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: isovue-370 attending: chief complaint: headache, neck pain major surgical or invasive procedure: cerebral angiography intubation/extubation history of present illness: 65 year-old right-handed man with a history of atrial fibrillation and pulmonary embolism () on warfarin, hypertension, dyslipidemia, with a left mca infarct in , and renal cell carcinoma, who presents with headache and neck pain since yesterday. history obtained primarily from wife given aphasia and dysarthria. the patient was apparently in his usual state of health until sunday. on the day prior, he had been doing some yard work at his home, though was primarily supervising others who were assisting. on sunday, his wife reports that he awoke with a severe headache, that began to involve his neck, as the day progressed. he reports that the discomfort has worse on the left. his wife was a bit alarmed, given that she could onlyremember him with only one prior headache. the pain only worsened over the course of the day, and he wore a collar to attend a dinner last evening in an effort to gain some relief. however, the pain became so severe that he left the dinner early. his concerned wife spoke by phone with a physician friend in who suggested some analgesic medication, as it sounded musculoskeletal by description. however, when the pain persisted this morning, his wife called his primary care physician, referred him to the emergency room. of note, the patient's inr was 3.2 yesterday, according to his wife. received his scheduled dose of baby aspirin this morning for cardiovascular protection, but had not received his warfarin. in the emergency room, he was emergently sent to ct scan. a non-contrast image of the head and neck suggested a "likely subdural spinal hematoma" extending from the cerebellopontine angle "to the c2-c3 level with cord compression and edema." there was no fracture or malalignment. neurology and neurosurgery were emergently consulted. review of systems: dysarthria and aphasia prevented gathering a coherent review from the patient, though his wife reports that he complained of some chest pain in the morning yesterday. other than that symptom, she has only noted that his speech has been increasingly dysarthric. past medical history: -left mca infarct, thought to be cardioembolic secondary to his atrial fibrillation, . he received ia tpa and merci clot retrieval at that time. he had a mixed aphasia with dysarthria, and right face, arm, and leg hemiplegia and sensory loss. his course was complicated by intermittent confusional episodes. with extensive physical and speech rehabilitation since that time, the patient has made great progress and was fully strong and fairly independent. he worked closely with dr. to improve his aphasic deficits. -atrial fibrillation on warfarin -hypertension -dyslipidemia -left cerebellopontine mass, likely schwannoma -pulmonary embolism, -papillary renal cell carcinoma of the right kidney. his stroke occurred in the setting of his anticoagulation being held for a renal biopsy. this has reportedly been watched closely with no growth on repeated imaging. -sciatica -gout the patient also reports that he was in an automobile accident on . he was the seat-belted driver of a suburban and was rear-ended. he apparently suffered no known ill effects from the accident. social history: married and lives with wife. in the oil industry. smokes cigars and occasional cigarette. has two alcoholic drinks per night. family history: father and mother- passed away from strokes in their 70's physical exam: vitals: t 98.1 f bp 167/92 p 64 rr 17 sao2 95 ra general: nad, well-nourished heent: nc/at, sclerae anicteric, mmm, no exudates in oropharynx neck: no bruits appreciated, deferred assessment of rom lungs: clear to auscultation cv: regular rate and rhythm, no mmrg abdomen: soft, non-tender, non-distended, bowel sounds present ext: warm, no edema, pedal pulses appreciated skin: no rashes neurologic examination: mental status: awake and alert, unable to relay fully coherent history in part due to aphasia and dysarthria, cooperative with exam where able; appears to know he is in the emergency room, but cannot tell me the date; language is non-fluent, with dysarthric speech, follows comprehension of basic examination commands bilaterally cranial nerves: optic disc margins sharp; visual fields are full to blink bilaterally. pupils equally round and reactive to light, 4 to 3.5 mm bilaterally. extraocular movements intact, no nystagmus. facial sensation reduced on right side, v1-v3. facial movement normal and symmetric. hearing reduced to finger rub on right. palate elevates midline, though cough response to gag is absent. tongue protrudes midline, no fasciculations. trapezii full strength bilaterally. motor: normal bulk and tone throughout. subtle right pronator drift. no tremor. d t b we fif ip q h ta edb right 5 5 5 5 5 5 5 5 5 5 5 5 5 left 5 5 5 5 5 5 5 5 5 5 5 5 5 sensation: light touch and pin prick reduced throughout to the right arm and leg. position sensation to skin is intact in all four extremities. reflexes: b t br pa pl right 3 3 3 3 0 left 3 3 3 3 0 toes were downgoing bilaterally. coordination: no intention tremor noted. slight dysmetria on right finger-nose-finger, preserved on left. no dysmetria on hks bilaterally. ffm slowed and clumsy on the right. gait: deferred given acuity of hemorrhage pertinent results: labs: micro: urine cx (): <10,000 organisms/ml. urine cx (, ): no growth urine cx (): enterococcus >100,000 organisms/ml; staphylococcus, coagulase negative. 