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: sulfa (sulfonamide antibiotics) attending: chief complaint: aphasia major surgical or invasive procedure: none history of present illness: ms. is a 65 year-old right-handed woman with a history including tobacco use, arrhthymia s/p cardioversion, and left mca stroke () with residual subtle comprehension deficits and paraphasic errors who initially presented to with a global aphasia and was transferred to the following the administration of t-pa. . the patient suffered a left mca stroke in (presenting syndrome included language deficits but is otherwise unclear). daughter states that she since regained the ability to speak in fluent, grammatical sentences. however, she continues to demonstrate paraphasic errors. her daughter thinks ms. comprehension is largely intact. she can watch television and engage meaningfully in conversations. however, the patient has trouble identifying the date and her birthdate at baseline. she has no residual weakness. although she has been living with her daughter, she is reportedly getting ready to move into independent housing. she is independent in activities of daily living. . she was in her usual state of health until about 11 am on the day of evaluation. at around 11:05 am, the patient went downstairs to find one of her relatives. at that time, she could no longer speak fluently; rather, she was "mumbling." she seemed to be able to understand to some degree and communicated a desire for coffee. her family member took her to get coffee. she was able to walk independently with no incoordination. no facial droop or non-language deficits were noted. when the language impairments did not improve, she was taken to for evaluation. there an nihss score of 8 was given. after a telemedicine evaluation, she was given t-pa at about 1406. she was then transferred to the for further evaluation and care. . a code stroke was called at the time of the patient's arrival. nihss score following thrombolysis was 7 (for inability to answer loc questions 2, failure to follow some loc commands 1, slight right facial palsy 1, severe aphasia 2, and slight dysarthria 1), although her baseline is estimated to be about 3 (inability to answer loc questions, slight aphasia). a non-contrast ct of the head performed at reveals a prior left mca stroke without clear evidence of new ischemic lesions; major territorial vessels appear patent without signifcant stenoses. the patient's daughter thinks the patient's ability to produce speech has improved since the t-pa was administered. . neurological, general review of systems: - positive for: headaches (baseline), recent flu shot and cold symptoms per her daughter - otherwise unobtainable past medical history: - left mca stroke as above () - hypothyroidism - depression - headache - "arrhythmia" s/p what sounds like cardioversion social history: lives with daughter, previously worked in a factory, had a 6th grade education, likes gambling, smokes cigarettes/day but previously ppd for "most of her life", her daughter denies alcohol or drug use. family history: - positive for stroke (sister), migraine (daughter, etc), cad physical exam: admission physical exam: physical exam: vs: 97.7, 148/64, 53, 17, 97%ra gen: elderly woman lying in bed, struggling to communicate heent: op clear pulm: cta-b anteriorly cv: rrr abd: soft, nt, nd ext: no peripheral edema . neuro exam: ms - able to follow some commands (show l thumb, squeeze hand, let go of hand), but no more than 1-step commands, able to count fingers, but unable to always answer appropriately, most answers are "i dunno" or "no", which are intermittently appropriate responses. she nodded her head when asked if she was in a hospital. cn - perrl, eomi, mild r facial droop, decreased blink to threat in r eye motor - effort/comprehension dependent exam, pt unable to cooperate with distal le's delt bic tric wrext wrflex ip quads ham l 5 5 5 5 5 5 4+ 4+ r 4- 5 5 5- 4+ 4 4+ 4 dtrs - 2 and symmetrical throughout, upgoing toe on r sensory - intact to light touch throughout coordination - deferred gait - deferred discharge physical exam: vs: 97.5 128/80 86 16 98% ra gen: awake and alert, sitting up in bed, nad heent: op clear pulm: ctab cv: rrr abd: soft, nt, nd ext: no peripheral edema . neuro exam: ms - awake and alert, able to state name. repeats some simple words (book) but not phrases. comprehension intact for questions, follows commands cn - perrl, eomi, mild r facial droop, decreased blink to threat in r eye motor - slight r pronator drift delt bic tric wrext wrflex ip quads ham l 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 dtrs - 2 and symmetrical throughout, upgoing toe on r sensory - intact to light touch throughout coordination - intact fnf gait - ambulates steadily with assitance pertinent results: admission labs: 04:48pm blood wbc-6.3 rbc-4.72 hgb-14.0 hct-42.5 mcv-90 mch-29.7 mchc-33.1 rdw-12.9 plt ct-195 04:48pm blood pt-11.4 ptt-23.8 inr(pt)-0.9 04:48pm blood glucose-105* urean-20 