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: penicillins attending: chief complaint: transient r sided weakness major surgical or invasive procedure: picc line insertion picc line removed history of present illness: 47 yo rhw s/p re-resection of large tuberculum sellae meningioma , with silent l basal ganglia infarct noted on post-op mri, and now with 2 hr episode of r weakness and speech difficulties yesterday. the patient was initially diagnosed with meningioma when she presented with l vision changes. she underwent a resection in , then a repeat for enlargement. neuro-optho evals pre-op did not show any new visual problems. surgery was uncomplicated, but post-op mri did not l basal ganglia infarct not seen on prior mri in . she denies ever having any symptoms of right sided weakness or numbness during the past several weeks, or having any problems post-op. she was discharged on keppra 500 mg for prophylaxis and a dex taper. she went home and was staying with her mother while she recovered. yesterday around 5pm, the patient was sitting watching tv when she tried to stand and realized she was weak on the right side. her mother saw what happened, and began asking her questions. the patient could reply only "yes" "no" or "okay." she was also repeatedly saying "hello mama" in a highpitched, child-like voice. her words were slurred. she was able to follow some commands, and her mother fed her dinner, she chewed and swallowed without difficulty. no lip smacking, automatisms, tongue biting, incontinence. after about 2 hours, she was suddenly able to get up and walk. she had a completely normal gait and no residual weakness at this time. the patient went to sleep, and the patient's mother checked on her with a flashlight every few hours- she would reply that she was awake and she was ok. this morning, the patient was 100% at her baseline. during this episode, the patient's mother did call neurosurgery on-call, who insisted she call 911 immediately, but the patient had eaten dinner then went to sleep, so she waited until this morning to drive her in. the patient never had a seizure before, or any episode like this. in the ed, neurosurgery saw the patient and recommended increasing keppra to 1000 mg and admitting to neuro due to neuroimaging findings. on neuro ros, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. denies numbness, parasthesiae. no bowel or bladder incontinence or retention. denies difficulty with gait. on general review of systems, the pt denies recent fever or chills. denies cough, shortness of breath. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. past medical history: htn x 7 yrs duodenal ulcer large tuberculum sellae meningioma resected with evidence of silent left frontal and basal ganglia infarcts on post-op mri social history: lives alone except since surgery staying with mother, works as editor. no tobacco, etoh or illicits. family history: mgm rectal cancer, mgf gi cancer, dm physical exam: admission physical examination: vitals: t: 97.4 p: 64 r: 16 bp:124/71 sao2:100/ra general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd extremities: no c/c/e bilaterally neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. attentive. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt. was able to name both high and low frequency objects. able to read without difficulty. speech was not dysarthric. able to follow both midline and appendicular commands. pt. was able to register 3 objects and recalled at 5 minutes (could not guess the 3rd even with multiple choice). there was no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. vff to confrontation. funduscopic exam revealed no papilledema, exudates, or hemorrhages- l optic disc pallor. no red desaturation. visual acuity 20/20 bilaterally. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, tone throughout. no pronator drift bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: no deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. no extinction to dss. intact graphesthesia. -dtrs: tri pat ach l 2 2 2 2 1 r 2 2 2 2 1 plantar response was flexor bilaterally. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf or hks bilaterally. -gait: good initiation. narrow-based, normal stride and arm swing. able to walk in tandem without difficulty. romberg absent. . . icu transfer physical examination : a+ox3 but mild phasia with paraphasic errors and some perseveration. some left/right confusion. mild rue weakness effort dependent with shoulder abd 4+/5 and finger ext 4+/5. no sensory or coordination abnormalities. extensor plantar on right. . . discharge examination: a+ox3 but mild aphasia with poor naming (only 6 animals and 3 words beginning with f) and difficulty with the finer details in conversation. full power all 4 limbs and mild right-sided weaknes appears to have resolved. no sensory or coordination abnormalities. pertinent results: laboratory investigations: 11:30am blood wbc-12.5* rbc-4.13* hgb-12.4 hct-34.2* mcv-83 mch-29.9 mchc-36.2* rdw-13.9 plt ct-259 11:30am blood neuts-79.4* lymphs-16.2* monos-3.8 eos-0.4 baso-0.2 11:30am blood pt-12.0 ptt-20.8* inr(pt)-1.1 11:30am blood glucose-168* urean-17 creat-0.7 na-140 k-3.7 cl-102 hco3-25 angap-17 . stroke risk factors: 11:30am blood cholest-192 