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: headache, mumbling speech major surgical or invasive procedure: intubation/extubation x2 evd placement () and removal transesophageal echocardiogram right ij placement and removal history of present illness: mr. is a 45 yo rh man with a pmh significant for htn (diet controlled) and hld p/w new onset headache. his headache started around 8 to 10:00 am on 04 25 09. it was localized in both temples, of progressive nature, she cannot tell if throbbing or of pressure quality. he was not unsteady. he had no evident dysmetria or diplopia, no dysphagia. he took ibuprofen 800 mg with mild response. he does not have a history of previous headaches. he spent the day in bed. during the night he slept comfortably. on 04 26 09 he woke up nauseated and finally vomited several times from 6 to 8:00 am. his wife recalls that his headache did not improve after his emesis episodes. he could have a conversation and follow commands at that time. however, a few hours later (2:00 pm), his wife noticed he was "mumbling", and could not engage on a regular conversation. he did not follow her commands, hence she called ems. ems assessed the pt at 3:34 pm. he was following simple commands, his right eye was deviated upward in abd his left eye was at midline as per ems report. he was "decorticating" with the right arm and had a left facial droop. eventually, he developed a symptomatic bradycardia with decreased mental status (hr<40). he then received naloxone 1mg iv, but his his mental status did not improve and required atropine 0.5 mg. he responded well with a hr> 50 bpm and following commands again. his vs where 120/ 80, 56 bpm, 16rr. ems reports left eye upgaze and abd and right eye at midline at this point. he was transferred to med. center ed. once at , he required endotracheal intubation (received etomidate 20 mg iv, succinylcholine 100 mg iv, versed 2 mg iv and was started on a propofol drip), given his depressed mental status. there is no reference to fsg values. a ct cns w/o contrast was performed and read as normal. he was then transferred to for further care. once at ed: vs: 100.0f, 62 bpm, 141/ 82, on vent: cmv fio2 50%, rr 18, tv 500 cc, ppeak 18, peep 5. he received decadron 10 mg iv, ceftriaxone 2 g iv, vanc 1 g iv, acyclovir 800 mg iv. he also received fentanyl and was continued on a propofol drip. ros: no sick contacts, no recent trips. his daughter had syndrome in (admitted at ch for 3 weeks). his dog recently died (not of an infectious process). he has had no fevers. he does not use drugs. rest of ros is negative. past medical history: hyperlipidemia hypertension social history: lives with his wife and 3 kids. self employed dental technician. tobacco 0.5 ppd for 30 years. no etoh. family history: no seizures, strokes or cns tumors. father died of cad. physical exam: vs: 100.0f, 62 bpm, 141/ 82, on vent: cmv fio2 50%, rr 18, tv 500 cc, ppeak 18, peep 5 gen: no evidence suggesting endocarditis or iv drug use (see below). lying in bed, unresponsive. heent: nc/at, moist oral mucosa neck: supple, no carotid or vertebral bruitback: no point tenderness or erythema cv: nl s1 and s2. importantly, there are no murmurs. no gallops/rubs lung: clear to auscultation bilaterally abd: soft, nontender, non-distended. no masses or megalies. percussion within normal limits. +bs. ext: no edema, no dvt data. pulses ++ and symmetric. no splinter hemorrhages. skin: no osler or lesions. no lesions suggesting iv drug use. neurologic examination: 5 minutes off propofol. no meningismus. ms:responsive to noxious stimuli: it seems that he initially extensor postures with the arms, but he then withdraws from pain, though he cannot localize it. the legs move spontaneously. cn: corneals + bl. pupils 2 to 1 bl and symmetrically. there is no gaze deviation. however, when i attempted to perform dolls eyes: he cannot cross midline toward the left. no bobbing or robbing. no nystagmus. gag +. no facial asymmetry (though he is ett'd) motor: as above. in addition, dtr:1+ throughout. toes upgoing bilaterally. sensory: as above. pertinent results: labs: 07:00pm blood wbc-17.8* rbc-5.09 hgb-14.8 hct-43.8 mcv-86 mch-29.1 mchc-33.8 rdw-14.8 plt ct-266 05:55am blood wbc-16.1* rbc-4.78 hgb-13.7* hct-40.7 mcv-85 mch-28.7 mchc-33.8 rdw-14.6 plt ct-457* 07:00pm blood neuts-87.4* lymphs-7.6* monos-3.4 eos-1.3 baso-0.3 07:00pm blood pt-13.7* ptt-22.9 inr(pt)-1.2* 05:55am blood pt-15.5* ptt-59.6* inr(pt)-1.4* 