10,000-100,000 organisms/ml blood cx (, x3, x2, x2): no growth imaging: ecg (): sinus rhythm at a rate of 62. rsr' pattern in lead v1. ct head (): impression: 1. acute extra-axial hematoma along the lower brainstem and upper cervical spinal cord with associated mass effect and edema. possible etiologies include vascular malformation or aneurysm or bleeding from the patients known left cp angle schwannoma. 2. hypodensity in the left cerebellopontine angle likely acoustic schwannoma previously diagnosed by mri. 3. large territory of hyperdensity and encephalomalacia in the area of the left mca consistent with prior left mca infarction. ct c-spine (): impression: 1. acute extra-axial hematoma (likely sdh) extending from the medulla along the cervical spinal cord to approximately the c3 vertebral level. there is resultant mass effect on the cord with rightward and posterior cord displacment and compression, as well as probable cord edema. recommend cta to further evaluate for vascular abnormality or tumoral bleeding. 2. no fracture or malalignment. 3. degenerative changes with mild canal narrowing extending from c4 through c7. cta head (): impression: no evidence of avm, aneurysm formation, or other vascular abnormality. enhancing lesion within the left cerebellopontine angle consistent with previously described schwannoma on prior mr. the location of the schwannoma, it is likely the source of bleeding. mr or catheter angiogram may be helpful for more definitive proof. cxr (): impression: no acute intrathoracic process. mr (): impression: 1. area of acute hemorrhage seen within left cerebellopontine angle mass, the source of the patient's extra-axial hematoma compressing the cervical spinal cord. 2. deviation of the cervical spinal cord to the right with severe edema within the cord. mr /mr (): impression: 1. mild increase in the size of the left cp angle mass lesion felt to represent vestibular schwannoma, with blood products within. 2. areas of blood products in the cp angle region, anterior to the medulla, and in the posterior fossa relate to the recently noted subdural/subarachnoid hemorrhage. 3. left mca chronic infarct with hemosiderosis, related to evolution of the chronic infarct. 4. patent major intracranial arteries without focal flow-limiting stenosis, occlusion, or aneurysm more than 3 mm within the resolution of mr angiogram. short segment stenosis of m1 segment of the left middle cerebral artery without flow limitation related to prior ischemic event. conventional angiogram can be considered to confirm the source of hemorrhage after discussion with the interventional neuroradiologist, if there is continued cocern. mr (): impression: 1. continued evolution of the blood products, noted in the csf space, anterior and to the left side of the medulla and in the upper cervical canal with mild decrease in the anteroposterior extent of the blood products as seen on the sagittal images; improvemed but persistent compression on the upper cervical cord and the left side of the medulla compared to the prior study (but persistent). 2. multilevel degenerative changes in the cervical spine as described above. cerebral angiography (): impression: 1. prominent venous/vascular structures in the region of the proximal v4 segment of the left vertebral artery may represent a developmental venous anomaly/venous angioma. hypervascular tumor cannot be excluded. 2. mild narrowing of the intradural v4 segments of the vertebral arteries more on the left than on the right may represent spasm versus hypoplastic intradural v4 segment of the vertebral arteries. ecg (): atrial fibrillation at a rate of 140. moderate artifact. incomplete right bundle-branch block. non-specific st segment changes in leads v4-v6. ecg (): atrial fibrillation at a rate of 98. incomplete right bundle-branch block. the previously described st segment changes are less prominent. bilateral lenis (): impression: no dvt in the bilateral lower extremities. ct head (): impression: 1. improving extra-axial hemorrhage. no new focus of intraparenchymal hemorrhage is identified. 2. stable left mca infarct. no new major vascular territorial infarction is detected. cxr pa/lateral (): the cardiomediastinal silhouette is unremarkable. the lungs are essentially clear except for minimal atelectasis at the left base. there is small right pleural effusion, part of it can be seen at the left apex. no pneumothorax is demonstrated. ct torso (): impression: 1. no evidence of abscess and no explanation for the patient's fever. 2. cholelithiasis without cholecystitis. 3. multiple renal cysts including two hyperattenuating, likely hemorrhagic, cysts in the right kidney. these cysts could be further evaluated by ultrasound on a non-emergent basis. 