11:30am blood triglyc-125 hdl-58 chol/hd-3.3 ldlcalc-109 11:30am blood %hba1c-5.3 eag-105 . other pertinent labs: 02:00am blood osmolal-289 07:40am blood crp-1.4 04:19am blood cortsol-0.5* 09:35am blood fsh-12 lh-3.9 prolact-11 tsh-4.0 09:35am blood free t4-1.0 . discharge labs: 09:35am blood wbc-12.0* rbc-3.69* hgb-11.0* hct-30.6* mcv-83 mch-29.7 mchc-35.9* rdw-13.9 plt ct-290 07:58am blood pt-23.2* ptt-31.3 inr(pt)-2.2* 09:35am blood glucose-122* urean-17 creat-0.6 na-138 k-3.8 cl-101 hco3-28 angap-13 09:35am blood calcium-8.5 phos-3.7 mg-1.8 . . urine: 10:40am urine color-straw appear-clear sp -1.017 10:40am urine blood-tr nitrite-pos protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-sm 10:40am urine rbc-3* wbc-40* bacteri-few yeast-none epi-<1 10:40am urine mucous-rare 02:21am urine hours-random creat-30 na-104 k-7 cl-91 02:21am urine osmolal-340 . . microbiology: blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient 10:40 am urine source: catheter. urine culture (preliminary): escherichia coli. >100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. proteus species. 10,000-100,000 organisms/ml.. presumptive identification. 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 . . radiology: ct head w/o contrast study date of 10:50 am findings: postoperative changes of the left frontal craniotomy are again noted. there is persistent pneumocephalus, decreased in comparison to prior study from . additionally, there is now a small amount of mixed attenuation fluid in the left frontal region, consistent with post-surgical changes and non-hemorrhagic. hyperdense material is again noted in the region of the sella (2:8), either representative of residual blood or volume averaging. there is no shift of normally midline structures. a hypodensity is again noted in the left globus pallidus (2:13), consistent with previously known subacute infarction. additionally, a hypodensity is noted in the left inferior frontal lobe (2:10), likely representative of either another evolving infarction or post-surgical edema and partly seen on the axial flair sequence of prior mr study. the visualized mastoid air cells and paranasal sinuses are clear. impression: 1. post-surgical changes again noted with left frontal craniotomy and expected postoperative changes with a small amount of non-hemorrhagic fluid and resolving pneumocephalus. 2. subacute left globus pallidus infarct is again noted. additionally, again noted is the hypodensity in the left frontal lobe near the midline (2:10) suggestive of either another evolving ischemic change or edema, partly seen earlier. further characterization may be obtained with an mri and mra if not ci. . mri brain and mra head/neck w&w/o contrast study date of 3:46 pm findings: mri head: the patient is status post left frontal craniotomy for resection of recurrent tuberculum sellae meningioma. there is expected resolution of postoperative pneumocephalus with persistent, yet less prominent left frontal subdural fluid collection (reduction from previous 9 to current 6 mm in maximal thickness). there is an unchanged 4-mm enhancing soft tissue focus in the planum sphenoidale which may be postoperative in nature or represent residual meningioma. there is evolution of scattered infarcts involving the left basal ganglia (globus pallidus), the inferior and left lateral frontal, and anterior left temporal lobe. none of these infarcted areas demonstrates interval mass effect or hemorrhagic transformation. no new areas of infarct are identified. the cerebral sulci, ventricles, and extra-axial csf containing spaces are otherwise normal in appearance, and there is no evidence of hydrocephalus. again seen is fluid retention within the right mastoid air cells. the paranasal sinuses are clear. mra head: there is a significant short segment stenosis at the proximal aspect of the left m1 segment with small caliber of the more distal portions. the m2 through m4 segments are patent. the intracranial internal carotids, vertebrobasilar, and anterior, right middle, and posterior cerebral arteries are patent with normal flow-related enhancement and branching pattern. there is bilateral fetal origin of the posterior cerebral artery. no aneurysms or arteriovenous malformations are identified. mra neck: the origins of the common carotid and vertebral arteries are patent without significant stenosis. the common, internal, and external carotid arteries are normal in appearance. there is no evidence of hemodynamically significant stenosis or dissection. the cerebral portions of the vertebral arteries likewise demonstrate normal contrast opacification. impression: 1. status post left frontal craniotomy with interval reduction of left frontal subdural fluid collection. 2. evolution of scattered infarcts involving the left basal ganglia, inferior and lateral frontal, and left temporal lobe. 3. high-grade stenosis at the proximal aspect of the left m1 segment with small caliber of the more distal branches, correlation with cta is advised. 