic chf - htn - hld - asthma - ckd - anemia attributed to a combination of chronic kidney disease and myelodysplasia. bone marrow biopsy performed showed erythroid-dominant marrow with megaloblastic maturation and dyserythropoiesis consistent with evolving myelodysplastic syndrome. no cytogenetic abnormalities were identified. she has been maintained on aranesp injections with a goal hemoglobin 11.0 g/dl. - osteoarthritis of knees, shoulders, gets frequent injections . psurghx: s/p total abdominal hysterectomy. s/p bilateral hip replacements social history: mrs lives alone but sons visit and a neighbour checks on her. she is a widow. she has four children. there is a restraining order against her eldest son. services where someone comes in to help with bathing and cooking. otherwise she is able to do her adls - can dress, eat and toilet herself. occupation: she is retired but previously worked as an american airlines interpreter. she speaks five languages. mobility: unaided per family. smoking: never alcohol: never illicits: denies family history: mother - died of bone cancer father - mi died lung ca sibs - brother had a stroke in early 70s. others apparently well. children - 3 sons 1 daughter all well. physical exam: at admission: vitals: t:afebrile p:105 r:32 bp:126/83 sao2:100% on 100% o2 general: drowsy, very dysarthric, retaining secretions but allowing suctioning. able to communicate. heent: nc/at, no scleral icterus noted, dry mm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity. pulmonary: lungs decreased bs right > left base cardiac: rrr (in flutter on monitor), nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds. extremities: 2+ radial, weak dp pulses bilaterally and cold peripheries. pitting edema to knees bilaterally. skin: no rashes or lesions noted. neurological examination: nih stroke scale score was 15-16 1a. level of consciousness: 1 latterly 2 but can awake with eyes open with this 1b. loc question: 1 1c. loc commands: 0 2. best gaze: 2 3. visual fields: 2 4. facial palsy: 2 5a. motor arm, left: 3 5b. motor arm, right: 0 6a. motor leg, left: 3 6b. motor leg, right: 0 7. limb ataxia: 0 8. sensory: 0 9. language: 0 10. dysarthria: 11. extinction and neglect: 0 - mental status: best gcs e4 v4-5 m6 (on right) but very drowsy and takes some effort to arouse orientation - alert, oriented to self and to , hospital not date speech unable to relate history. language is sparse but does not seem to be aphasic although is complicated by severe dysarthria. naming pt. was able to name several low frequency objects - did not use stroke card due to vision problems. - unable to due to vision problems (homonymous hemianopia) attention - unable to assess but very drowsy but will generally obey commands comprehension able to follow both midline and appendicular commands there was no evidence of clear neglect but difficult to assess given homonymous hemianopia although did not feeling me touching her on the left - cranial nerves: i: olfaction not tested. ii: perrl 2 to 1.5mm sluggish bilaterally. likely left homonymous hemianopia as doe snot blink to threat on left. funduscopic exam not possible due to poor cooperation with likely cataracts bilaterally with present red reflexes. iii, iv, vi: right gaze deviation and can look at best only just past midline but not fully to the left v: facial sensation intact to light touch. good power in muscles of mastication. vii: left facial droop viii: hearing intact to voice bilaterally. ix, x: palate elevates pretty symmetrically. : weak on left trapezius. xii: tongue protrudes in midline with reasonably normal velocity movements. - motor: normal bulk, tone throughout on right. flaccid on left. dense hemiparesis on left. no adventitious movements, such as tremor, noted. no asterixis noted. dense hemiparesis left arm weaker than leg - on right ue weakness proximally -/5 and otherwise strong in rue. best in left ue is finger flexion against gravity () and slight elbow flexion () to noxious. in rle hip flexion 4-/5 at best and good power distally likely 4+/5. to noxious, on left can dorsiflex ankle -/5 and plantar flex with contraction of ip () and knee extension () and otherwise no apparent power. - sensory: can feel light touch all 4 limbs and grimaces to noxious all 4 limbs. - dtrs: bj sj tj kj aj l 2 2 2 0 0 r 2 2 2 0 0 there was no evidence of clonus. negative. plantar response was flexor on right, extensor on left. - coordination: no evidence of ataxia on right and left hemiparesis so unable to assess. - gait: unable to assess. exam at time of transfer out of neuroicu: patient has eyes closed spontaneously, responds to voices/commands while eyes closed. opens eyes when asked. speaks in at least 4 word phrases (per son, speaks limited english), follows all commands and answers most questions appropriately. speech is dysarthric but improving. at time patient seems to perseverate on ideas. r gaze preference, can cross midline to left. left neglect is improving and responds to stimuli on left/identifies l hand as her own. perrl. inconsistent blink to threat on left. eomi. left facial droop. moves right side spontaneously and at least 3-4/5. flaccid lue that extensor postures to noxious. lle triple flexes to noxious. grimaces to noxious throughout. extinction on left to dss. . . discharge examination: patient has eyes closed