4. moderately extensive diverticulosis without diverticulitis. tte (): the left atrium is normal in size. the left ventricular cavity size is normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is normal (lvef>60%). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets are mildly thickened. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. no vegetation seen (cannot definitively exclude). mr /iac (): impression: 1. no evidence of acute infarct. 2. chronic left mca infarct is identified. 3. small tentorial subdural is identified extending into the retrocerebellar region indicating a small posterior fossa subdural. no significant mass effect on the cerebellum seen. 4. left-sided cerebellopontine angle mass consistent with vestibular schwannoma is identified which demonstrates intrinsic area of blood products as seen on the previous ct. limited comparison with the previous mri demonstrate no significant change in size when comparing the differences in technique. 5. no evidence of midline shift or hydrocephalus. pfts (): spirometry 11:11 am pre drug actual pred %pred fvc 4.90 5.68 86 fev1 3.52 3.83 92 mmf 2.68 3.25 82 fev1/fvc 72 67 107 lung volumes 11:11 am pre drug actual pred %pred tlc 7.48 8.69 86 frc 4.61 4.98 92 rv 3.04 3.01 101 vc 4.54 5.68 80 ic 2.87 3.71 77 erv 1.56 1.98 79 rv/tlc 41 35 118 he mix time 3.13 dlco 11:11 am actual pred %pred dsb 30.62 27.92 110 va(sb) 7.12 8.69 82 hb 13.90 dsb(hb) 31.25 27.92 112 dl/va 4.39 3.21 137 brief hospital course: 1. extra-axial hematoma extending from the medulla along the cervical spinal cord, likely due to bleeding around schwannoma: the patient was admitted with new headache and neck pain, and was found to have acute extra-axial hematoma extending from the medulla along the cervical spinal cord to approximately the c3 vertebral level, with resultant mass effect on the cord with rightward and posterior cord displacment and compression, as well as probable cord edema. cta head showed no evidence of avm, aneurysm formation, or other vascular abnormality. cerebral angiography showed prominent venous/vascular structures in the region of the proximal v4 segment of the left vertebral artery may represent a developmental venous anomaly/venous angioma, but hypervascular tumor cannot be excluded. it was thought that the cause of his bleeding was from the schwannoma. his inr was 3.6 on admission, and he was given prophylnine 2 vials, vitamin k 10 mg iv x1, and 2 u ffp. his coumadin and asa were discontinued, but his aspirin was added back at 81 mg daily at the time of discharge. neurosurgery was consulted on admission and recommneded reversing inr to 1.3. he was initially admitted to the neuroicu, where he returned to his baseline aphasia and dysarthria. hypercoaguable work up showed lupus ac neg, atiii nl, prot c nl, prot s nl aca igg/igm nl, homocysteine nl, fvl no mutation, mthfr heterozygous, prothrombin no mutation. he will follow up with dr. in neurology as an outpatient. 2. atrial fibrillation with rapid ventricular response: the patient has a history of atrial fibrillation on coumadin. during this admission, his coumadin and asa were discontinued given his extra-axial hematoma around his schwannoma. his asa 81 mg daily was added back at the time of discharge. his outpatient cardiologist, at was about this medication change. he went into atrial fibrillation with rvr requiring a diltiazem gtt. given that it was too risky to put him back on coumadin, ep was consulted for possible ablation and initiation of antiarrythmic. he was started on amiodarone 200 mg tid which should be continued for 1 month, then changed to 200 mg daily. baseline pfts were obtained. he will be sent out with of hearts monitor for the next 2 weeks, so monitor his qtc and heart rate while starting amiodarone. his qtc at the time of discharge was 462. his ditiazem was changed to diltiazem sr 240 mg daily. he will follow up with dr. in cardiac surgery to consider minimaze procedure with surgical pvi and . he will follow up with dr. in cardiology/electrophysiology. 3. fevers: the patient spiked temperatures during his hospital stay. wbc was 14.1 on admission with 88% neutrophils, and peaked at 18.7 urine cx (): <10,000 organisms/ml, (, ): no growth, and (): enterococcus >100,000 organisms/ml; staphylococcus, coagulase negative. 10,000-100,000 organisms/ml. id thought the enterococcus was likely a contaminent. blood cx (, x3, x2, x2): no growth. the team was unable to do an lp given his posterior fossa mass. cxr and lfts were normal, anca was negative, and tte did not show any vegetations. ct torso showed no evidence of abscess and no explanation for the patient;s fever. lenis showed no dvt in the bilateral lower extremities. id was consulted and recommended starting vancomycin 1 gm iv q12 hr and meropenem 500 mg q6 hr to cover for nosocomial organisms. he completed a 7 day course of these antibiotics. 4. hypertension: his bp was 167/92 on admission. his nadolol was discontinued, and he was started on diltiazem sr 240 mg daily and amiodarone 200 mg tid, to be changed to 200 mg daily in 1 month. 5. dyslipidemia: he was continued on simvastatin 40 daily. 