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: l mca stroke (transfer) major surgical or invasive procedure: endotracheal intubation and subsequent extubation left decompressive hemicraniectomy tracheostomy and subsequent removal percutaneous gastrostomy placement picc line placement history of present illness: this is a 62yo woman with a history of hysterectomy, frequent prior syncopal episodes versus falls (?), and no prior vascular risk factors who is transferred from hospital for the management of a left mca stroke. the history is obtained from the patient's family (as the patient is intubated without sedation at this time), as well as paper transcripts of outside hospital reports. is originally from the republic and visits her family in intermittently. her health has recently been well, although her daughters noted that she had perhaps had a 20 pound weight loss over the past year or so, and it's not clear whether this is intentional. over the past five days, she had been complaining of left sided neck pain, and further detials are not available. of note, the patient has previously complained of intermitted left arm and leg numbness that is paroxysmal and that has been worked up without a clear diagnosis. on , she was doing well, out and about with her daughters, walking and talking without difficulty. on the morning of , she woke up at about 750am to go to the bathroom. it's not exactly clear what happened then, but the daughters report that she walked to the bathroom but stumbled backwards. she somehow managed to walk back to the bed and lay back on the bed with a thump which woke her husband up. noticed that she was not able to talk or understand what he was saying to her. she was not moving her extremities on either side, and he did not notice if her eyes deviated one way or the other. ems was called and she was transported emergently to the ed. while in the ed, she was noted to be vomitting/drooling (?) and with "level of consciousness diminished. she was intubated for airway protection. on history and physical examination, the patient was noted to be hyporeflexic on the left, symmetric upper extremity reflexes, and no other abnormal cranial nerve signs. a nchct was done which was normal save for an old right cerebellar hypodensity. she was then admitted to the ccu. this was the assessment and plan at that time: - "change in loss of consciousness with possible cva. the patient is on a vent for airway protection. we will rule out exogenous causes such as myocardial infarction with ekg and enzymes. repeat neuro checks and ct for the head showed no bleed. aspirin was given in the emergency room. we will discuss further meds with neurology." her troponins remained stably negative. the following day, apparently there was a change in her neurologic examination for which a ct scan was done which showed a large left superior division mca stroke with 5mm of midline shift. a dense mca sign was noted. she was then transferred to the per patient's family's request for a higher level of care. laboratory analysis performed at this osh has shown no significant abnormality including a1c, lipids, tfts, tox panels, etc. she was subsequently transferred to and admitted to the neuro icu for further management. past medical history: - no history of hypertension, hyperlipidemia or smoking - hysterectomy - tonsillectomy/adenoidectomy - very unclear and unsure history of a previous bleed (?) requiring angiographic intervention, but then later confirmed to be not an intracranial bleed. experienced outside the us. - frequent falls: this was denied by one of the daughters, but has been mentioned in the outside hospital initial note social history: she lives in the dr her husband. of a large family with six children. no history of smoking, drinking or illicit substance use. family history: mother with history of "brain tumor", half brother with stroke in the past. daughters are healthy. physical exam: admission exam physical exam: vitals: af, 121/62, 59 (regular), 100%, 14 general: intubated without sedation, eyes closed, no apparent distress. heent: nc/at, no conjunctival icterus noted, mmm, no lesions noted in oropharynx neck: supple, no masses or lymphadenopathy pulmonary: lungs cta bilaterally without r/r/w cardiac: slow but regular, nl. s1s2, no m/r/g noted abdomen: obese, soft, nt/nd, no masses or organomegaly noted, no bowel sounds auscultated. extremities:warm and well perfused skin: no rashes or lesions noted. neurologic: - eyes are closed. she does not respond to her family or myself calling her name. she does grimace to painful supraorbital stimulation and on sternal rub, she will localize with her left arm. - both pupils are 5mm and reactive. eyes are conjugate and in midposition with positive vors. there is a gag/cough. corneal reflex is difficult to assess. she initiates her own breaths. - right arm is without spontaneous movements. tone is increased in the right arm with maintained reflexes. it does withdraw to noxious stimulation - right leg is without spontaneous movements. tone is symmetrically increased with dropped reflexes. it does withdraw/flex to pain. - left arm and leg do have some spontaneous movements and localize. reflexes are present and normal in both upper and lower extremity. tone is normal. discharge exam: vitals: t 98.6 bp 102/70 hr 84 rr 18 o2 98% ra general: awake and alert, sitting up in bed in nad, smiles and waves heent: nc/at, no conjunctival icterus noted, mmm, no lesions noted in oropharynx neck: supple, gauze dressing over trach stoma c/d/i pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bs, peg site c/d/i extremities: warm and well perfused, no edema skin: no rashes or lesions noted neurologic: mental status: awake and alert, interactive, smiles and waves. able to say a few words ("si", "te"). follows some basic commands although inconsistently, mimics well. cn: pupils 3->2 b/l, l gaze preference but able to cross midline to the right, gaze conjugate. r lower facial droop. motor: moves l arm and leg with full strength. spastic r hemiplegia. sensory: withdraws purposefully to noxious stimulation in rue. triple flexion in rle. responds to light touch over lue and lle. reflexes: hyperreflexic throughout on r with r upgoing toe coordination: reaches well on l without ataxia gait: unable to assess pertinent results: admission labs: 06:29pm wbc-15.2* rbc-4.70 hgb-13.0 hct-39.6 mcv-84 mch-27.6 mchc-32.7 rdw-13.4 06:29pm neuts-82.1* lymphs-12.4* monos-5.0 eos-0.3 basos-0.2 06:29pm plt count-182 06:29pm pt-11.5 ptt-33.7 inr(pt)-1.1 06:29pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-neg 06:29pm urine color-yellow appear-clear sp -1.016 06:29pm fibrinoge-466* 06:29pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 06:29pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg 06:29pm triglycer-68 hdl chol-72 chol/hdl-2.7 ldl(calc)-107 ldl()-120 06:29pm %hba1c-5.9 eag-123 06:29pm calcium-9.5 phosphate-3.1 magnesium-2.1 cholest-193 06:29pm ck-mb-2 ctropnt-<0.01 06:29pm alt(sgpt)-10 ast(sgot)-17 ld(ldh)-194 ck(cpk)-74 alk phos-70 tot bili-1.0 06:29pm glucose-121* urea n-10 creat-0.7 sodium-137 potassium-3.9 chloride-100 total co2-30 anion gap-11 microbiology: 12:12 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. moderate growth. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- 4 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- s tobramycin------------ <=1 s 12:12 am urine source: catheter. **final report ** urine culture (final ): staphylococcus, coagulase negative. >100,000 organisms/ml.. oxacillin sensitivity testing confirmed by . oxacillin result reported to and read back by # 9:40am. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | gentamicin------------ 2 s nitrofurantoin-------- <=16 s oxacillin-------------<=0.25 s tetracycline---------- =>16 r vancomycin------------ 2 s blood cultures negative x 2 negative x 2 negative x 2 negative x 2 1:00 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive rod(s). respiratory culture (preliminary): fungal culture (preliminary): cta head/neck: left mca infarct, which appears to have slightly more edema compared with the previous outside ct obtained earlier at 9 a.m. ct angiography of the head demonstrates thrombus in the left supraclinoid internal carotid artery extending to the middle cerebral artery with diminished flow in the region of left middle cerebral artery. ct angiography of the head demonstrates no evidence of occlusion or stenosis. nasogastric and endotracheal tubes are visualized. the endotracheal tube tip is approximately 2 cm above the carina. nchct stable appearance of a large left mca territorial infarction involving the left frontal and parietal lobes. stable subfalcine herniation with shift 6 mm to the right. no evidence of transtentorial herniation. nchct impression: overall similar appearance of left mca ischemic infarct with a stable extent of rightward shift and mass effect. no hemorrhagic conversion or new infarct. nchct impression: interval left craniectomy with stable appearance of left mca infarct and associated mass effect. tte suboptimal image quality. the left atrium is normal in size. no atrial septal defect or patent foramen ovale is seen (limited image quality) by 2d, color doppler or saline contrast at rest. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). 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 diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. no masses or vegetations are seen on the aortic valve. 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. if indicated, a tee would better assess for cardiac source of embolism or intracardiac shunt. nchct: status post left hemicraniectomy with increased mass effect with increase in rightward shift of midline structures from left mca infarct which has become more hypodense in involved regions and mildly increased in extent. no large hemorrhagic conversion or new infarct elsewhere. increased soft tissue swelling in the left frontal, parietal and temporal regions with mildly increased mixed attenuation fluid collection in the soft tissues- correlate clinically if this reactive or superimposed infection. tee: 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 velocities are good (>20 cm/s). no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast at rest. overall left ventricular systolic function is normal (lvef>55%). the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and trace aortic regurgitation. the mitral valve leaflets are mildly thickened with trivial mitral regurgitation. there is no pericardial effusion. no intracardiac source of embolism identified. no asd or pfo identified by color doppler and agitated saline administration at rest. normal biventricular function. cxr: as compared to the previous radiograph, there is no relevant change. the monitoring and support devices are in constant position. borderline size of the cardiac silhouette, normal hilar and mediastinal structures. no pleural effusions, no pulmonary edema. no pneumonia, no pneumothorax. mri: large left mca subacute infarct, with mass effect on the left lateral ventricle and rightward