spontaneously often with evident eye opening apraxia although can open her eyes spontaneously at times. she has had a fluctuating examination and has been more or less responsive at times but better currently. verbalising well without suggestion of significant aphasia and talking in short sentences. she follows commands and can answer questions appropriately. speech is dysarthric but improving. right gaze deviation, unable to cross the midline to left. left homonymous hemianopia. left facial droop. moves right side spontaneously and at least 3-4/5. flaccid lue with minimal flexion in ue to noxious, likely slight left dorsiflexion is a spinal reflex. grimaces to noxious throughout. left neglect and cannot identify left hand as her own consistently. pertinent results: laboratory investigations: admission labs: 08:50pm blood wbc-16.2* rbc-3.43* hgb-11.6* hct-35.3* mcv-103* mch-33.8* mchc-32.9 rdw-16.2* plt ct-501* 08:50pm blood pt-13.5* ptt-24.8* inr(pt)-1.3* 08:50pm blood glucose-166* urean-15 creat-0.8 na-140 k-4.0 cl-102 hco3-23 angap-19 08:50pm blood alt-12 ast-28 alkphos-68 totbili-1.6* 08:50pm blood albumin-4.3 calcium-10.1 phos-3.2 mg-1.8 . other pertinent labs: 03:00am blood albumin-4.0 calcium-9.6 phos-3.4 mg-1.9 cholest-141 03:00am blood triglyc-180* hdl-26 chol/hd-5.4 ldlcalc-79 03:00am blood %hba1c-6.0* eag-126* 03:00am blood tsh-0.91 06:20am blood vanco-18.1 08:50pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 08:57pm blood glucose-163* lactate-2.5* na-140 k-4.6 cl-103 calhco3-26 01:14pm blood lactate-0.9 01:14pm blood freeca-1.22 03:00am blood ck-mb-6 ctropnt-0.05* 02:45pm blood ck-mb-4 ctropnt-0.03* 01:15pm blood ck-mb-2 09:10pm blood ck-mb-2 08:50pm blood lipase-35 03:00am blood alt-14 ast-35 ck(cpk)-431* alkphos-61 totbili-1.6* 02:45pm blood ck(cpk)-484* 12:55am blood alt-19 ast-33 alkphos-48 totbili-0.8 01:15pm blood ck(cpk)-121 09:10pm blood ck(cpk)-71 06:20am blood ck(cpk)-214* 08:50pm blood fibrino-462* . discharge labs: 05:40am blood wbc-8.8 rbc-3.09* hgb-9.8* hct-29.6* mcv-96 mch-31.7 mchc-33.0 rdw-17.4* plt ct-573* 05:40am blood pt-16.2* ptt-32.1 inr(pt)-1.5* 05:40am blood glucose-141* urean-23* creat-0.7 na-137 k-4.0 cl-104 hco3-26 angap-11 05:40am blood alt-12 ast-21 alkphos-72 totbili-0.6 05:40am blood albumin-3.5 calcium-9.9 phos-3.2 mg-2.1. . urine: 02:05am urine color-yellow appear-clear sp ->1.050* 02:05am urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 02:05am urine rbc-3* wbc-1 bacteri-none yeast-none epi-1 09:23pm urine color-yellow appear-clear sp -1.010 09:23pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-sm 09:23pm urine rbc-2 wbc-13* bacteri-few yeast-none epi-1 transe-<1 09:23pm urine casthy-2* 09:23pm urine mucous-mod 05:53pm urine color-straw appear-clear sp -1.003 05:53pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 02:05am urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg . . microbiology: blood culture blood culture, routine-no growth blood culture blood culture, routine-no growth . catheter tip-iv wound culture-negative blood culture blood culture, routine-no growth blood culture blood culture, routine-no growth . 10:51 am sputum source: expectorated. **final report ** gram stain (final ): <10 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. . blood culture blood culture, routine-no growth blood culture blood culture, routine-no growth . 2:05 am urine source: catheter. **final report ** urine culture (final ): escherichia coli. 10,000-100,000 organisms/ml.. presumptive identification. cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . 9:23 pm urine source: catheter. **final report ** urine culture (final ): <10,000 organisms/ml. mixed bacterial flora ( >= 3 colony types), consistent with fecal contamination. . . cardiology: ecg study date of 8:35:34 pm atrial flutter with rapid ventricular response. diffuse st-t wave abnormalities. compared to the previous tracing of ventricular rate is more rapid. st-t wave abnormalities are more pronounced. ventricular ectopy is no longer seen. read by: , e. intervals axes rate pr qrs qt/qtc p qrs t 110 0 68 348/435 0 12 72 . portable tte (complete) done at 11:33:01 am conclusions the left atrium is elongated. a possible left atrial appendage thrombus is suggeseted in some views (clip ), but could not be confirmed. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is moderate pulmonary artery systolic hypertension. there is an anterior space which most likely represents a prominent fat pad. impression: possible left atrial appendage thrombus. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. mild aortic regurgitation. dilated ascending aorta. if clinically indicated, a tee would be better able to identify a possible left atrial appendage thrombus. compared with the prior study (images reviewed) of , the rhythm is now atrial fibrillation with a rapid ventricular response and a left atrial appendage thrombus is suggested. . portable tee (complete) done at 3:34:43 pm conclusions no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. right and left atrial appendage ejection velocity is good (>20 cm/s). no atrial septal defect is seen by 2d or color doppler. left ventricular systolic function is grossly normal (ef>55%). right ventricular chamber size and free wall motion are normal. there complex (>4mm, non-mobile) atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. impression: no left atrial appendage thrombus. complex, non-mobile atheroma in the descending thoracic aorta. mild mitral regurgitation. mild aortic regurgitation. . ecg study date of 10:00:04 am atrial flutter. borderline low voltage. compared to the previous tracing of no change. read by: , intervals axes rate pr qrs qt/qtc p qrs t 96 0 94 370/433 0 14 13 . . radiology: cta head and neck: findings: new hypodensity in the right parietotemporal and occiptal lobes, extending into the right basal ganglia and internal capsule, is consistent with an acute right mca and pca territory infarct. hyperdense appearance of the right mca, is most suggestive of a thrombus. there is mass effect on the body of the right lateral ventricle. small hyperdense area within the right globus pallidus (2:18), may represent small hemorrhage within the infarct. the basal cisterns are normal. there is complete opacification of bilateral maxillary sinuses and partial opacification of bilateral anterior ethmoid/frontal sinuses. the hypoplastic mastoid air cells are clear. ct angiogram: neck: minimal atherosclerotic calcification is seen at the aortic arch. the origins of both carotid and vertebral arteries are normal. mild atherosclerotic calcification is seen in both carotid bifurcations, without evidence of hemodynamically significant cervical stenosis. the cervical portions of the vertebral arteries are normal. head: there is complete occlusion of the supraclinoid right internal carotid artery (just distal to a patent right ophthalmic artery) with thrombus extending into the m1 segment of the right middle cerebral artery. there is minimal filling of the right m2 branches. there is occlusion of the distal basilar artery with the tip patent. moderate atherosclerotic calcification is seen in the cavernous portion of both internal carotid arteries. the intracranial portion of the vertebral arteries, basilar artery and their major branches are patent. the imaged lung apices are clear. a small amount of secretions are seen within the trachea. the pharyngeal mucosal spaces are normal. minimal anterolisthesis of c7 on t1, is likely degenerative in etiology. impression: 1. ct head: acute right mca and pca territory infarcts. dense right mca consistent with thrombus. possible small focus of hemorrhage within the right basal ganglia region. 2. ct of the head and neck: occlusion of the supraclinoid right internal carotid artery and m1 branch of the right mca. flow is seen within the right mca m2 branches distally. occlusion of the distal basilar artery with the tip patent and non visualization of the right posterior communicating artery. . nchct: impression: large right middle cerebral and posterior cerebral artery territory infarct, similar in appearance compared to prior. stable mass effect on the right lateral ventricle without evidence for herniation. . portable nchct: impression: large right middle cerebral and posterior cerebral arterial territory infarction overall unchanged in appearance compared to the most recent prior study performed five hours earlier with mass effect on the right lateral ventricle but no evidence of midline shift, hemorrhagic transformation, or herniation at this time. . nchct: impression: 1. focal hyperdensity in the right basal ganglia is concerning for early petechial or hemorrhagic changes with increased mass effect on the right lateral ventricle and 2 mm leftward shift of normally midline structures from . 2. narrowing of the right suprasellar cistern with effacement of the right cerebral peduncle but no frank uncal herniation. 3. unchanged extent of large right middle cerebral and posterior cerebral territorial infarction. . ct head w/o contrast study date of 6:09 pm impression: evolving right mca/pca territorial infarct with central hyperdensities compatible with hemorrhagic conversion, with slightly increased leftward parafalcine herniation and minimally increased right vertex sulcal effacement. no evidence for transtentorial or uncal herniation. attending note: subtle hyperdensities within infarct can be due to petechial hemorrhage or uninvolved brain paranchyma. . chest (portable ap) study date of 4:28 am impression: 1. small right pleural effusion and bibasilar atelectasis. 2. possible early chf. . chest (portable ap) study date of 9:57 pm findings: compared to the film from earlier the same day, lung volumes are lower. it is difficult to assess for a lower lobe infiltrate given volume loss in both lower lungs and probable effusions. . chest (pa & lat) study date of 9:18 am findings: feeding tube tip is in the proximal stomach. there is blunting of the cp angles, but no definite infiltrate. heart size is mildly enlarged. upper lungs are clear. . ct head w/o contrast study date of 9:32 am impression: evolving right mca/pca territorial infarct with slight improvement of edema. there are no new areas of hemorrhage or infarction; however, mr is more sensitive if not ci . . bilat lower ext veins study date of 1:33 pm impression: no dvt in the right or left lower extremity. . abdomen u.s. (complete study) study date of 8:20 am impression: 1. splenic infarct involving one-third of the splenic volume with an area of liquefaction. 2. splenomegaly, measuring 14 cm. 3. cholelithiasis without ultrasound evidence of cholecystitis. 