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: demerol / lactose attending: chief complaint: ha, nausea/vomiting, diarrhea major surgical or invasive procedure: none history of present illness: hpi: the patient is a 75 year old man with numerous vascular risk factors presenting with one day of nausea, vomiting, diarrhea, and headache. he was feeling well until 0400 on when he woke up with nausea and vomiting which recurred throughout the day (nonbloody, nonbilious). he had associated watery diarrhea at least 4 times. he also had an associated headache that worsened with vomiting; it was right frontal, monotone, and without any associated neurologic symptoms such as visual change, weakness, numbness, or severe or progressive lethargy. he didn't feel tired at all until he was evaluated in an osh. this am while showering, he experienced a fall: he felt that he lost his balance while feeling nauseated and fell onto his back. there was no head strike or loss of consciousness. he denies any other antecedent symptoms. he denies any vertigo but did feel dizzy ("imbalanced"); this did not worsen with position change, but he does feel more nauseated when sitting up. he went to an osh where his head was scanned and the nchct showed a large r cerebellar hypodensity, prompting a transfer to for further care. he was given decadron 10 and lorazepam after which he felt drowsy. on neurologic review of systems, the patient endorses headache. denies lightheadedness or confusion. denies difficulty with producing or comprehending speech. denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. denies muscle weakness. denies loss of sensation. denies bowel or bladder incontinence or retention. denies difficulty with gait. endorses a fall. on general review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. denies chest pain, palpitations, dyspnea, or cough. endorses nausea, vomiting, diarrhea. denies constipation or abdominal pain. denies dysuria or hematuria. denies myalgias, arthralgias, or rash. past medical history: cardiovascular - cad s/p cabg x 4, paf, htn, hl, chf endocrine - dm2 gastrointestinal - ulcerative colitis, s/p inguinal hernia repair (bilateral) renal - s/p nephrolithiasis msk - s/p r ankle surgery social history: lives with fiancee. uses a cane to walk. family history: mother with hx of aneurysm physical exam: physical examination on admission: vs t: 98.2 hr: 116 bp: 193/87 rr: 18 sao2: 97% ra general: nad, lying in bed comfortably but intermittently turns over. / head: nc/at, no conjunctival icterus, no oropharyngeal lesions / neck: supple, no nuchal rigidity, no meningismus / cardiovascular: initially irregularly irregular rhythm and then rrr with occasional premature beats/ pulmonary: equal air entry bilaterally, poor effort / abdomen: soft, nt, nd, +bs, no guarding / extremities: warm, ble pitting edema edema, palpable radial pulses / skin: stasis dermatitis ble neurologic examination: - mental status - awake, drowsy with eyes closed but easily arousable, oriented x 4. recalls a coherent history. registration and recall . attention easily attained and maintained. follows two step commands, midline and appendicular. language fluent with intact repetition and verbal/ comprehension, normal writing. normal prosody. no paraphasic errors. high and low frequency naming intact. no dysarthria. no apraxia or neglect. - cranial nerves - pupils 4->3 l, r 3->2 brisk. vf full to number counting. funduscopy obscured by eye movement but no papilledema. eomi, 3-4 beats extreme lateral end-gaze nystagmus, slow saccades. v1-v3 without deficits to light touch bilaterally. no facial asymmetry with volitional smile/forced eye closure/puffing cheeks, but looks slightly droopy on right at rest (notably edentulous, leaning to right in bed). hearing intact to finger rub bilaterally. palate elevation symmetric. ] scm/trapezius strength 5/5 bilaterally. tongue midline. unable to tolerate -hallpike maneuver. no reproducible symptoms with head jerk. - motor - normal bulk. increased tone in both legs. no pronation, no drift. no tremor or asterixis. = ] l 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 - sensory - no deficits to light touch, pinprick, proprioception. decreased vibratory sensation at least to knees bilaterally, ~ 6 seconds.. - reflexes = ] l 2 2 2 1 1 r 2 2 2 1 1 plantar response equivocal bilaterally. - coordination - minimal dysmetria on finger to nose testing, but prominent overshoot r > l with mirrored movements with hands and feet. dysdiadochokinesia with r > l. minimal or no truncal ataxia when sitting up with arms wrapped around torso. - gait - refused. ================================= pertinent