02:12pm blood protcag-pnd protsag-pnd 02:12pm blood aca igg-pnd aca igm-pnd 07:00pm blood glucose-129* urean-14 creat-0.8 na-142 k-3.7 cl-107 hco3-25 angap-14 05:55am blood glucose-135* urean-18 creat-0.8 na-137 k-4.1 cl-101 hco3-23 angap-17 07:00pm blood ck(cpk)-75 02:20am blood alt-25 ast-15 ld(ldh)-203 ck(cpk)-82 alkphos-65 totbili-0.9 01:15pm blood ck(cpk)-394* 02:20am blood lipase-34 07:00pm blood ck-mb-notdone ctropnt-<0.01 02:20am blood ck-mb-notdone ctropnt-<0.01 01:15pm blood ck-mb-3 ctropnt-<0.01 07:00pm blood calcium-9.3 phos-3.1 mg-2.1 02:20am blood calcium-9.3 phos-2.7 mg-2.1 cholest-230* 05:55am blood calcium-9.6 phos-3.9 mg-2.3 02:20am blood triglyc-142 hdl-51 chol/hd-4.5 ldlcalc-151* 06:16pm blood osmolal-297 12:11am blood osmolal-293 02:20am blood tsh-0.75 07:00pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 02:12pm blood factor v leiden-pnd 11:00pm urine color-yellow appear-clear sp -1.025 11:00pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-150 bilirub-neg urobiln-neg ph-7.0 leuks-tr 11:00pm urine rbc-0-2 wbc-0-2 bacteri-none yeast-none epi-<1 11:00pm urine bnzodzp-pos barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg 06:16pm urine osmolal-645 10:27pm urine hours-random creat-236 na-109 microbiology: blood cx (, ): no growth x2 urine cx (, ): no growth sputum cx (): gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): sparse growth oropharyngeal flora. gram negative rod(s). rare growth. mini-bal cx (): gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): no growth, <1000 cfu/ml. imaging: ct head (): impression: relative hypodensity with loss of -white matter differentiation in the left occipital region and right cerebellum concerning for infarcts of indeterminate age, acute versus subacute. given multiple foci, embolic etiologies are included on the differential diagnosis. an mri is recommended for further characterization. ethmoid and maxillary sinus disease. cxr (): impression: et tube 4.6 cm above the carina. tte (): 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. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 60-65%). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: no cardiac source of embolism identified. preserved global and regional biventricular systolic function. no significant valvular abnormality seen. cta head/neck (): impression: 1. markedly abnormal appearance to the proximal v1 segment of the right vertebral artery, which demonstrates crescentic and calcified plaque at its origin and central thrombus extending over an approximately 1.5-cm segment involving the proximal vessel, with no tandem thrombus identified. there is no specific finding to suggest dissection at this site. 2. this is a markedly dominant right vertebral vessel, largely supplying the basilar artery, likely accounting for the acute infarcts involving the right cerebellar hemisphere in ipsilateral pica, and left occipital lobe in contralateral left pca distribution. 3. no other significant abnormality involving the cervical vessels or those of the circle of . mri/mra brain (): impression: extensive foci of acute infarction in posterior circulation distribution, involving bilateral thalami, occipital lobes, cerebellar hemispheres and brainstem. etiology likely secondary to "embolic shower" from known thrombus within the proximal v1 segment of the dominant right vertebral artery. no hemorrhage. cxr (): tip of the new dobbhoff feeding tube, with a wire stylet in place ends in the upper stomach alongside a nasogastric tube. endotracheal tube has been advanced, tip now no less than 11 mm from the carina, 2 cm below optimal placement. infrahilar consolidation, left greater than right, has increased since , could be aspiration or atelectasis. upper lungs clear. heart size top normal, increased since . no pleural abnormality. cxr (): the et tube tip is relatively low, approximately 3 cm above the carina, but the patient's neck is in mild flexion, thus the position of the et tube is at the lower limits of accepted. the dobbhoff tube tip is in proximal stomach. the cardiomediastinal silhouette is stable. there is interval significant worsening of the left upper lobe predominantly perihilar consolidation containing air bronchogram, but given its rapid progression, is consistent with aspiration. rapidly progressing infection is another possibility, although is less likely given its absence on the chest radiograph from , obtained at 8:09 p.m. right basal opacity has improved since the most recent prior study consistent with partial resolution of aspiration with still present minimal atelectasis. small bilateral pleural effusions cannot be excluded. no overt pneumothorax is demonstrated. ct head (): impression: 1. expected evolution of multiple areas of infarction involving the bilateral occipital, cerebella, thalami, right pons, and midbrain. mass effect upon the fourth ventricle is identified with resulting obstructive hydrocephalus. 