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: codeine / quinidine/quinine / norvasc / pravachol attending: chief complaint: lightheadedness, dizziness, palpitations. major surgical or invasive procedure: cardioversion history of present illness: briefly, mrs. is a very pleasant yo woman with cad, paroxysmal atrial fibrillation s/p failed cardioversion (most recent on ), ckd (stage iii) who initially presented with 4 weeks of lightheadedness and vertigo and 3 days of sob. . she was seen by her primary cardiologist , at which time her flecainide was d/c'ed and her metoprolol and diltiazem were increased for rate control. apparently she had not been taking the prescribed doses of bb/ccb and presented to the ed with chest pressure and atrial fibrillation with rvr. initially she was admitted to where she was noted to be in volume overload and diuresed with furosemide, 40 mg iv. she was also given metoprolol (at increased dose from 12.5 to 25 then 50 over the course of two days) and verapramil (180 mg qd) for rate control. this morning she complained of chest pain, was noted to be bradycardic (60s) and hypotensive (sbp in mid 70s). she was given 1.5 lt of ivf bolus and started on dopamine (uptitrated to 20 mcg). after these interventions her pressure improved to the 100s but then decreased again to the 90s. her urine output remained low. she had cardiac enzymes drawn, the first set being negative, an ecg without st changes, and a tte, which showed global hypokinesis with ef of 25%. reportedly her ef from a tee done in early was near normal (reported as mild depressed lvef. last echo before that was in 90s with normal ef. also has had a cath in the 90s with normal coronaries, per report. notably her inr is also elevated to 3.7, presumably secondary to warfarin. . several days prior to presentation her vna found her to be tachycardic to 120s, and was referred dr. saw her and d/ced her fleicanide and increased her metoprolol, which the patient did not take as she did not pick up prescirption. she also reports having chest pain/pressure o/n 4d pta, non-radiating, no n/v/diaphoresis resolved w/ burping. patient was recently admitted with afib w/ rvr, was cardioverted on and discharged home on flecainide, verapamil, metroprolol. she has had no palpitations, no syncope, no pnd or orthopnea. pt. also reports persistent rle edema, since her rehab discharge, this is unchaged, pt. takes lasix prn for this. . in the ccu, the patient admits to feeling cold. she denies, chest pain, palpitations, fevers, chills, cough, abdominal pain, or bleeding. there is no difficulty w/ speech. no dysuria, no abdominal pain, constipation/diarrhea. past medical history: from omr: #. paroxysmal atrial fibrillation #. htn #. ? coronary artery disease - clean coronaries on c cath . #. chronic renal failure - baseline cr 1.0 #. left distal femur fracture w/ orif during hospitalization . rehab stay with complications incl cellulitis, pna. #. ? hyperparathyroidism #. osteoporosis #. cervical disc disease #. osteoarthritis #. gerd #. b12 deficiency . surgical history: #. s/p b/l tonsillectomy #. cholecystectomy #. left knee replacement #. appendectomy #. colon resection with colostomy (since reversed) - patient does not recall specifics #. hysterectomy for excessive bleeding social history: lives alone in apt in with vna. she is a retired accountant having graduated from . she has no children. her neice is her only family, is involved, and lives in . is independent in adls and uses walker. . -tobacco history: never -etoh: none -illicit drugs: never . family history: denies h/o htn, dm, hyperlipidemia, heart disease. physical exam: vs: 97.4f 98/64 107 22 100% 2l nc. gen: lying in bed, nad. heent: nc/at, moist oral mucosa neck: supple, no carotid or vertebral bruit back: no point tenderness or erythema cv: irregularly irregular s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: soft, nontender, non-distended. no masses or megalies. percussion within normal limits. +bs. ext: no edema, no dvt data. pulses ++ and symmetric. neurologic examination: no meningismus. no photophobia. ms: general: alert, awake, attention: follows simple/complex commands. speech/language: mute praxis/ agnosia: able to brush teeth. no field cuts. cn: i: not tested ii,iii: vff to confrontation, perrl 3mm to 2mm, fundus w/o papilledema. iii,iv,vi: eomi, no ptosis. no nystagmus v: sensation intact v1-v3 to lt vii: facial droop left viii: hears finger rub bilaterally ix,x: palate elevates symmetrically, uvula midline : scm/trapezeii bilaterally xii: tongue protrudes midline, no dysarthria motor: normal bulk. tone: normal. +postural/action tremor but no asterixis or myoclonus. delt;c5 bic:c6 tri:c7 wr ext:c6 fing ext:c7 left 3+ 4 4 5 5- right 5 5 5 5 5 ip: quad: hamst: dorsiflex: :pl.flex left 5 5 5 5 5 right 5 5 5 5 5 deep tendon reflexes: bicip:c5 tric:c7 brachial:c6 patellar:l4 toes: right 1 1 1 1 downgoing left 1 1 1 1 downgoing sensation: intact to light touch coordination: *finger-nose-finger normal. *rapid arm movements normal. *fine finger tapping: normal. *heal to shin: normal. *gait/romberg: normal. 