Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: patient recorded as having no known allergies to drugs attending: chief complaint: slurred speech major surgical or invasive procedure: endotracheal intubation central venous line insertion radial arterial line insertion history of present illness: 64yo rh m h/o htn, frontal dysfunction who was last known well at 1:30pm. at 6:10pm, he was seen to slump over by his son, who was alarmed that his speech was markedly slurred and he was difficult to arouse for 3-4 minutes. he wheeled him to the couch and called ems. on their arrival, their exam was notable for "altered mental status", saying he was 29yo and also for mild slurred speech and their screen for stroke was negative, with no significant droop or lateralized weakness. per the patient, he was "attacked by 4 naked women." on repeat questioning about what happened, he said that his son became alarmed that he had had a stroke. at present, the patient denies all complaints. he says his speech is now normal. he recalls the entire episode, which was not preceeded by any prodrome of feeling faint, palpitations, chest pain or alteration in his thinking. he denies vertigo, diplopia or visual changes, weakness, tingling/numbness, gait difficulty. this morning, he reports that he had a "migraine". these are preceeded by flashing white lights and followed by a retroorbital, throbbing headache. they are a/w photophobia and now occur 3-4 times a week. they first occurred in adolescence then remitted until he was in an mva a few years ago (with no associated loc). ros: on review of systems, the pt denied recent fever or chills. no night sweats or recent weight loss or gain. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. denied rash. past medical history: atrial fibrillation, treated with flecainide, which caused atrial flutter; now s/p two ablations, first in , another in h/o migraines hyperlipidemia h/o mva with frontal lobe dysfunction: deficits of attention/executive function on recent testing h/o tga h/o 1mm mca aneurysm no h/o htn, dm or cad psh: s/p appendectomy social history: lives at home independently. no h/o tob/etoh/illicit drugs. former mortgage broker family history: mother died at 86 of pna, chf. father is unknown to him. physical exam: code stroke scale: neurologic (nihss): 5 1a. loc: alert, responsive (0) 1b. loc questions: knew age and name of month (0) 1c. loc commands: closed eyes and gripped with **(nonparetic) hand (0) 2. best gaze: no gaze palsy (0) 3. visual: left inferior quadrantanopsia (1) 4. facial palsy: left facial asymmetry (1) 5a. left arm: mild drift (1) 5b. right arm: no drift (0) 6a. left leg: no drift (0) 6b. right leg: no drift (0) 7. limb ataxia: absent (0) 8. sensory: left face/arm sensory loss (1) 9. language: no aphasia, normal (0) 10. dysarthria: none (0) 11. extinction/inattention: extinguishes visual and tactile stimuli (1) pe vs 97.9 64 134/82 12 98% gen awake, cooperative, nad heent nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck supple, no carotid bruits appreciated. no nuchal rigidity lungs cta bilaterally cv rrr, nl s1s2, no m/r/g noted abd soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted ext no c/c/e b/l skin no rashes or lesions noted neuro ms awake, alert. fully oriented. recites forwards but only two backwards then trails off. disinhibited and reaches to poke my eyes (like the three stooges). impaired luria sequencing. unable to perform go-no go properly. speech fluent, with normal naming, , writing, comprehension and repetition. normal prosody. there were no paraphasic errors. able to follow both midline and appendicular commands. no apraxia. interprets cookie theft picture appropriately. no dysarthria. cn cn i: not tested cn ii: l inferior quadrantanopsia to confrontation, with extinction on the left to dss. pupils 3->2 b/l. fundi clear. cn iii, iv, vi: eomi no nystagmus or diplopia cn v: lt/pp decreased on the left cn vii: mild l facial droop (not on prior neuro eval) cn viii: hearing intact to fr b/l cn ix, x: palate rises symmetrically cn : shrug and symmetric cn xii: tongue midline and agile motor normal bulk and tone. no pronator drift d b t we fe ff ip q h df pf te sensory intact to lt, pp, jps, vibration throughout the right side; the left face and arm have decreased lt/pp. reflexes br tri pat ach toes l 2+ 2+ 2+ 2+ 2+ down r 2+ 2+ 2+ 2+ 2+ down coordination ffm, rams, ftn, hts all normal gait deferred, due to need for ct pertinent results: labs 07:50pm wbc-11.4* rbc-4.45* hgb-14.3 hct-42.7 mcv-96 mch-32.1* mchc-33.5 rdw-14.4 07:50pm plt count-274 07:50pm glucose-109* urea n-12 creat-1.2 sodium-141 potassium-4.0 chloride-104 total co2-28 anion gap-13 10:05pm pt-11.5 ptt-34.5 inr(pt)-1.010/26/07 06:05am blood triglyc-97 hdl-69 chol/hd-2.9 ldlcalc-114 06:20am blood pt-24.7* ptt-41.9* inr(pt)-2.5* ekg : probable atrial fibrillation. voltage changes and st-t wave abnormalities are consistent with left ventricular hypertrophy. clinical correlation is suggested. compared to previous tracing the patient is now in atrial fibrillation. imaging ct/ct-p/ cta head and neck (): head ct: there is no evidence of hemorrhage, mass, mass effect or shift of the normally midline structures. the - white differentiation is maintained. ct perfusion: there is decreased blood flow and increased transit time in the right temporal and right frontal regions in the distributions of teh inferior division of the right middle cerebral artery and the right anterior cerebral artery. there is moderate reduction of the blood volume in these areas, suggesting irreversible injury. ct of the head and neck: dental artifact limits visualization of the cervical portion of the carotid arteries and the cervical vessels, which are apperently irregular only in this area. otherwise, the visualized portions of the carotid and vertebral arteries are unremarkable without evidence of stenosis. the left vertebral artery is hypoplasic. scattered lymphadenopathy in the anterior neck is not enlarged by ct size criteria. impression: 1) ischemia in the territory of the inferior division of the right middle cerebral artery and the right anterior cerebral artery. this distribution is suggestive of embolic phenomenon. there is moderate reduction in blood volume in these regions, raising a concern that some of the tissue may be irreversibly injured. 2) limited evaluation of the vascular structures in the neck without cervical area mri (): mri of the brain: diffusion abnormalities are noted in the right mca territory consistent with acute/subacute stroke. there is no shift of normally midline structures, intra- or extra-axial hemorrhage. the orbits, paranasal sinuses and mastoid air cells within normal limits mra of the circle of : there is occlusion of the distal branches of the posterior right mca. the previously demostrated 1 mm aneurysm in the right m1 segment of the middle cerebral artery is again noted just proximal to the bifurcation and unchanged. multiple bilateral flair hyperintensity foci likely represent chronic microvascular ischemic changes. mra of the carotids and vertebral arteries: the carotids and vertebral arteries are visualized from the origins to the intracranial courses. hypoplastic left vertebral artery. no significant carotid stenosis. impression: 1. occlusion of the distal branches of the right mca with large acute stroke. 2. unchanged 1 mm right m1 mca aneurysm. transthoracic echocardiogram: the left atrium is moderately dilated. no left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are structurally normal. very mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the rhythm is now atrial fibrillation and mild mitral regurgitation is now identified. the severity of aortic regurgitation is similar. ct of the pelvis with intravenous contrast (): the rectum, sigmoid colon, bladder, prostate, seminal vesicles, ureters are within normal limits. the bladder contains a foley balloon . bone windows: no suspicious lytic or sclerotic lesion is detected. degenerative changes are seen, most notably at l5-s1 endplates. impression: 1. bilateral lower lobe atelectasis/consolidation. 2. patchy areas of low attenuation within both kidneys, some of which appear wedge-shaped concerning for renal infarction. 3. linear opacity within the proximal sma which is most concerning for dissection.* no evidence of bowel ischemia at this time. * was no borne out clinically on hospitalization brief hospital course: mr. is a 64 year old right handed gentleman with history of atrial fibrillation on antiarrhythmic s/p ablation, hyperlipidemia who had transient, severe dysarthria that resolved. his neuro exam at presentation, in addition to frontal lobe dysfunction that appears to be chronic, was significant for new onset left facial asymmetry, as well as either primary visual field defects (left homonymous inferior quadrantanopsia) and left face/arm sensory loss; or alternatively neglect (although cookie jar picture interpretation at presenation was intact). 