results: labs 03:00pm sodium-137 potassium-4.7 chloride-98 03:00pm ctropnt-0.05* 03:00pm osmolal-324* 07:57am glucose-266* urea n-26* creat-1.2 sodium-142 potassium-4.2 chloride-106 total co2-27 anion gap-13 07:57am ck-mb-3 ctropnt-0.03* 07:57am calcium-7.4* phosphate-3.3# magnesium-1.8 cholest-88 07:57am %hba1c-8.2* eag-189* 07:57am triglycer-71 hdl chol-27 chol/hdl-3.3 ldl(calc)-47 07:57am osmolal-320* 07:57am wbc-9.5 rbc-3.36* hgb-10.5* hct-31.1* mcv-93 mch-31.3 mchc-33.8 rdw-15.2 07:57am to ptt-unable to inr(pt)-unable to 07:57am plt count-119* 07:57am to ptt-unable to inr(pt)-unable to 01:15am glucose-311* urea n-29* creat-1.4* sodium-139 potassium-4.6 chloride-98 total co2-29 anion gap-17 01:15am estgfr-using this 01:15am alt(sgpt)-23 ast(sgot)-26 ld(ldh)-259* alk phos-95 tot bili-0.4 01:15am lipase-31 01:15am osmolal-314* 01:15am urine hours-random 01:15am urine gr hold-hold 01:15am wbc-9.7 rbc-3.62* hgb-11.3* hct-33.1* mcv-92 mch-31.1 mchc-33.9 rdw-15.0 01:15am neuts-93.8* lymphs-4.3* monos-1.6* eos-0 basos-0.2 01:15am plt count-118* 01:15am pt-13.0* ptt-30.9 inr(pt)-1.2* 01:15am urine color-yellow appear-clear sp -1.013 01:15am urine blood-neg nitrite-neg protein-100 glucose-1000 ketone-tr bilirubin-neg urobilngn-neg ph-7.5 leuk-neg 01:15am urine rbc-1 wbc-<1 bacteria-none yeast-none epi-0 06:14am blood wbc-6.7 rbc-2.53* hgb-7.7* hct-23.9* mcv-94 mch-30.5 mchc-32.3 rdw-14.9 plt ct-242 06:05am blood wbc-6.7 rbc-2.67* hgb-8.0* hct-24.4* mcv-91 mch-29.9 mchc-32.8 rdw-15.8* plt ct-246 05:17am blood wbc-6.7 rbc-2.72* hgb-8.2* hct-25.1* mcv-92 mch-30.1 mchc-32.6 rdw-15.9* plt ct-251 04:40am blood wbc-9.7 rbc-2.72* hgb-8.0* hct-25.2* mcv-93 mch-29.6 mchc-31.9 rdw-15.6* plt ct-255 06:57am blood wbc-11.5* rbc-2.79* hgb-8.9* hct-25.8* mcv-92 mch-31.8 mchc-34.4 rdw-15.4 plt ct-238 06:14am blood glucose-142* urean-32* creat-1.3* na-141 k-4.2 cl-100 hco3-34* angap-11 06:05am blood glucose-74 urean-29* creat-1.3* na-139 k-4.5 cl-100 hco3-33* angap-11 05:17am blood glucose-87 urean-30* creat-1.3* na-141 k-4.5 cl-102 hco3-37* angap-7* 04:40am blood glucose-101* urean-28* creat-1.3* na-139 k-4.2 cl-100 hco3-35* angap-8 06:57am blood glucose-116* urean-26* creat-1.2 na-143 k-4.1 cl-103 hco3-36* angap-8 06:05am blood alt-12 ast-19 alkphos-106 totbili-0.3 07:10pm blood ck-mb-2 ctropnt-0.03* probnp-2864* 07:57am blood %hba1c-8.2* eag-189* 07:57am blood triglyc-71 hdl-27 chol/hd-3.3 ldlcalc-47 mr head : 1. extensive right cerebellar acute infarct extending into the tonsil and vermis with narrowing of the cerebral aqueduct, placing patient at increased risk for obstructive hydrocephalus. 2. no current evidence for tonsillar herniation. 3. highly motion degraded mra evaluation revealing nonvisualization of distal v4 segment of right vertebral artery. recommend further assessment by cta if feasible and clinically relevant. 4. bilateral cerebral volume loss and corpus callosal thinning, likely age related involution. 5. remote left frontal infarct. 6. small vessel ischemic disease. ct head : impression: 1. extensive right cerebellar infarct with extension into the tonsil and vermis, with a similar degree of effacement of the cerebral aqueduct. no short interval change in ventricular size. 2. new small focus of hemorrhage in the right cerebellar infarct, concerning for impending hemorrhagic conversion or petechial hemorrhage. 3. slightly low lying tonsils without definite current tonsillar herniation. 4. remote left frontal infarct. 5. age-related involution. cxr : impression: new mild pulmonary edema with otherwise stable left lobe atelectais and bilateral pleural effusions. cxr : findings: as compared to the previous radiograph, the evidence of mild-to-moderate pulmonary edema is unchanged. the presence of a left pleural effusion still cannot be excluded. mild cardiomegaly, left-sided picc line. no newly appeared focal parenchymal opacities. ct head :impression: 1. no significant interval change in right cerebellar infarction with foci of hemorrhagic transformation. 2. mild interval increase in effacement of the aqueduct of sylvius and 4th ventriclefrom increasing edema/mass effect. 3. hypodense lesion in the left frontal lobe with a pattern resembling vasogenic edema is again noted. a post-contrast study might help differentiate whether this lesion is secondary to ischemic changes vs. underlying neoplastic lesion. 