na-141 k-4.4 cl-105 hco3-25 angap-15 03:00pm blood alt-15 ast-18 ld(ldh)-189 alkphos-76 totbili-0.2 04:48pm blood ck-mb-2 ctropnt-<0.01 03:00pm blood ck-mb-2 ctropnt-<0.01 04:48pm blood calcium-8.9 phos-4.3 mg-2.1 04:48pm blood %hba1c-5.6 eag-114 04:48pm blood tsh-0.030* 04:48pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg imaging: cxr : impression: ill-defined opacity projecting over the posterolateral left eighth rib, difficult to discern whether pulmonary. recommend further evaluation with oblique views to help localize and if finding persists, chest ct. echo : conclusions the left atrium is normal in size. no atrial septal defect or patent foramen ovale is seen by 2d, color doppler or saline contrast with maneuvers. the estimated right atrial pressure is 5-10 mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. no cardiac source of embolus seen. ct head : impression: acute left frontal lobe infarct in the left mca territory, similar to the preceding mri. no acute hemorrhage. carotid us : impression: 1. 60-69% stenosis in the bilateral internal carotid arteries. 2. mid systolic decelerations in the left vertebral artery consistent with occult left subclavian steal syndrome. cta neck : findings: there is calcified atherosclerotic plaque involving both carotid bulbs and proximal icas. the right cervical internal carotid artery has minimum diameters of 6.0 mm, proximally, and 4.5 mm, distally. within the proximal right ica, at the site of greatest narrowing due to atherosclerotic disease, the dmin measures 3.5 mm. the left cervical internal carotid artery demonstrates minimum diameter of 4.0 mm, proximally, and 4.5 mm, distally. at the site of greatest atherosclerotic narrowing within the proximal left ica, the dmin measures 3 mm. there is no site of significant atherosclerotic disease seen more distally in either internal carotid artery. the origin of the left vertebral artery demonstrates significant circumferential plaque, with resultant high-grade stenosis; there is slight post-stenotic dilatation and resumption of caliber, distally. the origin of the right vertebral artery is widely patent. otherwise, there is no focal stenosis involving the vertebral arteries. there appears to be a right fetal pca intracranially, incompletely imaged. a fetal-equivalent left pca is also likely present. visualized lung apices demonstrate mild paraseptal emphysema. mild-to-moderate degenerative changes are noted within the cervical spine, worst at c5-6, incompletely assessed. impression: 1. calcified atherosclerotic disease within the carotid bulbs and proximal icas, bilaterally. however, there is no site of greater than 50% diameter stenosis. 2. significant plaque at the origin of the left vertebral artery, with resultant high-grade stenosis. mr: mri: restriction of diffusion is seen in the left frontal and insular lobe in a cortical and subcortical distribution. there is associated t2 hyperintensity, suggesting an early subacute chronicity. blood products are not identified, and there is no mass effect. extensive encephalomalacia is seen involving large portions of the left temporal lobe. otherwise, the cerebral sulci, ventricles, and extra-axial csf-containing spaces have normal size and configuration. there is no shift of the midline structures. the visualized paranasal sinuses and mastoid air cells are clear. the orbits and osseous structures are unremarkable. mra: mra studies are limited in image quality due to extensive motion artifacts. the left superior m2 branching artery is not well visualized which could be related to technical factors or represent extensive narrowing or embolic occlusion. otherwise, the intracranial internal carotid, vertebrobasilar, and anterior, middle, and posterior cerebral arteries appear patent. there is a fetal origin of the right posterior cerebral artery. within the limits of this study, there is no evidence of aneurysm or arteriovenous malformation. the origins of the common carotid arteries and vertebral arteries are not visualized due to technical limitations. the left vertebral artery is hypoplastic; within the limiations of this exam, the bilateral cervcial portions of the ica and right vertebral artery do not demonstrate significant stenosis. impression: 1. early subacute cortical and subcortical ischemic infarct involving the left frontal and insular lobe. no evidence of associated hemorrhage. 