4. simple cyst within the upper pole of the right kidney. the remainder of the study is normal. . ct abd & pelvis with contrast study date of 6:05 pm findings: the left atrium is mildly enlarged. the left auricle is partially visualized (2, 1) with no apparent filling defect within it. calcifications are seen in the aortic valve and in the course of the rca. no pericardial effusion is identified. subcentimeter pulmonary nodule is seen in the right middle lobe (2, 5), unchanged from prior examination. inferior to the prior nodule another subcentimeter nodule is seen in the right middle lobe (2, 7) unchanged from prior examination. a tiny pulmonary nodule is seen in the lingula (2, 7), unchanged from prior examination. no pleural effusion is identified. the liver is within normal limits. no focal lesions are identified. a hyperdense material is seen in the gallbladder consistent with sludge. no signs of cholecystitis are seen. a hypoattenuating region is seen in the upper pole of the spleen measuring 38 x 75 x 89 mm consistent with the patient's known splenic infarct. the pancreas is within normal limits. both adrenals are unremarkable. several hypoattenuating lesions are seen within both kidneys, too small to characterize. the largest lesion is seen in the lower pole of the right kidney measuring 14 x 15 mm (2, 38) with a density of 30 hounsfield units. large amount of stool is seen in the large bowel. small bowel is within normal limits. a nasogastric tube is seen with its tip in the stomach. no peritoneal or retroperitoneal lymphadenopathy is identified. pelvis: streak artifact due to bilateral hip replacement. tiny gas bubble is seen within the urinary bladder, might be secondary to catheterization of the bladder. atherosclerotic changes are seen along the course of the aorta. atherosclerotic plaque is seen at the level of the sma (2, 29). at the level of the origin of the celiac axis there is a round filling defect (2, 24). no other filling defects are identified. the portal vein and its branches, the splenic vein and the smv are patent. the vena cava and its branches are within normal limits. osseous structures: degenerative changes are seen along the course of the spine. compressed fracture of l2 vertebra. bilateral hip replacement. no concerning lytic or osteoblastic lesions are seen. impression: 1. splenic infarct, as described. 2. atherosclerotic plaque at the level of the sma. 3. rounded peripheral filling defect is seen in just above the origin of the celiac axis. the appearance of the filling defect is most consistent with emboli. 4. gallbladder sludge without signs of cholecystitis . chest (pre-op pa & lat) study date of 2:56 pm comparison is made with prior study . there are persistent low lung volumes. left lower lobe opacities have almost resolved. there are no new lung abnormalities, pneumothorax or large pleural effusions. cardiomegaly is accentuated by the low lung volumes. ng tube tip is in the stomach. brief hospital course: 79rhf with paroxysmal atrial flutter/af previously well controlled on sotalol and on dabigatran for anticoagulation, cad, mild to moderate mitral regurgitation, diastolic chf, htn, hld, ckd presented on with unresponsiveness and left-sided weakness and found to have a severe right mca/pca syndrome on examination. ct showed extensive right mca and pca infarcts (pca infarct was felt likely embolic from fetal pca) which were felt to be embolic from her aflutter. on further questioning, the patient had been mistakenly taking once daily dabigatran which is a considerable underdosing and inadequate anticoagulation. she was admitted to the icu and dabigatran and other anticoagulation was held due to concern for hemorrhagic conversion and she was treated with aspirin alone initially. tte showed a possible left atrial appendage thrombus and she therefore proceeded to a tee which showed no evidence of thrombus but complex, non-mobile atheroma in the descending thoracic aorta. she had persistently poor swallow assessments and aspirated on all consistencies and a dobbhoff tube was placed. she had significant issues regarding af with rvr although she was in general not hemodynamically compromised and her rate control regimen was extensively changed and cardiology were involved. eventually hr heart rate was controlled on a combination of diltiazem and metoprolol. she was transferred to the floor and there, she was also noted to have intermittent prolonged apneic spells which were felt to likely represent osa and given her ng tube she could not have cpap. this should be assessed in the community for possible osa. she did not desaturate with these episodes. she was treated for a uti and then started spiking fevers which were attributed to likely aspiration pneumonia/hcap although little to find on cxr or other infectious workup, id were and eventually signed off and she completed an 8 day course of iv vancomycin and piperacillin/tazobactam and fevers settled. due to fluctuating conscious level, she had an eeg which showed no evidence of epileptiform discharges. in the process of working up her fevers she had an u/s abdomen which showed a splenic infarct and ct abdomen/pelvis suggested a likely embolic source with evidence of a likely embolus above the origin of the celiac axis and an atherosclerotic plaque at the level of the sma. due to her continued poor swallow, she