1a loc = 0 1b orientation = 0 1c commands =0 2 gaze =0 3 visual fields =0 4 facial paresis = 1 5a motor function r ue = 0 5b motor function l ue= 0 6a motor function r le= 0 6b motor function l le= 0 7 limb ataxia = 0 8 sensory perception = 0 9 language = 3 10 dysarthria = 1 11 extinction/inattention = 0 total = 5 pertinent results: 09:40pm ck(cpk)-36 09:40pm ck-mb-notdone ctropnt-<0.01 12:25pm glucose-162* urea n-31* creat-1.3* sodium-142 potassium-4.0 chloride-107 total co2-25 anion gap-14 12:25pm ck(cpk)-45 12:25pm ctropnt-<0.01 12:25pm calcium-9.6 phosphate-3.4 magnesium-2.1 12:25pm ck-mb-notdone 12:25pm wbc-6.0 rbc-3.77* hgb-10.2* hct-32.5* mcv-86 mch-27.2 mchc-31.4 rdw-16.4* 12:25pm neuts-76.1* lymphs-16.8* monos-5.8 eos-0.7 basos-0.6 12:25pm plt count-272 12:25pm pt-34.6* ptt-32.6 inr(pt)-3.6* cxr: relatively stable examination with marked cardiomegaly and no acute pulmonary process. . ekg: afib, 120, nl axis. no change in st-t segments since . no ecg showing sinus rhythm from last admission. . telemetry: none . tte: the left atrium is dilated. left ventricular wall thicknesses and cavity size are normal. there is severe global left ventricular hypokinesis (lvef = 20-25 %). the right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets fail to fully coapt. moderate tricuspid regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. significant pulmonic regurgitation is seen. there is no pericardial effusion. . impression: severe global lv systolic dysfunction with somewhat better function of the basal inferior and inferolateral segments and the apical segments. there is akinesis of the anterior and anterolateral segments. the right ventricle is dilated and hypokinetic. mild mitral and moderate tricuspid regurgitation. ct head (): probable acute/subacute infarct in the left posterior frontal lobe, though evaluation is limited given the extent of background chronic microvascular ischemic disease. recommended mri with dwi for confirmation. mri head ():acute infarct involving the subcortical white matter within the left frontal and temporal lobes. no evidence of hemorrhagic transformation or mass effect. brief hospital course: this is a yo f with h/o a fib s/p recent 2nd cardioversion on , htn, ? cad s/p clean cath , s/p recent femur fx, pna and cellulitis who p/w afib w/ rvr, persistent weakness, lightheadedness, vertigo and doe. . 1. afib w/ rvr. pt. was admitted with presyncopal symptoms and vertigo, likely from central hypoperfusion, though cerebellar dysfunction could not be ruled out given positive romberg in setting of intact proprioception. she was hd stable on admission and her inr was 3.6. her afib recurrence was felt to be exacerbating chf as evident on last tee. patient was restarted on verapamil of 180mg, her bb was increased to 37.5mg and her coumadin was held. on hd#2, patient developed afib with slow vr, chest pain, diaphoresis and nausea, her ecg was unchanged and her ce were negative x1. she subsequently developed hypotension to mid 70s mmhgs, which did not respond to ivf and required dopamine for hd stability. she was temporarily transferred to ccu where pressors were weaned within few hours of arrival. it was felt that her hypotension was secondary to poor inotropy in setting of bradycardia from multiple nodal blocking agents. throughout stay in ccu she was borderline tachycardic and was eventually placed back on small dose of lopressor for hr control. on hd#3 she was transferred to the floor w/ hr of 100bpm and only on 12.5mg of metoprolol. she remained hd stable and converted to atrial tachycardia vs. slow aflutter. her bb was increased and she was started on low dose digoxin without loading, 0.125 mg eod. . on this regiment her hr was difficult to control. she continued to remain in afib/flutter with hr in 100s despite 50mg tid of bb, digoxin. she was started on amiodarone and underwent cardioversion