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 / shellfish derived attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: ms. is an 86yo female with past medical history of childhood asthma but minimal contact with for the last twenty years who was admitted with five days of confusion. per her nephew she had not been hospitalized or sick since she was a child. four days prior to arrival her nephew arrived at her house for a scheduled meeting with some lawyers to discuss an on-going lawsuit involving her association. on arrival to her condominium he noticed that she was acutely confused and did not remember any details as to why the lawyers were there or the events that had led to her involvement with them. this is despite the fact she had previously been closely reviewing those contracts herself. on the night prior to admission her brother called her nephew and told him that he was concerned she wasn't eating. her nephew called her and asked what was in her refrigerator but she told him she didn't know. this worried him and he eventually convinced her to come to the ed. in the ed vs were t 98.6 hr 170s bp 112/100 20 99%ra. ekg looked like svt, so got adenosine, which slowed her, and the resultant ekg showed flutter waves. she was given 10mg dilt iv x 1 with bp to 90s and hr 80s and then received 30mg po dilt. her hr came down to the 80s then went back up to the 110s so she was started on a diltiazem gtt. her blood pressures were stable thereafter in the 110s-120s. her hr did increase a few times thereafter in the ed, usually when anxious, which was relieved with lorazepam x 2. for her altered mental status she had urine and blood cultures sent. a chest raidograph was unremarkable aside from slight volume overload. a head ct showed a left occipital hypodensity so neurology was consulted and concerned for an acute stroke. tehy recommended a head mri but this was not obtainable due to the patient's altered mental status and agitation. neurology also recommended an lp, but this was refused by the family. given concern for infection, she was empirically started on meropenem/vancomycin and acyclovir as she had a pcn allergy. eeg was also recommended but not obtainable in the ed. because of an unknown substance abuse history she also received thiamine, folate, and a banana bag. on presentation to the icu (sent there given concern for acutely progressing stroke vs cns infection) the patient denied neck pain, headaches, chills, chest pain, shortness of breath, or similar complaints. she reported that she had been depressed for a few days and decided to stop eating. she then got confused per her report and that's why she had to come to the hospital. past medical history: -asthma in childhood -bilateral cataract surgeries social history: she never married and worked as a social worker. she lives alone but speaks to her year old brother in daily. she also has multiple nieces and nephews who help her. she stopped smoking 20 years ago. she denied alcohol use. family history: notable for depression in a grandmother physical exam: vitals: t 98.4 hr 87 bp 112/54 o2 91% on 4l nc gen: thin elderly female in nad heent: nc/at anicteric sclerae dry mm with white plaque on tongue and punctate white spots on hard palate neck: jvp to angle of jaw no lad no thyromegaly no meningismus lungs: decreased air movement bilaterally. fine crackles at bases bilaterally. visibly tachypneic but able to speak in full sentences heart: tachycardic. regular. nl s1/s2 sm rusb abd: soft. nt/nd normoactive bs extrem: no edema pulses 2+ bilaterally. unable to assess strength 2/2 patient non-compliance neuro: alert. oriented to person. perseverating. no clonus. sensation in tact on bilateral extremities. right eye deviates inward on fixed gaze however patient unable to comply with eom exam so unable to assess if persists with lateral gaze. perrl. pertinent results: laboratory values ================== on admission: wbc-9.4 rbc-4.47 hgb-12.1 hct-35.0* mcv-78* rdw-14.6 plt ct-425 ---neuts-79.3* lymphs-14.5* monos-4.2 eos-1.4 baso-0.6 pt-14.4* ptt-27.3 inr(pt)-1.3* glucose-92 urean-20 creat-0.9 na-133 k-4.1 cl-92* hco3-20* angap-25* albumin-3.8 calcium-9.5 phos-3.1 mg-1.9 alt-19 ast-30 alkphos-68 totbili-0.5 lipase-26 lactate-1.0 ck(cpk)-187 ck-mb-6 ctropnt-0.02* probnp-3848* ck(cpk)-183 ck-mb-5 ctropnt-<0.01 blood: asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg urine: bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg urine color-yellow appear-clear sp -1.017 blood-neg nitrite-neg protein-tr glucose-neg ketone-150 bilirub-sm urobiln-1 ph-6.5 leuks-neg rbc-* wbc- bacteri-few yeast-none epi- casthy-21-50* on discharge: na 136 k 4.1 cl 97 bicarb 28 bun 12 cr 0.9 hgb 8.5 hct 26.6 inr 2.5 ptt 33.3 microbiology ============= blood culture x 2: no growth urine culture: no growth rpr: negative : urine culture: contaminated by fecal matter other studies =============== ecg : atrial flutter with 2:1 block. tendency toward low voltage in the standard leads. peaked t waves in leads v1-v4. no previous tracing available for comparison. repeat ecg : the patient is now in atrial flutter with 4:1 block and a heart rate of 88. there is low voltage in the standard leads. peaked t waves in leads v2-v3. no other diagnostic abnormality. chest radiograph : impression: findings suggestive of mild chf. ct head w/o contrast : impression: examination limited by motion. a focal left occipital hypodensity may represent acute infarct and mri with diffusion-weighted imaging is recommended for further evaluation, as patient can tolerate. no intracranial hemorrhage. echo : the left atrium is mildly dilated. the estimated right atrial pressure is 0-5 mmhg. 