2. extensive encephalomalacia of the left temporal lobe. 3. failure to visualize the left superior m2 branching artery which could be technically related or represent embolic or atherosclerotic occlusion. if clinically indicated cta should be performed for definite diagnosis. the study and the report were reviewed by the staff radiologist. brief hospital course: is a 65 yo rh woman w/ hx of tobacco use, arrhythmia s/p cardioversion, and l mca stroke in with residual subtle comprehension deficits and paraphasic errors who initally presented to with a global apahasia and was transferred to following tpa. . # neuro: patient presented initially not following commands, but by day 2 of her admission, she was following some simple commands and responding somewhat appropriately to questions. she was initially monitored in the icu for 24 hrs s/p tpa. her head ct 24 hrs s/p tpa showed no bleeding, so she was able to be started on plavix 75mg qd and sqh at that time. we continued pt's home dose amitriptyline and topmax once she was able to take po's. carotid ultrasounds showed 60-69% stenosis of the ica bilaterally. vascular surgery was consulted and recommended a cta neck, which showed an irregular extensive, likely ulcerated plaque bilaterally at the carotid bulbs and proximal icas, worse on the left. approximately 60% stenosis at worst level in proximal left ica. she was not felt to be a candidate for cea at this time. she was started on a heparin drip and bridged to coumadin per vascular recs. her neurologic exam remained stable. she continued to have significant nonfluent aphasia, able to say a few simple words and few-word phrases. she had no weakness or other significant deficits. she will follow up in stroke clinic to determine length of time of anticoagulation. # cards: we got an echo that showed no source of stroke. she had a carotid duplex done that showed bilateral 60% stenosis of ica. we continued pt's home dose pravastatin. we allowed for autoregulation of pt's bp, with goal of 140-180, and gave hydralazine prn sbp >180. patient was put on plavix 24 hrs s/p tpa and her aspirin was not restarted. she was subsequently changed over to a heparin drip and bridged to coumadin. # pulm: we continued pt's proair inhaler. cxr was clear. # endo: her tsh was low at 0.03. t3 and t4 were normal. we continued her levothyroxine at her home dose. she should follow up with her primary care physician for further management of her hypothyroidism. # psych: we continued her home dose sertraline at 100mg # code/contact: full; hcp is daughter transitional care issues: she will need rehab upon discharge with pt/ot and speech therapy. she will need to be maintained on coumadin with goal inr due to her carotid disease. she has an inr on dicharge of 1.9. medications on admission: - proair inh 2 puffs inh q6h prn sob - amitriptyline 25 mg po qhs (older rx) - topamax 25 mg po bid - levothyroxine 137 mcg po daily - pravastatin 40 mg po qhs - sertraline 100 mg po bid - asa 325 mg po daily discharge medications: 1. pravastatin 20 mg tablet sig: two (2) tablet po hs (at bedtime). 2. sertraline 50 mg tablet sig: two (2) tablet po bid (2 times a day). 3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q6h (every 6 hours) as needed for sob, wheezing. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. 6. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain, temp > 100.4. 7. amitriptyline 25 mg tablet sig: one (1) tablet po hs (at bedtime). 8. topiramate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 9. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 10. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 11. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. discharge disposition: extended care facility: rehabilitation center (at ) - discharge diagnosis: primary: left frontal and insular infarct secondary: hx of stroke, depression discharge condition: mental status: clear and coherent. +aphasia. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , you were seen in the hospital for a stroke. you were given tpa (the clotbuster medication) before you arrived. you were then monitored in the icu when you arrived here to ensure that you did not have any bleeding complications from the tpa. you were found to have narrowing of the carotid arteries which may be a possible cause of your strokes. you were started on a blood thinner called coumadin to help reduce your risk of future strokes. an echocardiogram of your heart was normal. we made the following changes to your medications: started on coumadin 5mg daily. you will need an inr checked daily until your level is at goal of . please continue to take your other medications as previously prescribed. if you experience any of the below listed danger signs, please contact your doctor or go to the nearest emergency room. it was a pleasure taking care of you on this hospitalization. followup instructions: department: neurology when: monday at 2:30 pm with: , md building: sc clinical ctr campus: east best parking: garage procedure: diagnostic ultrasound of heart diagnoses: tobacco use disorder unspecified acquired hypothyroidism occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction depressive disorder, not elsewhere classified personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits dysarthria aphasia examination of participant in clinical trial occlusion and stenosis of carotid artery with cerebral infarction status post administration of tpa (rtpa) in a different facility within the last 24 hours prior to admission to current facility 

Answer: The patient is high likely exposed to