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: garbled speech major surgical or invasive procedure: splenectomy history of present illness: hpi: the pt is a 83 year-old right-handed woman with a history of hypertension, hld and prior stroke with residual left sided weakness, presenting with garbled speech and right sided weakness. her son reports that he picked her up at her house at ~2pm, and when she got in the car he noted that her speech seemed 'garbled'. he is unable to provide specific examples of things that she said, but notes that she would be speaking at the last few words of a sentence would either drift off, or come out as nonsense words. since her prior stroke he has noticed that she will occasionally do this when tired, but not to this degree. upon arriving to the house he noted that her gait, which is usually unsteady, with a mild degree of circumduction on the left, was worse than usual. when at the house he tried to give her lunch, but it was noted that she was unable to hold a cup or a fork in her right hand, and seemed very clumsy. ems was called, and upon arrival found her to have right sided weakness and impaired speech. she was taken to for further evaluation. of note, 2 weeks prior the patient fell in the bathroom, landing on her left side, resulting in significant bruising on that side. she underwent further imaging for this at , which raised concern for multiple rib fractures, and a possible splenic laceration. at this point she was transferred to for further evaluation. on neuro ros, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. no bowel or bladder incontinence or retention. on general review of systems, the pt denies recent fever or chills. no night sweats or recent weight loss or gain. denies cough, shortness of breath. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rash. past medical history: - htn - hld - s/p stroke 5 years ago with residual left sided weakness and garbled speech when she is tired - hx of renal artery stent social history: lives independently in . family provides her with meals and helps with housework. no etoh, smoked at age 20 but not since, no illicits family history: mother died in her 60s of cad. father died at age , hx of cad. physical exam: vitals: t:96 p:65 r: 16 bp:124/87 sao2: 96% on ra general: 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 pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. significant bruising noted over left flank extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: bruising on left flank neurologic: -mental status: alert, oriented to hospital when given a choice of 3 locations, and can pick from a list. states the day is 'near friday' and cannot name the holiday, however states 'they should get me some handy' when told it is . fumbles for awhile, and then says 'obraka' when asked to name the president. able to name dow forward, but when asked to state backwards says saturday, friday, thursday, then pauses and goes forward from monday. can repeat short words and phrases, as well as 'today is a sunny day in boston' but is completely unable to repeat 'no ifs ands or buts' and states 'if she comes, i will go' when asked to repeat 'if i come, she will go.' could name all objects on the stroke card except for the cactus, which she calls '...hactus ...plant in the west'. could name a thumb, and watch, but not finger or collar. could not name a stethoscope, but when asked what it does, states 'for testing the heart'. could read, however reads 'dearth the earth' instead of 'down to earth'. could show thumb and 2 fingers, but when asked to touch the ear on the opposite side, would consistently touch her nose instead. unable to even register 3 objects. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk on l, 2.5->1.5mm on r. blinks to threat bilaterally. when asked to point to the finger that is moving, keeps reaching out and touching my nose instead. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch. vii: left facial droop viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, increased tone in l upper and lower extremity. left pronator drift. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 4 4 4 4 5 4 5 4 5 5- 5 5 5 5 r 5 5 5 5 5 4 5 5 5 5 5 5 5 5 -sensory: sensory testing not completely reliable, however does seem to have decreased sensation to light touch and temperature in right lower extremity compared to left. -dtrs: tri pat ach l 3 3 3 2 1 r 2 2 2 2 1 plantar response was flexor on right, and extensor on left. -coordination: does not fully cooperate with exam, however does periodically touch my nose w/o dysmetria when attempting to test visual fields. when asked to perform rapid movements, holds her fingers up and says 'tap tap tap' without actually moving her fingers on either side. -gait: deferred. pertinent results: admission labs: 139 | 106 | 22 ---------------< 105 4.6 | 23 | 1.0 9.8 8.8 >-------< 344 29.4 imaging: findings: ct abdomen (): pleural fluid at the base of the left hemithorax has slightly increased in comparison to the prior ct, and probably represents hemothorax. several fractured ribs are again identified at the lower left hemithorax. there is atelectasis of the basilar segments of the left lower lobe. perisplenic fluid has not changed significantly in size since the prior ct. linear areas of low attenuation within the splenic parenchyma are stable, probably representing lacerations. a prominent linear enhancing area at the posteromedial aspect of the spleen (series 2, image 15) is unchanged, and is consistent with a pseudoaneurysm. the splenic artery and splenic vein are patent. there is severe luminal narrowing at the origin of the celiac artery, although the vessel is opacified with iv contrast. this may represent a tight stenosis or complete occlusion with retrograde filling of the celiac artery. the superior mesenteric artery is patent, but contains calcified and noncalcified plaque in its proximal portion causing luminal narrowing (series 2, image 30). bilateral renal artery stents are identified, which are patent. small cortical cysts are identified in both kidneys, which otherwise appear mildly atrophic. no focal parenchymal lesion is seen in the liver. the gallbladder appears unremarkable and there is no intrahepatic or extrahepatic biliary duct dilatation. there is fatty atrophy of the pancreas. the visualized portions of the small and large bowel appear grossly unremarkable. no adrenal mass lesions are seen. impression: 1. no significant change in appearance of the spleen, with prominent perisplenic fluid and a linear enhancing area at the posteromedial aspect consistent with a pseudoaneurysm. multiple rib fractures are again identified. 2. increased pleural fluid in the left hemithorax, consistent with hemothorax. ct head (): non-contrast head ct: study is limited by motion artifact. there is no intracranial hemorrhage or mass effect. there is a large area of hypodensity identified within the posterior left temporal lobe, likely reflecting prior infarct. though no prior imaging studies are available for review, review of careweb notes reveals that this finding has been by report present on prior studies. additional white matter hypodensities are scattered diffusely, with more focal lacunes seen in the right centrum semiovale and left thalamus. this all likely represents the sequelae of prior infarct, with no definite vasogenic edema to suggest acute infarct. the -white matter differentiation in the basal ganglia is preserved. the ventricles, sulci, and cisterns appear mildly prominent, suggesting underlying atrophy. there is no shift of midline structures, and no abnormal extra-axial fluid collection. the bones demonstrate no acute bnormality identified, including no fracture. there are no suspicious lytic or sclerotic osseous lesions. the visualized paranasal sinuses and mastoid air cells are normally aerated. impression: encephalomalacia in the posterior left temporal lobe, likely reflecting prior infarct, with additional white matter disease and thalamic lacune as detailed above reflecting chronic small vessel infarcts. accounting for these underlying changes, there is no definite ct evidence for acute large vascular territory infarction, though if clinically indicated, mri is recommended for its greater sensitivity. cta (): findings: noncontrast ct head: over the 22 hr interval, here has been slight progression with enlargement of the hypoattenuating region within the posterior left temporal extending into that parietal lobe, likely representing evolving early subacute infarction. there is patchy hypoattenuation of the periventricular and deep subcortical white matter, unchanged. the ventricles and cortical sulci are prominent and appropriate in size for the patient's age of 83 years without evidence of mass effect or shift of the normally midline structures. the visualized paranasal sinuses and mastoid air cells are well aerated. cta head: the left vertebral artery is dominant. the right vertebral artery appears to terminate as the pica. there is a 5mm segment of narrowing involving the distal left vertebral artery best seen on series 401b image 45. there is also short-segmental narrowing involving the mid-basilar artery. there is dense atherosclerotic calcification of both cavernous internal carotid arteries without high-grade stenosis. there is diffuse mural irregularity throughout the circle of and proximal branches without evidence of occlusion or flow-limiting stenosis. there is no evidence of aneurysm or arteriovenous malformation involving the