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 valve leaflets are moderately thickened. there is moderate aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is severe mitral annular calcification resulting in mild functional mitral stenosis (mean gradient 8 mmhg). mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. moderate aortic valve stenosis. mild mitral stenosis. at least mild-moderate mitral regurgitation. pulmonary artery systolic hypertension. carotid ultrasounds : findings: duplex evaluation was performed of bilateral carotid arteries. on the right there is mild heterogeneous plaque in the bulb and ica. on the left there is moderate heterogeneous plaque in the ica. on the right systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 63/14, 95/20, 74/19 cm/sec. cca peak systolic velocity is 72 cm/sec. eca peak systolic velocity is 72 cm/sec. the ica/cca ratio is 1.3. these findings are consistent with <40% stenosis. on the left systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 125/20, 120/20, 105/21 cm/sec. cca peak systolic velocity is 105 cm/sec. eca peak systolic velocity is 124 cm/sec. the ica/cca ratio is 1.2. these findings are consistent with 40-59% stenosis. there is antegrade right vertebral artery flow. there is antegrade left vertebral artery flow. impression: right ica stenosis <40%. left ica stenosis 40-59%. no comparison available. mri head w/o contrast (incomplete study): impression: subacute infarct involving the left occipital lobe. given its appearance on the ct examination, it was likely late acute/subacute upon presentation on . cxr : pa and lateral chest radiographs compared to show increased interstitial abnormality compatible with worsening pulmonary edema. there is probably mild left atrial enlargement, although the overall heart size is normal. the mitral annulus is extensively calcified. bilateral pleural effusions are small. there is no pneumothorax. mpression: increased interstitial abnormality compatible with worsening pulmonary edema. non-contrast head ct : impression: no frank intraparenchymal hemorrhage or hemorrhagic conversion of evolving left occipital stroke identified. linear regions of high attenuation surrounding the region of infarction are most suggestive of laminar necrosis with possible superimposed regions of petechial hemorrhage. can consider serial followup with ct as warranted by clinical exam. eeg : results pending brief hospital course: this is an 86 year old female with unclear past medical history admitted for altered mental status. 1) altered mental status: at presentation given the lack of previous contact with the medical system and the report of sudden decline in function provided by the patient's nieces and nephew there was a broad differential. given unclear chronicity at presentation the patient was broadly covered for multiple infectious etiologies and encephalitis/meningitis with meropenem/vancomycin/acyclovir. as the patient remained afebrile, had no meningismus or neck stiffness, and ct head revealed a new stroke providing a clear alternative cause for mental status changes these antibiotics were stopped on hospital day two. after initial agitation the patient's mental status improved on day two simply with hydration and there was no progression of symptoms. when mri brain was initially obtained despite being an incomplete study there was a clear occipital stroke and neuro/stroke attending suspected a hippocampal lesion as well. these appeared subacute in nature and it was thought the patient had sustained strokes in the week or weeks prior to presentation leading to short term memory deficiency. however, on the evening of the patient developed naming difficulties and would often misname objects (i.e. referring to watches, pens, etc... as telephone). given the patient had recently been started on coumadin there was concern for acute hemorrhagic transformation. head ct was obtained and did not show clear hemorrhage. neurology consult and the team thought this most likely occurred secondary to her occipital strokes, partially contributed by her low blood pressure on antihypertensives. metoprolol and lisinopril were subsequently held. over the course of the next few days, patient's mental status improved with only occasional naming difficulties and perseverence. a second mri was deferred because it required the patient be intubated, and it was felt that the risks of intubation outweighed the benefit/possibility of mri revealing any significant new lesions to explain the mental status changes. of course, given the patient lives alone some underlying element of dementia was considered a contributing factor particularly given self neglect of unclear duration but this could not be conclusively confirmed or denied. eeg was also obtained during this hospitalization, results pending on discharge. ultimately, given the patient's short term memory deficits she was not considered safe to return to her home and with her agreement was discharged to a skilled nursing facility. upcoming improvement (or lack thereof) is likely to provide more suggestions about etiology of mental status changes. 