4. unchanged focus of enhancement in the planum sphenoidale which may be postoperative in nature or represent a small amount of residual tumor. . cta head w&w/o c & recons study date of 12:44 pm findings: non-contrast head ct: post-operative changes adjacent to the left frontal craniotomy are again noted. pneumocephalus has decreased. there is fluid in the left frontal region consistent with post-surgical changes. previously seen hyperdense material in the region of the sella is less apparent and likely represents evolving blood products. the hypodensities are again noted in the left globus pallidus, left inferior and lateral frontal lobe, and left temporal lobe. there are no new hypodensities. there are no new areas of edema or hemorrhage. there is no shift of normally midline structures. the ventricles and sulci are normal in size and configuration. cta of the head: there is high-grade stenosis in the proximal left m1 segment. the vessels distal to the stenosis are still opacified however the overall vessel caliber in the left mca distribution are decreased. the visualized portions of the carotid and vertebral arteries are patent with no evidence of stenosis. the posterior circulation vessels are normal and patent. the posterior cerebral and anterior cerebral arteries are patent without evidence of stenosis. impression: 1. previously seen hypodensities in the left basal ganglia, inferior and lateral left frontal lobe, and left temporal lobe are unchanged. no new hypodensities. 2. high-grade stenosis at the proximal aspect of the left m1 segment is again seen with overall decreased caliber of more distal vessels of the left middle cerebral artery. 3. status post left frontal craniotomy with some residual left subdural fluid collection, unchanged. . ct head w/o contrast study date of 6:17 am findings: post-left frontal craniotomy changes are again seen with a small subdural collection and trace pneumocephalus as well as overlying skin staples. allowing for streak artifact in the left temporoparietal region, there is no new hemorrhage. previously seen hypodensity within the left globus pallidus is also unchanged. ventricles and sulci are similar in caliber as before. suprasellar and basilar cisterns are patent. patient is status post left frontal craniotomy. there is trace polypoid mucosal disease involving a single right posterior ethmoidal air cell. remainder of paranasal sinuses and mastoid air cells are well aerated. globes and orbits are within normal limits. impression: no short interval change since . . portable head ct w/o contrast study date of 7:59 am findings: current examination is highly limited by streak artifacts from metallic device about the calvarium. allowing for such, there is no significant interval change in the caliber of the lateral ventricles as compared to most recent preceding exam to indicate increased mass effect. the suprasellar and basilar cisterns remain patent. a sliver of left frontal subdural collection is again seen but not well assessed. patient is status post left frontal craniotomy with trace operative pneumocephalus and overlying anterior scalp surgical staples. parenchymal assessment is highly limited. impression: likely no increased mass effect since most recent preceding exam. . chest (portable ap) study date of 2:01 pm cardiac size is top normal. there are low lung volumes. the lungs are clear. there is no pneumothorax or pleural effusion. impression: no evidence of pneumonia. . . cardiology: portable tte (congenital, complete) done at 12:16:07 pm final conclusions the left atrium is normal in size. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the number of aortic valve leaflets cannot be determined. the mitral valve leaflets are structurally normal. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a trivial/physiologic pericardial effusion. impression: no cardiac source of embolism identified. preserved global and regional biventricular systolic function. no significant valvular abnormality seen. . . neurophysiology: eeg study date of findings: abnormality #1: there are intermittent few second runs of blunted sharp waves in the left temporal area phase reversing at f7/t3. in addition, there are brief runs of independent left frontal sharp waves lasting one second or less with narrower base and lower amplitude as compared to the left temporal sharp discharges. the sharp waves are less predominant in sleep. abnormality #2: the background activity is asymmetric showing an hz rhythm on the right and a mixed theta and delta activity on the left reaching maximum hz posteriorly. left-sided slowing is more prominently present over the temporal region. background: the same as abnormality #2 and #1. there are no epileptic discharges or electrographic seizures. hyperventilation: hyperventilation could not be performed due to history of intracranial mass. intermittent photic stimulation: stepped photic stimulation from flashes per second (fps) produces no activation of the record. sleep: the patient progresses to drowsiness and stage ii sleep. during sleep the left sided sharp waves are suppressed. cardiac monitor: a single ekg channel shows a generally regular rhythm with an average rate of 62 bpm. impression: this is an abnormal awake and sleep eeg, because of background asymmetry with slowing over the left hemisphere more prominently the left temporal region. this finding is indicative of diffuse cortical and subcortical dysfunction over the left hemisphere particularly the left temporal area. in addition, there