on . this was successful, pt. was in sinus rhythm. her bb was decreased to 12.5 due to temporary bradycardia to high 40s, digoxin was discontinued and amiodarone decreased to 200mg . with this regimen, hr maintained in 50s, her doe improved significantly and her lightheadedness and dizziness resolved. on at ~ 11pm patient was noted be unable to speak. her neurological deficits included r facial droop and eye lid muscle weakness. code stroke was called, ct head showed a l distal mca stroke in insular region. no tpa was administered due to inr of 2.9. her inr became supratherapeutic with inr 3.9 on her day of discharge hence coumadin is held for now. it needs to be restarted at 1mg once daily once inr <3.0 and needs daily monitoring until stable. dosing may need to go up once amiodarone dosing decreases to daily dosing on . also, patient should be started on lisinopril for heart protection on . . 2. cad - pt. had h/o cad with no h/o mi, cabg or pci. she had a clean cath in . based on above pmhx it was not suspected that she had flow limiting cad, especially with no elevation of ces in setting of cardiogenic shock. she ruled out for mi. she was continued on bb as above. . 3. systolic chf. pt. had a nl ef in echo, but no other imaging except a tee, where it was noted that she had mild systolic dysfunction. tte here prior to hypotensive episode showed global vertricular dysfunction w/ ef of 20-25% given lack of significant cad, this was felt to be most likely tachycardia-related cardiomyopathy and treatment was focused on hr control. pt. was volume overloaded on exam, likely contributed by the tachycardia and poor filling. she was continued on home dose of lasix. she was started on ace-i, lisinopril 5mg daily, however due to renal failure, cr. 1.5 this was discontinued. her lasix was held on . this should be restarted within a day as tolerated by volume status, likely (home lasix dose of 40mg po). . 4. acute on chronic rf: cr on admission up to 1.3 likely due decreased co w/ lv chf in setting of afib. cr recovered to 1.1, near baseline after complications with hypotension, however bumpted back up s/p cardioversion in setting of receiving extra 10mg iv lasix. cr improved to 1.2 on . her lasix is currently being held. . 5. left mca infarct in the setting of therapeutic inr: most likely cardioembolic given the risk factor and patient returned to afib rhythm from sinus after cardioversion. pt was not a thrombolytic or endovascular therapy candidate due to high inr hence high bleeding risk. patient was transferred to the neurology service on and mri showed that she has acute superior division of l mca infarct (precentral gyrus) but not a large infarct hence safe for anticoagulation. patient remains unable to speak, but can make vocalizations, and is able to swallow. she has mild r facial droop with weakness, more in the arm than leg. physical and occupational therapy recommended acute rehab. medications on admission: on discharge from : 1. flecainide 25 mg po q12h - d/ced on 2. furosemide 40-80mg po daily - taking 40mg daily 3. hydralazine 25 mg po bid 4. omeprazole 20 mg po daily 5. calcium carbonate 500 mg chewable po bid 6. cholecalciferol 400 unit po daily 7. multivitamin po daily 8. ranitidine hcl 150 mg po hs 9. isosorbide mononitrate 15 mg po daily - pt taking 20mg daily 10. verapamil 180 mg po q24h - patient taking 120mg daily 11. warfarin 5 mg po once daily. 12. potassium chloride 10 meq po bid 13. metoprolol succinate 25 mg po once a day - patient taking 12.5mg . 14. cyanocobalamin 1,000 mcg/ml qmonth 15. nitroglycerin 0.3 mg prn 16. ginko discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po daily (daily). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po q12h (every 12 hours). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 6. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed. 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 8. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous asdir (as directed). 9. amiodarone 200 mg tablet sig: one (1) tablet po bid (2 times a day) for 6 days: starting , please titrate down to once daily dosing. 10. coumadin 1 mg tablet sig: one (1) tablet po once a day as needed for once inr < 3.0: dosing may need to be titrated as amiodarone dosing gets changed to onec daily on . please check inr daily until coumadin dosing becomes more stable. 11. outpatient lab work daily inr until coumadin dosing stable - coumadin dose will likely need to be increased once amiodarone decreases to dialy dosing on . goal inr 2~3 12. lisinopril 5 mg tablet sig: one (1) tablet po once a day: please start on . 