1) right inferior division mca infarction- the patient was found to have a r inferior division mca infarct by ct perfusion images. he presented out of the window for iv tpa. ia tpa or merci retrieval was not justified due to the nature of his deficits risks of the procedure. the etiology of his infarct was likely embolic in the setting of recurrent atrial fibrillation. he was admitted to the stroke service where he was started on heparin iv goal ptt 50-70 given suspected cardioembolic source of the infarct. the morning following admission the patient developed transient worsening of left facial droop and dysarthria. repeat head ct was stable in appearance. this recurred later in the afternoon, and his ptt was noted to be above therapeutic range at 97.5. repeat head ct revealed stable size of hyperdense r mca parietal territory however microhemorrhages vs. hyperdense mca sign consistent with vessel occlusion. his blood pressures were noted to be sbp's 110's and it was thought the infarct penumbra may be hypoperfused given loss of cerebral blood autoregulation s/p infarction. he was transferred to the icu for tighter blood pressure regulation, with goal sbp's > 140 and closer neurological monitoring given concern for early hemorrhagic conversion. in the icu the patient underwent central line placement and aterial line placement and was started on neosynephrine to maintain sbp's > 140mmhg. the patient became markedly agitated on icu day #2 and required four point restraints, leading to intubation. on hd #4 pressors were weaned and the patient was intubated. he was started on vancomycin and zosyn on for fevers in setting of rml infiltrate by chest x ray for presumed aspiration pneumonia; he completed a 10-day course of these antibiotics. he was transferred to the neuroscience step-down unit for further care. neurologically, his exam improved over time: he had significant improvement of the strength and attention to his left arm and by the time of discharge, the facial droop was barely noticable. his walking remained mildly unsteady, thus physical therapy recommended rehab. his course in the stepdown unit was initially notable for agitation and confusion at night (consistent with sundowning), sometimes with hallucinations. this was felt to be a combination of reversal of his sleep-wake cycle, his underlying frontal lobe dysfunction (chronic, question of frontotemporal dementia) and the new stroke. initially he required medications for sleep and a 1:1 sitter. this improved with time and with orientation via family members involved in his care, and by the time of discharge he was sleeping well at night. of note, mr. was discovered to have vocal cord paralysis and oropharyngeal paresis, likely a result of the intubation in the icu. he worked with the speech pathologists and should continue at rehab to work on vocalization exercises. initially he was unable to swallow safely due to incomplete vocal cord closure and thus risk of poor cough. he was reassessed by the swallow specialists and approved for a modified diet the week of discharge. no further signs of aspiration were seen, and the swallowing function was not felt to have been damaged by the stroke. periodically he complained of mild, dull headaches and was treated with tylenol, ibuprofen (discontinued after rising creatinine), and fioricet. the headaches responded to percocet at times. there were no changes in his neuro exam or other symptoms associated with these headaches. of note, he has r frontal headaches at baseline and has so for many years, many with visual scotomata, suggestive of migraines. he had no similar headaches in the last week of his hospital stay. 2) atrial fibrillation- he had failed ablative therapy and pharmacotherapy on flecainide, and had presented with this acute r mca infarction. he will require life long anticoagulation on coumadin for secondary prevention of stroke. metoprolol was started for rate control, and eventually he was restarted on anticoagulation with heparin and then coumadin. on the day of discharge, his rhythm was again normal sinus. at the time. in response to this, cardiology recommended restarting his calcium channel blocker and flecanide. he should follow up with his cardiologist as an outpatient following discharge. of note, cardiology had concerns about anticoagulation in this patient, who was found incidentally to have a possible 1mm aneurysm at the rmca; however, the neurology service felt that the benefits of prevention of further strokes outweighed the minimal risks associated with a small vascular anomaly, and he was anticoagulated after discussion with the family. 3) renal infarcts and possible sma occlusion- the patient complained of abdominal pain on icu day #2. he underwent contrasted ct of the abdomen revealing concern for wedge shaped renal infarcts and partial superior mesenteric artery occlusion. vascular surgery was consulted and did not deem the sma partial occlusion a surgical condition; further imaging revealed this to be potentially artifactual. renal infarcts were felt to be likely embolic in nature relating to afib and will require coumadin anticoagulation. further in his hospital course on the floor, he developed an elevated creatinine. he was seen by the renal specialists for this problem (below). 