are intermittent independent left temporal and left frontal epileptic discharges indicative of epileptogenic foci in these regions. no electrographic seizures are present. . eeg study date of findings: routine sampling: the background activity is asymmetric showing a 9-9.5 hz rhythm on the right and a slower hz rhythm over the left hemisphere. there is continuous polymorphic delta slowing over the left frontotemporal regions. in addition, there are intermittent broad-based blunted sharp waves over the anterior left hemisphere phase reversing at f3/c3 and f7/t3. no electrographic seizures are present in the recording. spike detection programs: there are 224 automated spike detections predominantly for electrode and movement artifact. there are no epileptiform discharges in the automated file. seizure detection programs: there are no automated seizure detections. pushbutton activations: there are no pushbutton activations. sleep: the patient progresses to drowsiness and stage ii sleep with well-formed sleep potentials over the right hemisphere. cardiac monitor: shows a generally regular rhythm with an average rate of 60-70 bpm. impression: this is an abnormal continuous icu monitoring study because of asymmetric background with significant slowing over the left hemisphere. this finding is indicative of diffuse left hemispheric cortical and subcortical dysfunction. in addition, there are frequent low voltage wide-based epileptiform discharges over the left frontotemporal region as well as polymorphic slowing in the same region. these findings are indicative of a potential epileptogenic focus in left frontotemporal region with underlying structural abnormality. no electrographic seizures are present in the recording. there are no significant changes compared to prior day's study. . eeg study date of findings: routine sampling: the background activity is asymmetric showing to 9 hz rhythm on the right and an attenuated slower hz rhythm over the left hemisphere. there is continuous left frontal temporal polymorphic delta slowing. in addition, there are intermittent blunted wide-based sharp discharges at t3 and f3. no electrographic seizures are present. spike detection programs: there are no automated spike detections predominantly for electrode and movement artifact. there are no epileptiform discharges. seizure detection programs: there is one automated seizure detection for fast artifact at cz electrode. there are no electrographic seizures. pushbutton activations: there are no pushbutton activations. sleep: the patient progresses from wakefulness to stage ii, then slow wave sleep at appropriate times with sleep morphologies better developed over the right hemisphere. cardiac monitor: a single ekg channel shows a generally regular rhythm with an average rate of 54 bpm. impression: this is an abnormal continuous icu monitoring study because of asymmetric background with slowing over the left side indicative of cortical and subcortical dysfunction in these regions. in addition, there are low amplitude blunted epileptic discharges over the left fronotemporal regions with polymorphic delta slowing of background consistent with potential epileptogenic foci with underlying subcortical dysfunction. compared to the prior day's recording, there are no significant changes. . . neurology: transcranial doppler ultrasound report impression: abnormal tcd evaluation. in the distal left mca, there were blunted waveforms with lower velocities suggesting that there is significant stenosis in the proximal left mca. higher velocities in the left aca and left p2 segment of the pca suggested that there is hemodynamically significant diversion of flow from the left mca to the left aca and left p2 segment of the pca. clinical correlation is needed. . transcranial doppler ultrasound report tcd results: transcranial doppler son was performed with insonation of the left middle cerebral artery at a depth of 67mm and at 56mm. at the start of the exam, the systolic bp was 138. the patient was receiving phenylephrine at 1mcg/min for two minutes. then the phenylephrine dose was decreased to 0.5 mcg/min for ten minutes. the sbp decreased to 128. for the next ten minutes, phenylephrine drip was turned off. at the end of this period, the sbp was 119. the total length of recording time was 22 minutes. results show normal velocities of the proximal left mca. no abnormal waveforms were seen. five microembolic signals were detected by manual inspection. four of the microembolic signals were seen at a depth of 67mm and one microembolic signal was seen at a depth of 56mm. impression: abnormal tcd evaluation. five microembolic signals were detected. clinical correlation is needed. . transcranial doppler ultrasound report tcd results: transcranial doppler son was performed with insonation of the left middle cerebral artery for 32 minutes at a depth of 63mm. results did not show any microembolic signals. there were normal velocities of the proximal left mca except for above normal velocities at depth of 51mm. no abnormal waveforms were seen. impression: abnormal tcd evaluation. above normal velocities of the left mca at a distance of 51mm suggesting that there may be stenosis at this distance. no microembolic signals were seen, representing