4. chronic conditions including small vessel ischemic disease and cerebral volume loss are again noted. ct head : impression: continued evolution of right cerebellar infarction with hemorrhagic transformation. no new foci of hemorrhage are identified. similar configuration of the ventricles as compared to the prior examination. video swallow : impression: aspiration and penetration with thin and nectar liquids. mild penetration, mild to moderate pharyngeal residue with puree. for details, please refer to speech and swallow note in omr. posterior parapharyngeal lesion at level of c3-c4 may represent a lymph node or less likely, a stent. neck radiographs would be helpful in evaluating this finding. neck radiograph : impression: extensive dish with associated cervical spine fusion c3-7. these findings probably account for findings noted on swallowing study video swallow : impression: penetration, but no aspiration, with thin and nectar thick-liquids, which is an improvement since the prior study. no penetration with honey-thick liquids. ct head : impression: stable evolution of a right cerebellar infarct. no new acute process. cxr : findings: as compared to the previous radiograph, there is unchanged evidence of moderate-to-severe bilateral effusions. unchanged signs of mild fluid overload. in the interval, the nasogastric tube has been removed, the left picc line remains in place. unchanged moderate cardiomegaly video swallow : report impression: deep penetration with thin liquids. normal swallowing with other barium consistencies. ******** brief hospital course: the patient is a 75yom h/o paf, cad s/p cabg, chf, dm2, hl, uc who presented on with a 1-day history of nausea, vomiting, diarrhea and headache. exam notable for r facial droop, ?r horner's, mild rebound/overshoot on r without frank dysmetria, no strength deficits. ct head showed large right cerebellar hypodensity with significant edema and mass effect. the patient was started on mannitol and admitted to the neuro icu for close monitoring. he was seen by neurosurgery who did not feel that there was any indication for acute surgical intervention. . icu course: . # neuro: mri on showed large acute infarct in r cerebellar hemisphere with extension into vermis and significant surrounding edema with narrowing of aqueduct of sylvius. there was no evidence of hydrocephalus. mra showed poor visualization of distal r vetebral. repeat ct on showed stable appearance of infarct with small area of hemorrhagic conversion. mannitol was stopped on due to worsening renal function. his neurologic exam remained stable, with mild r-sided dysmetria with overshoot on fnf as well as slow and clumsy on the r. he remained rather lethargic but was easily arousable and responded appropriately once awoken. he was continued on aspirin 300mg pr; the rest of his home medications were held initially due to his dysphagia. these were restarted once oral access was obtained. an echocardiogram showed no cardioembolic source. hba1c was 8.2, and lipids were at goal with ldl of 47. . on a repeat head ct was obtained as he appeared slightly more lethargic than before. this showed no significant interval change in cerebellar infarct with mild interval increase in effacement of the aqueduct of sylvius without any evidence of hydrocephalus. his neurologic exam was otherwise stable, and on repeat evaluation he was more arousable and responding appropriately, consistent with prior examinations. . # cv: he was maintained on telemetry monitoring, which showed intermittent irregular heart rate likely a fib. he was maintained on aspirin 300mg pr while npo and restarted on his home aspirin 325mg and atorvastatin 80mg daily for his history of cad once po access was obtained. bp was initially allowed to autoregulate up to 160. he was maintained on metoprolol 10mg iv q6, which was then converted to 25mg once able to take po. transthoracic echo showed a moderately dilated la, normal systolic function with ef > 55%, mild lvh, and mild mr. there was no evidence of pfo. . # pulm: his course was complicated by the development of likely aspiration pneumonia. cxr showed bilateral pleural effusions without clear infiltrate. he was placed on supplemental o2 and started on vanc/zosyn with improvement. . # id: he developed a low grade fever to 100.3 on the morning of , after noted to have been coughing on sips of thin liquids. his wbc increased to 14.2. blood and sputum cultures were sent. ua was negative. cxr showed slight progression in bilateral pleural effusions and left basal atelectasis without clear infiltrate. he continued to have low grade fevers with leukocytosis and also developed a new oxygen requirement. on he was started on vanc and zosyn for empiric coverage for likely aspiration pneumonia. he subsequently defervesced and his wbc normalized. . # renal: mannitol was stopped on due to acute renal failure with a peak cr of 3.6. nephrology was