shift of midline structures. left-sided subdural fluid collection better seen on the prior ct study. no new acute infarction. non- visualization of the left ica termination and left mca as before. diminutive right vertebral artery throughout its course, likely developmental. no increased signal intensity in the carotid or the vertebral arteries in the neck to suggest dissection. mild narrowing of the left cervical internal carotid artery proximally as before. other details as above. cxr: in comparison with the study of , the monitoring and support devices remain in place. there is increased indistinctness of pulmonary vessels, suggesting elevated pulmonary venous pressure. although the image is somewhat degraded by respiratory movement, there is the suggestion of an area of increased opacification at the right base medially that would be worrisome for supervening pneumonia in the appropriate clinical setting. mild atelectatic changes are seen at the left base. lenis: no evidence of deep vein thrombosis in either leg. visualization of the right calf veins is somewhat limited. cxr: tracheostomy tube terminates in the standard position. the left picc terminates in the low svc. in comparison to , there no significant change. there are low lung volumes and no focal consolidation, pleural effusion, or pneumothorax. the cardiomediastinal silhouette is stable. cta head/neck: conclusion: no evidence of vascular stenosis or occlusion. again seen is a large left middle cerebral artery distribution infarction with mass effect similar to or slightly improved since the head ct of . ct torso: impression: 1. no evidence of malignancy in the chest, abdomen, or pelvis. 2. notably distended urinary bladder containing gas. correlate with history of recent instrumentation. video swallow study: findings: barium passes freely from the oropharynx into the cervical esophagus without evidence of obstruction. there was moderate swallowing delay. symptomatic aspiration was witnessed with thin and nectar-thick liquids. no aspiration or penetration was seen with pureed or ground solids. for full details, please refer to the speech and swallow division note in the omr. impression: 1. gross aspiration of thin and nectar thick liquids. 2. delayed swallowing. brief hospital course: neurologic - the patient was transferred from an osh for management of a new l mca stroke with midline shift and concern for a malignant mca syndrome. the etiology of the stroke was obscure as she has no past medical history and her risk factor assessment was unrevealing. there were reports of up to five days of neck pain prior to the day of the original admission to the osh as well as reports of an antecedent prolonged flight from the republic as she was visiting her family. she was originally intubated at the osh for airway protection since she had a depressed loc and vomiting. after transfer, she was started on hyperosmolar therapy with mannitol which initially prevent further swelling but eventually was not sufficient. neurosurgery was consulted for a decompressive hemicraniotomy on . postoperatively, her mental status initially remained suppressed although her initial right sided plegia became less prominent and she has gradually had improvement in her level of consciousness. a tte was negative for pfo/asd, but given the high suspicion for paradoxical embolism, a tee was also performed which similarly revealed no pfo/asd or laa thrombus. an mra neck with fat sat was performed to evaluate for dissection which was not apparent. her repeat mri did show increase areas of infarction and midline shift, so she was continued on mannitol for three more days with subsequent reduction of midline shift. she was transferred to the neurology floor for further evaluation by pt and ot. she was continued on aspirin therapy. a ct torso was also performed which was negative for malignancy. since her transfer to the floor, her examination has continued to improve. she is now alert and interactive, able to say a few words though mostly communicates via gestures. she continues to have a dense r hemiplegia. her diet has been advanced to ground solids with thin liquids. with improvement in her level of alertness and respiratory status her trach was able to be removed on . ultimately the etiology of her stroke was not determined. she will need to be maintained on aspirin 325mg daily as well as simvastatin 20mg daily for secondary prevention. a hypercoagulability work-up was not pursued; this can be further discussed as an outpatient. she will need to have her bone flap replaced by dr. of neurosurgery within 6-8 weeks post-op (operative date ). her family as well as her rehab facility will be contact once this is scheduled. in the meantime she is required to wear her helmet at all times when she is out of bed. cardiovascular - she was maintained on telemetry monitoring throughout her admission with no evidence of arrhythmias. bp remained well-controlled with sbp 100-120's without medication. tte and tee were both performed as above and showed no evidence of pfo or cardioembolic source. she was started on aspirin 325mg and simvastatin 20mg daily. infectious disease - her initial cultures at admission were unremarkable, but a sputum culture from revealed pan-sensitive pseudomona aeruginosa. she completed an 8-day course of ciprofloxacin. she also had > 100,000 coag-negative staphylococcus growing in her urine culture. while on the floor, her leukocytosis gradually worsened from 13k to 19k over several days. we were not able to find a source of any presumed infection, and