an improvement from the tcd study on . clinical correlation is needed. brief hospital course: 47 yo rhw with htn and recently s/p re-resection of large tuberculum sellae meningioma , with silent l basal ganglia infarct noted on post-op mri, and presented on with a 2 hr episode of r weakness and speech difficulties that resolved after 2 hours and was taken to hospital the following morning. initial neurological examination was unremarkable. mri showed scattered recent left frontal craniotomy with interval reduction of left frontal subdural fluid collection, evolution of scattered infarcts involving the left basal ganglia, inferior and lateral frontal, and left temporal lobes with an increase in the size of the left frontal lobe and most significantly a high-grade stenosis at the proximal aspect of the left m1 segment with small caliber of the more distal branches on mra. this confirmed on cta which again demonstrated a very high grade stenosis. she was therefore started on iv heparin and started on concomitant warfarin. stroke risk factors were assessed with hba1c 5.3%, flp chol 192 tgcs 125 hdl 58, ldl 109. eeg ltm was performed which was asymmetric and demonstrated right hz and left sided theta and delta slowing. patient developed sudden onset mild right arm weakness at 0600 on with persistent aphasia which was predominantly expressive with some paraphasic errors and initial difficulty following commands. concern was for hypoperfusion given her very significant left mca stenosis and stat ct-head showed no new infarct and eeg bedside monitoring showed pronounced left hemisphere slowing but no seizures which could be compatible with hypoperfusion. echo with bubble on showed no cardiac source of embolism and ef 60-65% with preserved global and regional biventricular systolic function. she was initially trialled on the floor and latterly stepdown unit with aggressive ivf resuscitation but her sbp was only maintained in 120s and deemed not sufficient to maintain perfusion, with persistence albeit with some improvement of her symptoms she was transferred to the icu on for initiation of pressors. her eeg was stopped when in the icu as there had been no seizure activity seen. in the icu she was continued on pressors and had a picc line inserted, which kept her sbp in the 130-140's. we then weaned her off the pressors, and her neurological exam remained stable. it was determined that she also had a uti, so she was started on ceftriaxone and treated for 3 days. patient was having microemboli felt due to her likely mca dissection noted on tcd on but this had settled by . she was started on fludrocortisone to help maintain her bps with an oral medication and lisinopril was stopped and given patient stability, she was able to be transferred back to the floor on . on the floor, to further assess her hypotension, she had a morning cortisol taken which was low at 0.5. endocrinology felt this was not concerning and was likely due to her concomitant dexamethasone administration and did not require further evaluation. pituitary hormone panel with fsh, lh, tsh and prolactin were all entirely normal. while on the floor, keppra was tapered and stopped and dexamethasone taper was completed and stopped prior to discharge. therefore, her left mca high-grade stenosis was felt likely secondary to a dissection at the time of surgery which would also account for her prior infarcts in this region. she was started on fludrocortisone as above due to relative hypotension to aid in left mca perfusion. patient was assessed by pt/ot and deemed safe for discharge home and warfarin was therapeutic with inr 2.2. due to continued mild aphasia persistent at the time of discharge and only obvious on probing (poor ability to name animals as described) she was discharged home on with outpatient speech therapy and neurology stroke follow-up in addition to her planned neuro-oncology follow-up. picc line was removed on discharge. given her persistent language deficits, the need for formal neuropsychological evaluation regarding aphasia will be addressed at time of follow-up and possible functional language necessary for return to work given her job as an editor. patient was therefore discharged on warfarin which will be managed by her pcp and had instructions to have her inr drawn on . medications on admission: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain or fever > 101.4. 2. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. disp:*60 tablet(s)* refills:*0* 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. lisinopril 10 mg tablet sig: one (1) tablet po daily (daily). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily) for 1 months. disp:*30 capsule, delayed release(e.c.)(s)* refills:*0* 7. dexamethasone 2 mg tablet sig: taper tablet po taper for 1 weeks: 4mg po q8h on , then 3mg po q8h x2days, 2mg po q8h x2days,1mg po q8h x2 days then d/c. disp:*qs tablet(s)* refills:*0* 8. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* other home medications: flonase prn and multivitamin daily discharge medications: 1. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 2. warfarin 1 mg tablet sig: one (1) tablet po once a day as needed for as needed for possible dose changes: as needed for possible dose changes.do not take unless directed. disp:*20 tablet(s)* refills:*0* 3. fludrocortisone 0.1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. outpatient lab work inr to be taken on and faxed to patient's pcp dr at . 