proceeded to a peg on without complication. following her peg insertion, she was restarted on anticoagulation with warfarin with an overlap of aspirin until therapeutic inr. she had brief episodes of rvr and this eventually settled and rate was eventually well controlled. she was noted to have a hb drop from 9 to 6.8 in the setting of an inadequate reticulocyte count and although stool was minimally guaiac positive, this was not enough to explain this loss and after hematology, gi and general surgery consults, this was felt to represent her mds and required 2 units of rbcs. post-transfusion, her hb remained stable and she had no episodes of hemodynamic compromise with this hb drop. she was transferred to rehab on . she has neurology, hematology and cardiology follow-up. . . # neurology: patient has had no prior stroke but has considerable stroke risk factors of paroxysmal atrial flutter/af previously well controlled on sotalol but taking an inadequate dose of dabigatran, cad, mild to moderate mitral regurgitation, diastolic chf, htn, hld. initial neurological exam revealed patient to be drowsy but arousable, oriented x2 (to self and place) with no apparent aphasia (names reasonably/follows commands) but significant dysarthria. cn examination reveals perrl, eomi, a left facial droop, right gaze deviation but cannot cross midline with left homonymous hemianopia. limb exam revealed a dense left hemiparesis with slight withdrawal in lue and toe extension and knee flexion on le and good spontaneous movement on right, grimaces to noxious throughout, brisker reflexes on right and right extensor plantar. cta head and neck showed a hyperdense right mca sign, acute right mca and pca territory infarcts, a dense right mca consistent with thrombus and a possible small focus of hemorrhage within the right basal ganglia region with mass effect on right lateral ventricle but no mls. cta showed occlusion of the supraclinoid right ica and m1 cutoff reconstituting distally. there was also thought to be occlusion of the distal basilar artery with the tip patent with no right pca seen although her pca embolism was felt to be secondary to a fetal pca. ct on was stable. stroke risk factors were assessed and patient was monitored on telemetry. this revealed multiple episodes of rvr requiring prn diltiazem, metoprolol and at times requiring iv medications. patient was treated with a hiss with a goal for normoglycemia. stroke risk factors were assessed with hba1c 6.0% and flp revealed chol 141 tgcs 180 hdl 26 ldl 79. tsh was 0.91. ua was positive and ucx revealed pan sensitive e coli. simvastatin was changed to atorvastatin 20mg qd. the likely cause of her extensive infarcts was felt to be embolic from her af/aflutter in the setting of the patient mistakenly underdosing dabigatran resulting in inadequate anticoagulation. she was admitted to the icu and dabigatran and other anticoagulation was held due to concern for hemorrhagic conversion and she was treated with aspirin alone initially. tte on showed possible left atrial appendage thrombus with mild symmetric lvh with preserved global and regional biventricular systolic function, mild ar and a dilated ascending aorta. she therefore proceeded to a tee the same day which showed no left atrial appendage thrombus and complex, non-mobile atheroma in the descending thoracic aorta. ideally, she required anticoagulation but due to the large infarct, this was felt to be too great a risk for considerable hemorrhagic conversion and was deferred until after peg placement. she was seen by s&s and found to have significant dysphagia, she was therefore made npo and a dobbhoff tube was inserted. in the icu she had episodes of rvr and she was initially treated with iv diltiazem. ct head remained stable and patient clinically improved such that she was transferred out of the icu to neuro step-down on but returned a few hours later after sbp decreased to 80s and she was having 20s apneic episodes. repeat ct scan showed central hyperdensities compatible with hemorrhagic conversion, with slightly increased leftward parafalcine herniation and minimally increased right vertex sulcal effacement and patient clinically improved. the apnea was felt to be due to osa with superimposed stroke. patient again remained stable and patient was transferred back to the floor on . there, she was noted to be more lethargic with fluctuating conscious level and an eeg was requested which showed slowing but no epileptiform activity. she had continued rvr and diltiazem much improved hr but bp was borderline hypotensive and metoprolol was tapered and uptitrated diltiazem and eventually bp improved and rate was well controlled on the last 3 days of her hospitalisation. general surgery were regarding possible peg placement given continued severe dysphagia but wanted to defer surgery until fevers settled. general surgery were re-contact after she had no further fevers and patient proceeded to peg insertion on without complication. following her peg insertion, she was restarted on anticoagulation with warfarin (dabigatran cannot be crushed) on with an overlap of aspirin until inr is therapeutic. she remained stable (see hb drop and rationale in hematology section) and was transferred to rehab on . we held darbepoetin due to possible increased stroke risk and this should be re-addressed by