consulted and he was started on gentle iv hydration with improvement in his renal function. . # endo: hba1c was 8.2%. he was maintained on fingersticks q6 with insulin sliding scale as needed. . # gi/fen: he was initially cleared for a regular diet by bedside swallow evaluation but was subsequently noted to be coughing with sips of liquid. he was made npo and started on maintenance ivf. he subsequently failed formal swallow eval and a dobhoff tube was placed. tube feeds were started on . . # prophylaxis: he was maintained on heparin sc and pneumoboots for dvt prophylaxis. he was maintained on a bowel regimen for gi prophylaxis . # code status: full . . patient was transferred to the neurology step-down unit on . . floor course: he was transferred to the neurology floor on . his neurologic exam remained stable, with mild r-sided dysmetria and overshoot on fnf as well as slow and clumsy on the r. he remained rather lethargic but was easily arousable and responded appropriately once awoken. overnight between he desaturated to the 80's and was placed on nrb. he was then placed on humidified face mask and maintained sats 90-95%. however throughout the day he remained tachypneic with increasing o2 requirements. he was transferred back to the icu on for increasing respiratory distress. . icu course: in the icu he was initially started on bipap which he reportedly did not tolerate well. he was then placed on 100% humidified fask mask and has been maintaining his saturation well in the 90's. he also received 2 doses of lasix 40mg iv for likely component of volume overload. this am he has been weaned to 70% face tent. he remains somewhat tachypneic with rr in the 20's and appears tired. other than his lethargy his neurologic exam is unchanged. once stable the patient was again transferred to the floor. while on the floor, the patient continued to have issues with his respiratory status and was difficult to wean off of oxygen. he was on tfs to maintain an adequate nutritional status. he underwent a video swallow study on which showed aspiration and penetration with thin and nectar liquids, mild penetration, mild to moderate pharyngeal residue with puree. the patient's diet could not be advanced at this time. he was re-evaluated with another video swallow on which showed penetration, but no aspiration, with thin and nectar thick-liquids, which is an improvement since the prior study. the patient was started on pureed with honey-thickened liquids at this time. on , the patient was much more somnolent than usual. he was difficult to arouse late in the day, and his oxygen requirements increased. at this time he was transferred to the icu for management of his somnolence and increased oxygen requirement. a stat head ct was done which did not showed stable evolution of a right cerebellar infarct with no new acute processes. he was started on bipap to maintain adequate oxygen saturation. he was also diuresed with both lasix and acetazolamide while in the icu. he was transferred back to the stepdown unit on . diuresis was continued with lasix. his goal fluid balance should be even to 1 l negative daily while at rehab and lasix dosing should be adjusted accordingly in rehab. he was switched to face mask during the day and bipap at night to maintain adequate oxygenation. pulmonary recommended advair, spiriva, and duonebs to assist his respiratory status. he pulled his dht on . it was decided to not restart his tfs. a discussion with the patient and family about peg placement was pursued, but ultimately the family decided to hold off and give the patient a chance to advance his diet. his diet was advanced to ground solids and nectar liquids on , but the patient continued to have poor intake. during this time his respiratory status continued to improve and he was gradually weaned off oxygen. the patient's foley was d/c'ed on . the patient was started on coumadin 5mg qd on . the day of discharge the patient's picc line was pulled. his diet was ground pureed solids and nectar thickened liquids. he was requiring 2l nc oxygen at time of discharge. medications on admission: asa 325, atorvastatin 80, valsartan 160 daily, ?metoprolol tartrate 100 qhs, furosemide 40 daily, insulin 70/30 63 units qam and 33 units qpm allopurinol 100 q8h, docusate, ferrous sulfate 325 , fluticasone 50 , lidoderm patch, mvi, klorcon 10 meq daily, sulfasalaine 1000 q6h, prochlorperazine 5 prn, cholecalfirerol, omega 3 fish oils discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 3. sulfasalazine 500 mg tablet sig: two (2) tablet po qid (4 times a day). 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 6. docusate sodium 50 mg/5 ml liquid sig: two (2) po bid (2 times a day). 