2. no areas of acute hemorrhage or hemorrhagic transformation identified. 3. ethmoidal and sphenoidal sinus opacification. mri/mra brain (): findings: there are multiple areas of slow diffusion which have increased in size within the bilateral cerebellar hemispheres, right medial temporal lobe, bilateral thalami, and pons. findings are secondary to embolic phenomenon from known clot within the proximal v1 segment of the right vertebral artery. there is a right frontal ventricular shunt with its distal end in the region of the inferior right frontal . there is persistent effacement of the fourth ventricle. there is a left maxillary sinus air-fluid level. there is mucosal thickening of the right maxillary sinus, ethmoid and sphenoid sinuses. fluid is identified within the left mastoid air cells. normal intracranial vascular flow voids are present. there is effacement of the cerebellopontine cistern. the cerebellar tonsils protrude 8 mm below the foramen magnum. mra brain: there is a dominant right vertebral artery. the left vertebral artery is not identified. the anterior and posterior circulations appear patent without evidence of focal stenosis or aneurysm. there is no arteriovenous malformation. impression: interval increased size of the infarctions involving the cerebellar hemispheres, occipital lobes, medial temporal lobe, thalami, and pons as described above. ct head (): impression: no definite evidence of acute intracranial process compared to prior study. status post removal of right frontal ventriculostomy catheter without new intracranial hemorrhage. ventricular size stable compared to prior study. no significant interval change in appearance of multifocal bilateral evolving infarcts. tee (): no mass/thrombus is seen in the left atrium or left atrial appendage. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the aortic arch. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. there is no pericardial effusion. impression: there were no echocardiographic evidence of valvular vegetations, patent foramen ovale, atrial septal defect, or intracardiac thrombus. normal biventricular contractile function was present. mild, simple aortic arch plaque was visible. brief hospital course: the patient is a 45 year old right handed man with a history of hyperlipidemia and hypertension who presented with headache and mumbling speech, and was found to have right vertebral thrombus and multiple bilateral posterior circulation strokes likely from artery to artery embolization. he was initially taken to an outside hospital, where he had bradycardia down to the 50s and required intubation. he was transferred to for further evaluation, and in the ed he initially received decadron, ceftriaxone, vancomycin, and acyclovir. he was initially placed in the neuroicu. mri/mra on admission showed extensive foci of acute infarction in posterior circulation distribution, involving bilateral thalami, occipital lobes, cerebellar hemispheres and brainstem, etiology likely secondary to "embolic shower" from known thrombus within the proximal v1 segment of the dominant right vertebral artery. he was thought to have a left pca and right sca infarction. tte showed no evidence of thrombus. he was started on a heparin gtt with goal ptt 50-70. icu course: pt was extubated on and was following commands with left side greater than right. duboff feeding tube was placed and tube feeds were started. pt was noted to be oliguric. a fluid bolus was given and ivf were increased from 70cc/hr to 100cc/hr. pt was then noted to have some additional respiratory distress with fever. blood and urine cultures were negative. sputum culture showed rare growth gram negative rods. cxr was done which revealed a left pna. vanco/zosyn were started, and subsequently stoped on . flp showed chol 230, ldl 151, tg 142, and hdl 51, and his simvastatin was increased to 80 mg qhs. on , the patient was found to be lethargic, was not following commands, and