hematology at her soon o/p appointment. . # cvs: patient has a history of af/aflutter diagnosed in s/p a failed cardioversion in , htn, hld and single vessel cad who presented with embolic right mca/pca stroke as above likely due to cardioembolism from her af in the setting of inadequate anticoagulation as the patient has been taking her dabigatran only once daily. dabigatran and other anticoagulation was held due to concern for hemorrhagic conversion and she was treated with aspirin alone initially. patient had been well controlled rate-wise in the community on sotalol and diltiazem xr 240mg qd. her rate control and anti-hypertensive agents were initially held and during her hospitalisation, she had several episodes of rvr requiring iv rate control agents (diltiazem and metoprolol) and her diltiazem was uptitrated. whilst in the icu, the patient had second pauses on telemetry for which she was asymptomatic and this was felt likely related to medications given patient had been started on both metoprolol, diltiazem, in addition to her sotalol. patient was initially transferred out of icu on but due to a drop in bp to sbp 80s and 20 sec apneic episodes, was transferred back to icu for overnight monitoring. she received ivf 250ml boluses x2 and her bp improved although in general her sbo was mainly in 90s and 100s. the patient was initially continued on only sotalol 80mg po bid but due to persistent pauses and further af with rvr, cardiology were , sotalol was stopped and she was continued on diltiazem and metoprolol. she had continued episodes of rvr and diltiazem was uptitrated. other than very occasional tachycardic episodes, she achieved good rate control with diltiazem 75mg q4h and metoprolol 25mg tid. following her peg insertion, she was restarted on anticoagulation with warfarin (dabigatran cannot be crushed) with an overlap of aspirin until inr is therapeutic. . # id: patient had an initial leucocytosis with wbcs up to 17.6 and this resolved. ua was positive and she was started on ciprofloxacin on for uti (10,000 -100,000 ecoli in urine) and was treated with a 3 day course. she however started to spike fevers to 102.5f on and she was started empirically on vancomycin and piperacillin/tazobactam on for possible hap but no good evidence of infection on cxrs. she was pancultured and these revealed no growth to date. to further investigate fevers, doppler u/s of the legs revealed no evidence of dvt and id were when she again spiked a fever to 101.5f on who recommended awaiting cultures and completing antibiotic course with further investigations if further fevers. abdominal u/s showed a large splenic infarct and to better characterise this, the patient was evaluated with ct abdomen/pelvis which showed her splenic infarct but no evidence of metastatic infection or occult infection. her fevers settled and were felt likely secondary to hap/aspiration pneumonia and she completed an 8 day course of vancomycin and piperacillin/tazobactam stopped on . she remained stable after this and had no further fevers. . # gis: in the process of her infectious workup, she was found to have a splenic infarct on her abdominal ultrasound. she had some mild generalised abdominal pain and ct abdomen/pelvis showed her previously documented 38 x 75 x 89 mm splenic infarct, in addition to an atherosclerotic plaque at the level of the sma and a rounded peripheral filling defect just above the origin of the celiac axis likely representing emboli and the likely cause of her splenic infarct was therefore felt to be embolic. there was no evidence of metastatic infection in addition to unchanged pulmonary nodules (stable from prior study) and gallbladder sludge without cholecystitis. she had significant fecal loading and she was treated with laxatives. she had guaiac positive stool as below but did not represent melaena and did not require endoscopy after gi consultation. her hb drop was felt to represent her mds given grossly inadequate reticulocyte count 0.1. . # hematology: patient has a history of mds on darbepoetin. given her stroke and risks associated with increasing blood viscosity, darbepoetin was held while in hospital. she had a chronic anemia with hct 27-30. she developed what we feel to be a reactive thrombocythemia and from he was noted to have a hb drop from 8.5 to 6.8 in the setting of an inadequate reticulocyte count (0.1) and although stool was minimally guaiac positive, this was not enough to explain this loss. after hematology, gi and general surgery consults, this was felt to represent her mds and required 2 units of rbcs and she had been usually requiring 2 units per month in the community prior to starting darbepoetin. post-transfusion, her hb remained stable at 9.8 and she had no episodes of hemodynamic compromise with this hb drop. she has hematology follow-up. her cbc will need to be trended at rehab and there they should consider restarting darbepoetin as per hematology. . # rs: patient was persistently tachypneic during her hospitalisation and this improved. her o2 stats were stable throughout. cxrs showed atelectasis and effusions which improved after her home furosemide was restarted and she was treated with an 8 day course of iv piperacillin /tazobactam for presumed hcap/aspiration pneumonia although there was no clear evidence of pneumonia on cxr. she remained stable from