2) embolic cerebrovascular accident(s): the patient was found to have one or two cerebral infarctions with appearance consistent with embolic strokes. the likely source of these emboli was considered to have been an intracardiac thrombus as the patient also had aflutter at presentation and was not anticoagulated. no thrombus was seen on echocardiogram but this was considered possibly due to embolization event already having occurred. unfortunately, full angiogram of brain was not obtainable due to patient cooperation but carotid ultrasounds revealed relatively minor lesions unlikely to have been source of clot. given patient's chads score of at least 3 and possibly 4 (stroke, age, ?chf) anticoagulation was considered indicated and was started on after at least a week had passed after presentation minimizing the risk of hemorrhagic conversion (aspirin had been used previously). of note, the patient's nieces expressed considerable concern about the patient's ability and willingness to adhere to coumadin therapy as an outpatient but given her mental status would require at least temporary placement following discharge this decision was deferred for the moment and the medically indicated anticoagulation was begun. 3) acute on chronic diastolic heart failure: the patient presented with chest radiograph consistent with pulmonary edema and received fluids initially given concern for poor self care and poor po intake. this led to persistent pulmonary edema thought most likely due to diastolic dysfunction and valvular disease as the patient had a normal ef. diuresis was attempted and the patient responded well to 20mg po lasix with good urine output. lisinopril was also added to her regimen secondary to known as to help with afterload reduction but her blood pressure was unable to tolerate this medication. her lisinopril was therefore discontinued. if her blood pressure tolerates in the future, it is suggested that lisinopril be added to her regimen. on the days before discharge her blood pressure ranged between 90-115 systolic. she should electrolytes, including bun/creatinine checked this friday, and again next wednesday. results should be faxed to her pcp. 4) hypoxia: though patient was not hypoxic in the ed per vitals recorded she did develop an o2 requirement as of the time of her arrival in the icu and there were persistent difficulties in weaning this. likely much of the issue was her pulmonary edema though also suspected to have some copd given long smoking history and reports of severe asthma as a child. she would likely benefit from outpatient pft's but these were not expected to affect management acutely in the hospital. 5) anion gap metabolic acidosis with acute respiratory compensation: the patient had a ketoacidosis at presentation and anion gap. this was thought most likely due to starvation ketosis given known poor po intake and lack of other causes (no osmolal gap, negative tox screen, only slightly elevated bg). this resolved with fluids and food. 6) atrial flutter: the patient was discovered to have new atrial flutter on presentation though chronicity was unclear due to her infrequent encounters with medical care. her initial rate control was initially controlled with diltiazem gtt, which was gradually switched to escalating doses of po diltiazem. as these doses increased the patient converted back to sinus rhythm and would spend most time in this rhythm with occasional lapses to a flutter. metoprolol was also added but this was discontinued secondary to hypotension. heart rate ranged between 85 and 115, and she was usually in sinus rhythm. the patient was started on coumadin, and inr was therapeutic on discharge. search for secondary causes of af (i.e. tsh check, echo) were unremarkable. 7) microcytic anemia: the patient had a microcytic anemia with iron studies consistent with anemia of chronic disease and/or iron deficiency. the cause of this anemia was unknown though inadequate po intake could certainly contributed. pt refused guiacs. since this anemia was stable over several days prior to discharge, this can be followed up as outpatient. the patient eventually tolerated a full, cardiac diet. she had pneumoboots for dvt prophylaxis. contacts are (nephew) cell: home: and (niece) cell: . medications on admission: none discharge medications: 1. ipratropium bromide 0.02 % solution sig: two (2) puffs inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 2. multivitamin tablet sig: one (1) tablet po daily (daily). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 4. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 5. warfarin 2 mg tablet sig: 1.5 tablets po daily (daily). 6. olanzapine 2.5 mg tablet sig: one (1) tablet po hs (at bedtime). 7. olanzapine 5 mg tablet, rapid dissolve sig: 0.5 tablet, rapid dissolve po tid (3 times a day) as needed for delirium, agitation. 8. furosemide 20 mg tablet sig: one (1) tablet po twice a day: one dose at 8am and the second dose at 2pm. 9. outpatient lab work please check inr weekly, beginning . titrate warfarin dose to goal inr of . please fax results to pt's pcp, . at . 10. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 11. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 12. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day) as needed for take with meals. 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for sob. 14. outpatient lab work please have electrolytes (including bun, cr) checked on friday and again on wednesday , and have the results faxed to pt's pcp, . at . 15. colace 100 mg capsule sig: one (1) capsule po twice a day. 16. senna 8.6 mg tablet sig: 1-2 tablets po twice a day as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: embolic cerebrovascular accidents (chronicity unclear) atrial flutter/fibrillation diastolic congestive heart failure aortic stenosis mitral regurgitation discharge condition: stable, in sinus rhythm, alert, occasional disorientation to time and place but able to choose the right answers from multiple choices, poor working memory, and occasional naming difficulities. heart rate ranging between 80-115, systolic blood pressure ranging between 92-115. discharge instructions: you were admitted because of confusion and we found that you had an irregular heartbeat. this irregular heart beat caused the formation of blood clots in your heart that then went to your brain. these caused strokes, which we believe are the cause of your confusion. we started you on medications to slow and attempt to normalize your heartbeat and blood thinners to help prevent further clots and strokes. unfortunately, you are still experiencing problems with memory related to the strokes, it is unclear how much this will resolve. you also had trouble naming objects during this hospitalization which has been waxing and . we had neurologists evaluate your naming difficulties, and we believe this is also related to your strokes. when you were admitted you received fluids for low blood pressures and dehydration. these then caused fluid to back up in your lungs due to valve problems in your heart making it unable to pump blood forward ideally. we gave you diuretics to help remove this fluid. to help with your breathing, we also started you on two nebulizers. your medications have been changed. you have been started on.. -diltiazem a medication to slow and normalize your heartbeat -simvastatin a medication to help prevent further strokes -coumadin a medication to prevent further blood clots in the heart and thus to protect against stroke -furosemide a medication to help prevent excess fluid build up in the lungs -ipratroprium and albuterol, inhalers to help your breathing please call your doctor or come to the emergency department if you have fevers or chills, chest pain, shortness of breath, severe headache, increased confusion, bleeding that does not stop, or any other concerning changes in your health. followup instructions: please set up an appointment with a primary care provider after you're discharged from rehabilitation. if you would like to see dr. again, her office can be reached at . if you have not seen her in some time and would be interested in establishing care in the primary care practice at , you can reach that practice at . dr. , who took care of you during your hospital stay would be very happy to see you in the future in the clinic. you can ask to schedule an appointment with dr. if you would like. please keep your previously scheduled appointments: md: dr h. specialty: neurology date and time: at 10am location: , building, , autonomic laboratory phone number: . provider: phone: date/time: 10:00 procedure: electroencephalogram diagnoses: tobacco use disorder congestive heart failure, unspecified atrial fibrillation acute on chronic diastolic heart failure other chronic pulmonary heart diseases atrial flutter candidiasis of mouth occlusion and stenosis of carotid artery without mention of cerebral infarction mitral valve insufficiency and aortic valve stenosis hypoxemia surgical or other procedure not carried out because of patient's decision cerebral embolism with cerebral infarction chronic obstructive asthma, unspecified dehydration occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction mixed acid-base balance disorder other specified iron deficiency anemias 

Answer: The patient is high likely exposed to