6. papillary renal cell carcinoma: ct torso showed multiple renal cysts including two hyperattenuating, likely hemorrhagic, cysts in the right kidney. he had recently had an mri abdomen at () which showed: -stable in size partially exophytic solid mass in the lower pole of the right kidney, consistent with known papillary renal cell carcinoma, unchanged in size and appearance since comparison study from -multiple stable in size bilateral renal cysts. the cyst in the lower pole of the right kidney with slighly thickened walls is also unchanged. -bilateral adrenal nodules likely representing adenoma -cholelithiasis -linear scarring in the parenchyma of the spleen, likely sequela of prior infarcts. 7. gout: he was continued on allopurinol 300 mg daily. 8. urology: the patient failed bladder trains and voiding trials during this admission. he was started on flomax daily, and will be discharged to rehab with a foley in place. the foley can be attempted to be removed at rehab. medications on admission: -warfarin 7.5 mg on mondays, 10 mg daily on other days -asa 81 mg on monday, wednesday, and friday -corgard 20 mg daily -simvastatin 40 mg daily -allopurinol 300 mg daily discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po tid (3 times a day): ***200 mg tid for 1 month, then change to 200 mg daily***. 2. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. allopurinol 300 mg tablet sig: one (1) tablet po daily (daily). 4. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po hs (at bedtime). 5. sodium chloride 0.65 % aerosol, spray sig: sprays nasal qid (4 times a day) as needed. 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain or fever. 7. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) u injection tid (3 times a day). 8. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po qid (4 times a day) as needed. 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 10. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 11. lactulose 10 gram/15 ml syrup sig: forty five (45) ml po tid (3 times a day) as needed for constipation. 12. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 13. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). discharge disposition: extended care facility: of discharge diagnosis: primary: extra-axial hematoma extending from the medulla along the cervical spinal cord, likely due to bleeding around schwannoma schwannoma atrial fibrillation with rapid ventricular response secondary: chronic left mca infarct hypertension dyslipidemia history of pulmonary embolism papillary renal cell carcinoma gout discharge condition: aphasia, dysarthria. full strength, decreased sensation on right face and rue, slightly increased reflexes on the right discharge instructions: you were admitted to the hospital with headache and neck pain, and were found to have a hematoma around your medulla to the cervical spinal cord which was likely due to bleeding around your schwannoma. your coumadin was discontinued, but you were continued on aspirin 81 mg daily. you were started on amiodarone 200 mg three times a day and diltiazem sr 240 mg daily to help control your atrial fibrillation. in one month, you should increase the amiodarone to 200 mg daily. you will follow up with dr. in cardiac surgery as an outpatient for consideration of procedures to control your atrial fibrillation. you were discharged with of hearts monitor for the next 2 weeks while you are starting the amidodarone. the information from this monitor should be sent to dr. office. you spiked fevers while hospitalized, but no infectious source of the fevers was found. the following changes were made to your medications: your coumadin was discontinued given the bleeding around your schwannoma. your nadolol was discontinued. you were started on amiodarone 200 mg three times a day, which should be changed to amiodarone 200 mg daily in 1 month. you were started on diltiazem sr 240 mg daily. you were started on flomax daily as we were unable to successfully remove your foley catheter. in a week while in rehab, they can attempt to remove the foley. if you develop increased headache or neck pain, new weakness or numbness, increased difficulty speaking or swallowing, decreased vision or blurry vision, fevers/chills, cough, chest pain, diarrhea, pain or burning on urination, or any other symptoms that conern you, call your pcp or return to the ed. followup instructions: you have a follow up appointment with dr. in cardiac surgery () on at 1:00 pm in the , . you have a follow up appointment with dr. in neurology () on at 2:00 pm in the center, . you have a follow up appointment with dr. in cardiology/electrophysiology () at 1:00 pm in the building, . md, procedure: arteriography of cerebral arteries transfusion of other serum diagnoses: unspecified essential hypertension gout, unspecified atrial fibrillation malignant neoplasm of kidney, except pelvis compression of brain other and unspecified hyperlipidemia other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation long-term (current) use of anticoagulants retention of urine, unspecified personal history of venous thrombosis and embolism other encephalopathy subdural hemorrhage late effects of cerebrovascular disease, aphasia meningitis, unspecified vascular myelopathies other specified cystic kidney disease benign neoplasm of cranial nerves 

Answer: The patient is high likely exposed to