had absence of his gag reflex. patient was re-intubated, heparin gtt was discontinued, and stat head ct was completed which showed severe hydrocephalus secondary to posterior right sca stroke edematous evolution and compromise of his 4th ventricle, (diameter of 5.9 mm as compared to 13mm) on . neurosurgery was immediately consulted for evd placement on . repeat post-evd head ct showed reduced hydrocephalus. mannitol was started, tube feeds were held and all ivf were discontinued. keppra and cefazolin were started while the evd was in place. pt was successfully re-extubated on . mannitol was weaned off. on the evd was clamped, and the patient was transferred out of the neuroicu. the evd was removed by neurosurgery on . keppra and cefazolin were discontinued once the evd was removed. on , the heparin gtt was restarted, for a goal ptt 50-70. coumadin 5 mg daily was started on , for a goal inr . hypercoaguable work up was pending at the time of discharge, but did include factor v leiden, protein c and s, and anticardiolipin ab. subsequent tee did not show any evidence of intracardiac thrombus. the patient will follow up with dr. in neurology as an outpatient. evd sutures/staples can be removed on at rehab. medications on admission: simvastatin 10 qhs discharge medications: 1. simvastatin 80 mg tablet sig: one (1) tablet po once a day. 2. heparin (porcine) in d5w 25,000 unit/250 ml parenteral solution sig: nine y (950) units/hour intravenous drip: goal ptt 50-70, can check ptt q12 hours if therapeutic. 3. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 4. labetalol 100 mg tablet sig: one (1) tablet po tid (3 times a day). 5. hydralazine 10 mg iv q6h:prn sbp > 180 or map > 110 please keep sbp 120-180 6. quetiapine 25 mg tablet sig: one (1) tablet po hs (at bedtime). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 10. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheezing. 12. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed for wheezing. 13. hydromorphone (dilaudid) 0.25-1 mg iv q3h:prn pain 14. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. 15. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for fever. 16. medication regular insulin sliding scale discharge disposition: extended care facility: hospital - discharge diagnosis: primary thrombus in right vertebral artery bilateral posterior circulation strokes, left pca and right sca territory cerebral edema s/p evd pneumonia secondary hypertension hyperlipidemia discharge condition: fluent aphasia, does not look completely to the right with either eye, cannot adduct right eye, smile symmetric, does not use the right side as spontaneously as the left but full strength discharge instructions: you were admitted to the hospital with headache and speech changes, and were initially taken to an outside hospital where you were intubated. you were transferred to , where you were initially in the neuroicu. you were found to have a blood clot in your right vertebral artery which caused multiple strokes in your posterior brain. you subsequently became more lethargic and were found to have increased brain swelling, so neurosurgery placed an external ventricular drain. you had echocardiograms done which did not show a cardiac source of a clot. you improved, and were started on anticoagulation with a heparin drip for a bridge to coumadin. your simvastatin was increased to 80 mg in the evening. you were started on heparin drip (goal ptt 50-70) for a bridge to coumadin 5 mg daily (goal inr ). you were started on labetalol 100 mg three times/day. if you develop headache, weakness/numbness, difficulty speaking or swallowing, or any other symptoms that concern you, call your pcp or return to the ed. followup instructions: you will need to make a follow up appointment with dr. , your pcp (), within 1 week after your discharge from rehab. you have a follow up appointment with dr. in neurology () on at 11:30 in the center, . md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization ventricular shunt to extracranial site nec removal of catheter(s) from cranial cavity or tissue diagnoses: pneumonia, organism unspecified obstructive hydrocephalus unspecified essential hypertension other and unspecified hyperlipidemia cerebral edema long-term (current) use of anticoagulants occlusion and stenosis of vertebral artery with cerebral infarction dysphagia, oral phase dysphagia, pharyngeal phase 

Answer: The patient is high likely exposed to