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 6. flonase 50 mcg/actuation spray, suspension sig: one (1) spray nasal once a day as needed for allergy symptoms. 7. multivitamin tablet sig: one (1) tablet po once a day. 8. outpatient speech/swallowing therapy patient requires outpatient speech therapy discharge disposition: home discharge diagnosis: primary diagnosis: likely left middle cerebral artery dissection likely traumatic at the time of surgery with resultant high-grade stenosis and prior left mca distribution embolic infarcts relative hypotension and started on fludrocortisone to aid in left mca perfusion secondary diagnosis: urinary tract infection discharge condition: mental status: clear and coherent but still word-finding difficulties which are relatively mild level of consciousness: alert and interactive. activity status: ambulatory - independent. neurologic: a+ox3 but mild aphasia with poor naming (only 6 animals and 3 words beginning with f) and difficulty with the finer details in conversation. full power all 4 limbs and mild right-sided weaknes appears to have resolved. no sensory or coordination abnormalities. discharge instructions: it was a pleasure taking care of you during your stay at the . you presented with transient right sided weakness and word-finding difficulty. mri showed strokes on the left side of your brain which had also been present post-operatively. you were also noted to have a very tight blood vessel supplying blood to the left side of the brain. this was felt likely due to a dissection (tear) of an artery called the left middle cerebral artery, which we feel likely occurred at the time of your surgery. as a result, you were started on iv heparin which is a blood thinner in addition to warfarin to stop blood clots forming at the site of this dissection and causing further strokes. the heparin was stopped when the warfarin level was therapeutic. you were briefly transferred to the icu and treated with iv medications to maintain higher blood pressures after a further episode of word-finding difficulty and this improved and we were then able to be transfer you back to the floor. you had a picc line inserted which was subsequently removed. in order to improve blood flow to the left side of your brain, given this narrowing in the blood vessel, we started you on a medication to increase the blood pressure called fludrocortisone. the continued need for this medication will be assessed at the time of follow-up. we also monitored you on eeg and as there was no evidence of seizures, we have tapered and now stopped the keppra medication you were taking. you have now also finished the dexamethasone taper per neurosurgery. you have been started on a medication called warfarin (as above) which is a blood thinner and as a result, the major side-effect is bleeding. if you have a cut or other area of bleeding, it will therefore take longer for this to stop. in addition, if you have a head injury, you are at risk of bleeding and should always present to the ed for evaluation if this were to happen. warfarin requires close monitoring and therefore you should have your labs taken tomorrow and regularly after this as your pcp will have to let you know about any need for a dose change. you also had evidence of a urinary tract infection which was treated with 3 days of iv antibiotics. you still have some word-finding difficulties and we have referred you for out-patient speech therapy. you were seen by pt and deemed safe for discharge. you have neurology follow-up and neuro-oncology follow-up as below. as above, you will need to have labs taken tomorrow to assess your warfarin level (inr). medication changes: we started warfarin 5mg daily - as above please have your inr drawn tomorrow we started fludrocortisone 0.1mg daily we stopped dexamethasone as you have now finished your taper we stopped keppra we stopped lisinopril to allow for higer blood pressures given your brain artery narrowing followup instructions: given that we started you on warfarin you should have your warfarin level (inr) taken tomorrow and checked by your pcp as your dose may need to be changed. you should see your pcp as soon as possible for follow-up. in addition, we have arranged the following neurology stroke follow-up: department: neurology when: friday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage you also have the following existing neuro-oncology followup where you will also be seen by neurosurgery: department: neurology when: monday at 9:30 am with: , md building: campus: east best parking: garage procedure: central venous catheter placement with guidance diagnoses: urinary tract infection, site not specified unspecified essential hypertension accidental puncture or laceration during a procedure, not elsewhere classified other specified cardiac dysrhythmias hypotension, unspecified other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation aphasia epistaxis dissection of other artery other musculoskeletal symptoms referable to limbs 

Answer: The patient is high likely exposed to