13. outpatient lab work please check weekly tsh while on amiodarone discharge disposition: extended care facility: hospital - discharge diagnosis: primary: atrial fibrillation with rapid ventricular response, atrial flutter, atrial tachycardia, cardiogenic shock secondary: left mca (middle cerebral artery) infarct while inr therapeutic. discharge condition: hemodynamically stable, improved heart rate - mostly non-verbal/mute with new left mca stroke with right facial droop and some right arm weakness (more proximal and distal) but strong in the lower extremities. discharge instructions: you were admitted to with recurrence of your rapid heart rate and lightheadedness. this was felt to be due to your failed cardioversion. you were treated with medications to reduce your heart rate. your course was complicated by a rapid slowing of your heart and very low blood pressures that require temporary stay in an intensive care unit. it was also determined that your heart's pumping action was also poor. for this reason and your heart rate control, your medications were readjusted. you undewent cardioversion on but afterwards was found to have right facial droop due to left mca infarct. this was while your inr was therapeutic hence you were not candidate for thrombolysis or endovascular therapy given high risk of bleeding. you were transferred to neurology service on and evaluated per physical and occupational therapy who recommend acute rehab given your new stroke. speech therapist also evaluated who recommended pureed diet with nectar liquid and crushed meds in puree. you were restarted on amiodarone 200mg twice daily on which is to be continued for 1 week then starting on , please switch to 200mg once daily. starting , please also start low dose acei (e.g. lisinopril) for your severe chf. you will also need a repeat echo i 2~3 months and follow-up appointment with dr. within 4~8 weeks. you are going to an acute rehabilitation facility for aggressive physical and occupational therapy plus speech therapy. you will also need telemetry to for heart rate monitoring plus daily labs including inr for coumadin dosing. coumadin dose may need to be increased once amiodarone dose decreases plus please continue to monitor tsh while on amiodarone. should you develop chest pain, shortness of breath, dizziness, lightheadedness, severe weakness, worsening leg swelling, difficulties with balance, worsening palpitations or any other symptoms concerning to you, please call your primary care doctor, your cardiologist or go to the nearest emergency room. followup instructions: please follow up with your primary care doctor, dr. , within 2 weeks of discharge from the acute rehab facility in , please call for an appointment. repeat echo in 2~3 months plus follow-up with dr. within 4~8 weeks. please call to reschedule your appt given that the current appointment is too remote. provider: , md phone: date/time: 1:00 neurology ( clinical center floor 8) provider: xray (scc 2) phone: date/time: 9:10 provider: , md phone: date/time: 9:30 provider: , m.d. phone: date/time: 10:00 procedure: venous catheterization, not elsewhere classified other electric countershock of heart diagnoses: other primary cardiomyopathies abnormal coagulation profile coronary atherosclerosis of native coronary artery congestive heart failure, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified cardiac complications, not elsewhere classified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation atrial flutter other b-complex deficiencies other and unspecified hyperlipidemia chronic kidney disease, stage iii (moderate) other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure other specified cardiac dysrhythmias cardiogenic shock osteoporosis, unspecified osteoarthrosis, unspecified whether generalized or localized, site unspecified cerebral embolism with cerebral infarction anticoagulants causing adverse effects in therapeutic use hypovolemia acute on chronic systolic heart failure knee joint replacement aphasia iatrogenic cerebrovascular infarction or hemorrhage cervical spondylosis without myelopathy cardiac rhythm regulators causing adverse effects in therapeutic use other musculoskeletal symptoms referable to limbs personal history of traumatic fracture dysphagia, oral 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Answer: The patient is high likely exposed to