4) renal failure- he was found to have a rising creatinine and was seen by the renal service for this while he was on the floor. though he had been on some renally cleared medications and ibuprofen at time for headaches, renal felt ultimately after checking urine eosinophils (negative) and urine lytes (unremarkable) that the most likely explanation was damage incurred with the renal infarcts and possible dehydration. of note, his foley was discontinued periodically with some difficulty urinating, likely the result of prostate hypertrophy. the day of discharge, he had trouble voiding; nursing recommended timed voids attempted with straight-catheterization if necessary every 6 hours once he arrives at rehab. he was hypernatremic to 147, then receiving d5w over 2 days at 55 cc/hr to correct a free water deficit. on the day of discharge, his sodium was 146 and he received addition free water, per renal recommendations. his sodium should be checked periodically at rehab. 5) fen- ng tube was attempted multiple times, in addition to assistance from interventional radiology without initial success, but later with success. he eventually was able to swallow following the vocal cord paralysis (as above), and he resumed a modified diet. 6) id- his aspiration pneumonia was treated with ten days of antibiotics (as above); on the day of discharge, his white blood cell count was stably high (12-13,000 range) with no fevers and no abnormal blood or urine cultures. medications on admission: asa 325 lipitor 10 flecanide 150mg cartia 120 zoloft 100mg discharge medications: 1. sertraline 100 mg tablet sig: one (1) tablet po bid (2 times a day). 2. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 3. ipratropium bromide 0.02 % solution sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 4. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. 5. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours). 6. warfarin 2.5 mg tablet sig: one (1) tablet po daily16 (once daily at 16). 7. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for headache. 8. flecainide 50 mg tablet sig: two (2) tablet po q12h (every 12 hours). 9. diltiazem hcl 120 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). discharge disposition: extended care facility: discharge diagnosis: -right mca stroke -atrial fibrillation -renal failure in the setting of bilateral renal infarcts -aspiration pneumonia -vocal cord paralysis and pharyngeal paresis possibly related to intubation discharge condition: good. neurologically, his exam improved over time: he had significant improvement of the strength and attention to his left arm and by the time of discharge, the facial droop was barely noticable. his walking remained mildly unsteady. discharge instructions: please take your medications as prescribed and follow up with appointments as scheduled. you are on warfarin to thin your blood for stroke given your history of atrial fibrillation. the inr should be checked regularly (daily at first), with the target range between . should you have any additional concerning, worsening, or new symptoms, such as new visual changes (loss), dysarthria, or weakness, then please contact dr. office ( or the on-call neurologist at (. of note, the patient voided on the morning of hospitalization, but not thereafter. a straight-cath revealed 250cc of urine in the afternoon. if the patient does not urinate, he should be bladder-scanned (and straight-cathed, if necessary) every 6 hours until he does so on his own. furthermore, his sodium was mildly elevated on the day of discharge at 146; the sodium level should be checked daily until it is stably within normal limits. the patient may require additional free water to correct this hypernatremia. followup instructions: 1) please call the office of dr. at ( to set up an appointment with him in the neurology stroke clinic in the next 2-4 weeks. 2) you have the following appointment cardiologist in approximately 4 weeks. please call his office to determine if he would like to see you sooner. provider: , md phone: date/time: 3:20 3) please call your primary care physician, . at (, to arrange follow up after your hospitalization. he should be seen in the next 2-4 weeks, if possible. md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization injection of antibiotic computerized axial tomography of head diagnoses: acidosis acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) pneumonitis due to inhalation of food or vomitus long-term (current) use of anticoagulants cerebral embolism with cerebral infarction dehydration encephalopathy, unspecified staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus migraine, unspecified, without mention of intractable migraine without mention of status migrainosus vascular disorders of kidney paralysis of vocal cords or larynx, unspecified hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (luts) facial weakness dissection of other artery aneurysm of artery of neck other dysphagia urinary obstruction, not elsewhere classified 

Answer: The patient is high likely exposed to