we checked numerous blood, urine cultures and leni's which were all negative. her wbc subsequently trended down. she remained afebrile with no signs of infection throughout the rest of her admission. respiratory - due to her depressed loc and inability to breathe on her own a tracheostomy was placed on . she was weaned to trach mask and began to tolerate trials of a passy-muir valve well. given significant improvement in her level of alertness and respiratory status her trach was removed on . she is currently breathing comfortably on room air. nutrition - due to persistent dysphagia, a peg tube was placed on . she was started on tube feeds per nutrition recommendations. she has been followed closely by speech therapy and her swallowing function has gradually improved to the point that she is now able to take ground solids and thin liquids. tube feeds have been adjusted to cycle overnight only to allow her to take more po during the day. disposition - once insurance coverage was obtained she was discharged to on in good condition. transitional care issues: - she will need intensive pt, ot, and speech therapy. she will need to be followed by nutrition and respiratory therapy as well. - she has an appointment with dr. from stroke neurology on - she will need to have her bone flap replaced by dr. of neurosurgery within 6-8 weeks post-op (operative date ). her family as well as her rehab facility will be contact once this is scheduled. medications on admission: from osh: aspirin 300mg pr daily lovenox 40mg daily insulin sliding scale d5 1/2 ns with 20meq/l of kcl @75ml/hr tylenol prn colace/senna/versed/morphine/zofran prn home medications: none discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for t>38.3c or headache. 5. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day). 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed for constipation. 7. atorvastatin 20 mg tablet sig: 1-2 tablets po daily (daily). discharge disposition: extended care facility: discharge diagnosis: left middle cerebral artery stroke high cholesterol discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. neurologic exam on discharge: mental status: awake and alert, interactive, smiles and waves. able to say a few words ('si', 'te'). follows some basic commands. cn: pupils 3->2 b/l, l gaze preference but able to cross midline to the right, gaze conjugate. r lower facial droop. motor: moves l arm and leg with full strength. spastic r hemiplegia. sensory: withdraws purposefully to noxious stimulation in rue. triple flexion in rle. responds to light touch over lue and lle. reflexes: hyperreflexic throughout on r with r upgoing toe coordination: reaches well on l without ataxia gait: unable to assess discharge instructions: ms. was admitted to the neurointensive care unit of the for the management of a large left mca stroke. she was transferred here from . - she was started on aspirin 325mg for secondary prevention. anticoagulation was deferred as the patient had a very large stroke volume and there was concern for hemorrhagic transformation. - she underwent a decompressive hemicraniectomy (removal of skull flap) as we were not able to control the swelling around her stroke with medical therapy. she will need to follow up with neurosurgery so that her skull flap can be replaced in the near future (6-8 weeks post-op from procedure on ). in the meantime she has been fitted for a helmet which she is required to wear while out of bed. - following the surgery her neurological examination has remained stable. she continues to have difficulty speaking and weakness on the right side of her body. she will need intensive rehabilitation to regain her strength. - she received an 8 day course of antibiotics with ciprofloxacin for pneumonia - a feeding (peg) tube was placed due to difficulty swallowing. she has been followed by speech therapy and has now been cleared for a ground diet with thin liquids. she is still receiving tube feeds cycled overnight only to help support her nutritional needs. peg tube should be able to be removed in the near future once she is able to maintain adequate po intake. - a tracheostomy tube was also placed due to her difficulty breathing on her own. she tolerated trials of a passy-muir valve well and as her respiratory status improved the tracheostomy was removed on . we made the following changes to her medications: started aspirin 325mg daily started atorvastatin 20mg daily it was a pleasure taking care of her during her hospital stay! followup instructions: **** neurology follow up provider: , md, phd , , ma: building, phone: date/time: 2:00 **** neurosurgery follow up she will be scheduled for replacement of her bone flap 6-8 weeks post-op (operative date ) per dr. . her family and rehabilitation facility will be notified once this has been scheduled. procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] temporary tracheostomy bronchoscopy through artificial stoma removal of tracheostomy tube other craniotomy diagnoses: pure hypercholesterolemia urinary tract infection, site not specified compression of brain hemorrhage complicating a procedure pneumonia due to pseudomonas methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site cerebral edema altered mental status cerebral embolism with cerebral infarction aphasia leukocytosis, unspecified dysphagia, oropharyngeal phase history of fall facial weakness surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation spastic hemiplegia and hemiparesis affecting unspecified side 

Answer: The patient is high likely exposed to