a pulmonary perspective. she had episodes of sleep apnea up to 20s during her hospitalisation and this improved as her mental status improved. pcp should consider /p sleep study evaluation for this. . # fen: patient was too lethargic during the first few days of her stay to participate in official swallow evaluation. a dobbhoff was placed and she was started on low dose tfs that were then titrated up to a nutritional level. speech re-evaluated patient and found persistent poor swallow aspirating on all consistencies and she proceeded to a peg tube insertion on . . # endo: hba1c was 6%. patient was placed on a hiss with a goal of normoglycemia. . # : she had urinary retention following catheter removal and straight cathed 700ml. a urinary catheter was placed on the day of transfer due to continued retention. further voiding trial to be performed at rehab. . . transitional issues: - hb trended down from 9 to 6.8 and was seen by gi, gen surgery and hematology and felt due to her mds. will need regular cbc checks at rehab and may require transfusion as required. was not hemodynamically unstable as a result of her hb drop. - darbepoetin has been held and should be restarted as deemed appropriate by hematology - she has hematology follow-up - she has had episodes of af with rvr and she may require further uptitration of her diltiazem or metoprolol although has been well controlled over the past 3 days. - following peg, patient was started on warfarin with goal inr . she will be overlapped with aspirin 81mg and s/c heparin until inr is therapeutic. - next inr to be drawn on . - patient had peg tube on and has been discharged on tube feeds. - patient had urinary retention following removal of catheter. further voiding trial to be performed at rehab. - pcp should consider evaluation for osa in the community. medications on admission: alendronate - (prescribed by other provider) - 35 mg tablet - 1 tablet(s) by mouth weekly dabigatran etexilate - 150 mg capsule - 1 capsule(s) by mouth twice a day - per report patient had only been taking this once daily prior to admission darbepoetin alfa in polysorbat - (prescribed by other provider) - 300 mcg/ml solution - weekly diltiazem hcl - (prescribed by other provider) - 240 mg capsule, ext release 24 hr - 1 capsule(s) by mouth once a day folic acid - (dose adjustment - no new rx) - 1 mg tablet - 1 tablet(s) by mouth daily furosemide - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth once a day lidocaine - 5 % (700 mg/patch) adhesive patch, medicated - apply one patch to painful area once a day for 12 hours, then off for 12 hours omeprazole - (prescribed by other provider) - 20 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth once a day simvastatin - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth daily sotalol - (prescribed by other provider) - 80 mg tablet - 1 tablet(s) by mouth twice a day tramadol - (prescribed by other provider) - 50 mg tablet - 1 tablet(s) by mouth three times a day as needed for pain medications - otc acetaminophen - (prescribed by other provider) - 500 mg tablet - 1 tablet(s) by mouth twice a day calcium carbonate-vitamin d3 - (prescribed by other provider) - 600 mg-400 unit tablet - 1 tablet(s) by mouth twice a day docusate sodium - (prescribed by other provider) - 100 mg capsule - 1 capsule(s) by mouth twice a day multivitamin - tablet - 1 tablet(s) by mouth once a day. please do not dispense an iron-containing multivitamin. sennosides - (prescribed by other provider) - 8.6 mg tablet - 1 tablet(s) by mouth twice a day discharge medications: 1. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily). 2. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 3. senna 8.8 mg/5 ml syrup sig: one (1) po bid (2 times a day). 4. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain, fever. 5. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 6. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 7. polyvinyl alcohol-povidon(pf) 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 8. insulin regular human 100 unit/ml solution sig: per sliding scale injection asdir (as directed). 9. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for fungal rash. 10. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching. 11. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 12. alendronate 35 mg tablet sig: one (1) tablet po once a week. 13. folic acid 1 mg tablet sig: one (1) tablet po once a day. 14. calcium carbonate-vitamin d3 600 mg(1,500mg) -400 unit capsule sig: one (1) capsule po twice a day. 15. multivitamin tablet sig: one (1) tablet po once a day. 16. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po once a day: continue until inr therapeutic. 17. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 18. metoprolol tartrate 25 mg tablet sig: one (1) tablet po three times a day. 19. diltiazem hcl 30 mg tablet sig: 2.5 tablets po q4h (every 4 hours). 20. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day): continue s/c heparin until inr theraputic. discharge disposition: extended care facility: hospital for continuing medical care - ( center) discharge diagnosis: primary diagnoses: 1. embolic large right middle cerebral artery and posterior cerebral artery infarcts likely secondary to af/aflutter and inadequate anticoagulation (taking half dose dabigatran) 2. dysphagia secondary to above requiring peg tube insertion 3. splenic infarct likely embolic 4. myelodysplastic syndrome requiring transfusion as an inpatient . secondary diagnoses: 1. atrial fibrillation/atrial flutter with episodes of rapid ventricular rate 2. hospital acquired pneumonia 3. likely obstructive sleep apnea 4. urinary tract infection discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. neurologic: patient has eyes closed spontaneously often with evident eye opening apraxia although can open her eyes spontaneously at times. she has had a fluctuating examination and has been more or less responsive at times but better currently. verbalising well without suggestion of significant aphasia and talking in short sentences. she follows commands and can answer questions appropriately. speech is dysarthric but improving. right gaze deviation, unable to cross the midline to left. left homonymous hemianopia. left facial droop. moves right side spontaneously and at least 3-4/5. flaccid lue with minimal flexion in ue to noxious, likely slight left dorsiflexion is a spinal reflex. grimaces to noxious throughout. left neglect and cannot identify left hand as her own consistently. discharge instructions: it was a plesuare taking care of you during your stay at the . you presented with unresponsiveness and left sided weakness. ct showed a very large stroke affecting the right side of your brain. this was felt to be a result of a combination of your irregular heartbeat and that you were mistakenly only taking your pradaxa once as opposed to twice per day. you were initially admitted to the icu and you had high heart rates which required medications to treat this. you had a heart ultrasond (echocardiogram) including a repeat tran-esophageal echocardiogram which showed no clear evidence of clot in your heart. ct scans of the head remeined stable and you were initially transferred back to the floor but due to bloodpressure issues you were transferred back. you were eventually able to be transferred out of the icu. you were treated for a urinary tract infection and then you began spiking fevers and the infectious diseases doctors . you were treated with broad spectrum antibiotics for a likely pneumonia and the fevers settled. in tthe process of your work-up, we found a stroke to your spleen which is also likely because of a blood clot. for this reason and to reduce your risk of strokes we started you on warfarin which is another blood thinner. risks of this are as before namely increasd bleeding risk for instance if you cut yourself it will be more difficult to stop bleeding and if you hit your head you need to seek urgent medical attention as there is a risk of bleeding in the brain. you had significant swallowing problems and you were initially fed with an ng tube but given continued poor swallowing on repeated assessments, you had a feeding tube called a peg tube inserted into your stomach on . there were no complications from your surgery and you were transferred to rehab on . we thought you likely have sleep apnea given pauses in respirations observed on the floor. assessment with a sleep study can be organised by your pcp. your blood cpount dropped an this was felt likely due to your myelodysplastic syndrome and you required a blood transfusion for this. we have arranged hematology follow-up as below. medication changes: we started aspirin to overlap with warfarin until inr is therapeutic we started warfarin 5mg daily we stopped dabigatran we held darbepotin and this can be restarted on the advice of hematology who you will see in clinic we changed diltiazem extended release to diltiazem 75mg every 4 hours we stopped sotalol we changed omeprazole to famotidine we changed simvastatin to atorvastatin 20mg daily we stopped tramadol we started metoprolol 25mg three times daily please continue your other medications as prescribed followup instructions: please see your pcp on discharge from rehab. we have arranged the following stroke neurology follow-up: department: neurology when: friday at 1:30 pm with: , md building: sc clinical ctr campus: east best parking: garage we have arranged the following hematology follow-up: department: hematology/oncology when: wednesday at 1:30 pm with: , md building: sc clinical ctr campus: east best parking: garage you have the existing cardiology follow-up: department: cardiac services when: thursday at 2:40 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] diagnoses: obstructive sleep apnea (adult)(pediatric) mitral valve disorders urinary tract infection, site not specified congestive heart failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation subarachnoid hemorrhage atrial flutter chronic kidney disease, unspecified compression of brain myelodysplastic syndrome, unspecified other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure retention of urine, unspecified cerebral embolism with cerebral infarction dysarthria embolism and thrombosis of other specified artery ventilator associated pneumonia chronic diastolic heart failure hip joint replacement other and unspecified escherichia coli [e. coli] essential thrombocythemia facial weakness unspecified pruritic disorder homonymous bilateral field defects dysphagia, unspecified flaccid hemiplegia and hemiparesis affecting nondominant side 

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