7. acetaminophen 650 mg/20.3 ml solution sig: one (1) po q6h (every 6 hours) as needed for pain/ha. 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 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. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 11. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 12. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 13. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours). 14. warfarin 5 mg tablet sig: one (1) tablet po daily (daily). 15. furosemide 10 mg/ml solution sig: two (2) injection daily (daily). 16. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed for nausea. discharge disposition: extended care facility: northeast - discharge diagnosis: right cerebellar infarct aspiration pneumonia acute renal failure atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear mr. , you were admitted to on with headache, nausea, and unsteady walking. you were found to have a stroke affecting your right cerebellum in the back of your brain. we believe the most likely cause of your stroke was cardioembolic in nature. . you had several imaging studies including a head ct, head mri, multiple chest x-rays, and video swallow studies. the imaging of your head showed a right cerebellar infarct. a chest x-ray in the icu showed a possible aspiration pneumonia for which you received treatment. video swallow studies initially showed aspiration, but improved during your hospital course. . during your admission you were treated for pneumonia and kidney dysfunction which have now improved. your pneumonia was treated with a full course of antibiotics, vancomycin and zosyn. your kidney dysfunction was likely medication induced by mannitol, which was used to decrease swelling in your brain after your stroke. your kidney dysfunction has improved and is now at baseline. . your respiratory status was an ongoing issue during your stay. you were sent back to the icu twice for increased oxygenation requirements. a contributor to this was excess fluid in your lungs called pulmonary edema. you were given a medication called lasix to pull some of this fluid out of your lungs. while at rehab your goal fluid balance should be even to negative 1 liter daily. you were also started on spiriva, advair, and duonebs as recommended by the pulmonary service. another component may be either an underlying sleep apnea or new onset sleep apnea related to your stroke. you were started on bipap at night to assist your breathing and oxygen requirements. you received your nutrition via a dobhoff tube during your stay. this was removed and your diet was slowly advanced as tolerated. you will go to rehab on ground solids and nectar liquids diet. . during your stay you had several new medications started. advair and spiriva were added to assist your breathing. you were also started on coumadin as we believe the newly diagnosed atrial fibrillation potentially caused a clot to form in your heart and was released to your blood circulation in your brain causing your stroke. you will need your inr followed closely after discharge from rehab. you should also get a sleep study and pulmonary function testing done as an outpatient. . if you experience any of the below listed danger signs, please call your doctor or go to the nearest emergency department. . thank you for allow us at to particpate in your care. followup instructions: provider: , md phone: date/time: 11:00 upon discharge from rehab you will need close followup for management of coumadin at dr. office located at medical in , ma phone number . this should be scheduled before discharge from rehab. at some point after your discharge from rehab, you should get pulmonary function tests done. your pcp, . will be able to refer you for this testing. md procedure: enteral infusion of concentrated nutritional substances diagnoses: obstructive sleep apnea (adult)(pediatric) congestive heart failure, unspecified acute kidney failure, unspecified unspecified protein-calorie malnutrition hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation aortocoronary bypass status percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified pneumonitis due to inhalation of food or vomitus cerebral edema long-term (current) use of anticoagulants diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled cerebral embolism with cerebral infarction acute diastolic heart failure hyperosmolality and/or hypernatremia chronic respiratory failure mixed acid-base balance disorder other diuretics causing adverse effects in therapeutic use dysphagia, unspecified 

Answer: The patient is high likely exposed to