intracranial arterial vasculature. cta neck: there is atherosclerotic calcification involving the aortic arch extending into the origins of the great vessels without narrowing. the origins of the great vessels are patent. the vertebral artery origins are patent. the right vertebral artery is diminutive in its entirety, but patent. there is marked medialization of both common and internal carotid arteries, with the left ica crossing the midline. otherwise, the common and external carotid arteries are unremarkable, bilaterally. there is dense atherosclerotic calcification extending from the carotid bifurcation into the proximal right internal carotid artery with approximately 60% narrowing by nascet criteria. there is atherosclerotic calcification at the origin of the left internal carotid artery with approximately 40% stenosis by nascet criteria. cross-sectional analysis of the internal carotid arteries is as follows: on the left: proximal dmin. 3.5 mm; distal dmin. 5.5 mm. on the right: proximal dmin. 2.4 mm; distal dmin. 5.3 mm. there is a moderately large left pleural effusion reaching the apex and a small right pleural effusion. there is smooth thickening of the interlobular septae, likely interstitial edema. there are bilateral hypodense thyroid nodules, measuring up to 1.0 cm on the right and 0.5 cm on the left. the airway is patent. there is no evidence of pathologically enlarged lymph nodes by ct criteria. there are extensive degenerative changes involving the entire cervical spine, with multilevel spinal canal and neural foraminal stenosis, most pronounced at c3-4 and c5-6. impression: 1. evolving left temporoparietal infarction, likely early subacute, over the 22 hour time interval; there is no hemorrhagic conversion. mri may be obtained for further evaluation, if there is no contraindication. 2. moderate sequelae of chronic microvascular ischemic white matter disease. 3. approximately 60% narrowing of the proximal right and approximately 40% narrowing of the proximal left internal carotid artery, by nascet criteria. 4. apparent high-grade narrowing involving the distal left vertebral and mid-basilar artery. no evidence of aneurysm or arteriovenous malformation. 5. multiple thyroid nodules; recommend thyroid ultrasound for further evaluation, if this has not been performed. 6. bilateral pleural effusions, left greater than right. smooth interlobular septal thickening consistent with interstitial pulmonary edema. correlate clinically and with chest radiography. 7. multilevel spinal canal and neural foraminal stenosis. echo (): conclusions the left atrium and right atrium are normal in cavity size. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. left ventricular systolic function is hyperdynamic (ef>75%). no valvular or resting lvot gradient is identified. 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) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a promient fat pad. impression: suboptimal image quality. normal biventricular cavity sizes with preserved regional and hyperdynamic global biventricular systolic function. no significant pericardial effusion. carotid dopplars (): findings: duplex evaluation was performed of bilateral carotid arteries. on the right there is moderate heterogeneous plaque in the ica, eca. on the left there is mild heterogeneous plaque in the ica and mild to moderate homogeneous plaque in the cca . on the right systolic/end diastolic velocities of the ica proximal, mid and distal respectively are, 132/53, 163/58, 33/15, cm/sec. cca peak systolic velocity is 80 cm/sec. eca peak systolic velocity is 156 cm/sec. the ica/cca ratio is 2.0. these findings are consistent with 60-69% stenosis. on the left systolic/end diastolic velocities of the ica proximal, mid and distal respectively are 83/31, 83/28, 71/27, cm/sec. cca peak systolic velocity is 118/32 cm/sec. eca peak systolic velocity is 134 cm/sec. the ica/cca ratio is .70. these findings are consistent with <40% stenosis. there is antegrade right vertebral artery flow. there is antegrade left vertebral artery flow. impression: right ica stenosis 60-69%. left ica stenosis <40%. urine culture (): >100,000 organisms/ml.. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. brief hospital course: ms. is an 83 year-old woman with a history of hypertension, hld and prior stroke with residual left sided weakness, presenting with garbled speech and right sided weakness. patient is rather frontal, limiting exam to some degree, but is notable for left arm and leg weakness in and umn pattern, with increased tone and hyperreflexia. she also has a primarily fluent aphasia with multiple paraphasic errors, and intact repetition for short phrases, but impaired with more complex phrases. hospital course: #splenic laceration: s/p fall two weeks prior to presentation, found to have splenic laceration and hematoma with concern for active extravasation by ct scan. initally, angiography was considered for potential embolization, however patient was hemodynamically stable with stable hematocrit and the decision was made to manage expectantly. pt was able to tolerate po and did not have significant abdominal pain in the first several days of her hospital course. however, with continued concerns for futher neurologic processes, there was a desire to start anticoagulation therapy. given the potential for further bleeding, the surgery team decided to preform a splencetomy on hospital day 3. the procedure was uncomplicated, see op note for more detail. patient recovered well from the operation. staples were removed on post op day 7. #rib fractures: multiple rib fractures were visulaized on intial ct. pain was well controlled throughout hospitalization and did not have difficulty with respirations and did not have an oxygen requirement. #neuro: the patient was initially admitted to the trauma service for evaluation of her splenic laceration. as there was some question whether she had new deficits, vs. recrudescence of her prior stroke, it was recommended that she undergo mri/mra for further evaluation, or at least carotid dopplars if that wasn't possible given her history of a renal artery stent. she had mild renal failure on admission, so cta was not an option. the initial stroke evaluation was deferred, given the primary concern for management of her splenic laceration. overnight from however there was concern for possible worsening of her aphasia. she underwent a nchct which showed the known left parietal-temporal infarct with encephalomalacia, also seen on the head ct on admission. the decision was made to undergo splenectomy on in order to allow for possible anticoagulation. following this, as her renal function had improved, she underwent a cta which showed 60% narrowing of the right carotid and 40% narrowing of the left carotid, which was also observed on carotid dopplars. vascular surgery was consulted, but did not recommend intervention. she had a tte which was suboptimal, but showed no obvious sign of a pfo. she was initially restarted on aspirin and plavix, however later was noted to develop atrial fibrillation on telemetry so was started on a heparin drip. we planned to transition her to coumadin but her refusal of all oral meds prevented this change. she has never taken coumadin during this stay. it was thought that she likely had an old conduction aphasia that she had previously been able to compensate for, which became worse both in the context of blood pressure fluctuation, and acute illness, limiting her abilities to continue to compensate. with that reservation, her ability to communicate has improved over the last week - with patience and by giving her yes/no questions, a reasonable exchange of information can take place. #gi: the patient was initially admitted to the trauma service for management of a splenic laceration obtained in a fall 2 weeks prior. the initial plan had been to follow her conservatively, holding her aspirin and plavix. however, with her worsening aphasia, on the decision was made to undergo splenectomy to allow for anticoagulation if needed. she has done very well post-splenectomy, no complications. #cv: the patient was initially maintained on her home blood pressure regimen of lisinopril, clonidine, hydralazine and metoprolol. however overnight from she was npo for possible surgical intervention, and in that context all of her blood pressure medications were inadvertently held, at which point her systolic blood pressures went up to 200. she was then given all of her blood pressure medications, which briefly dropped her down to 89 systolic. in the context of her worsening aphasia, the clonidine and hydralazine were temporarily held to allow for permissive hypertension. the patient was initially in sinus rhythm, however overnight on she developed atrial fibrillation with rvr, for which she was started on a diltiazem drip. we later tried to transition her to po diltiazem, but she refused oral meds. we have achieved better bp control with a clonidine patch, well tolerated. #id: during her hospitalization she was noted to have a rising wbc count. several urine cultures were sent, growing alpha hemolytic streptococcus. she was started on ampicillin on for a 7 day course, completed on . repeat urine cultures were negative. #fen: post-operatively she was noted to be refusing po intake. she was evaluated by speech and swallow, who found no swallowing difficulties, and noted that this seemed to be primarily volitional. she had a nutrition consult for calorie counts, and the decision was made to support her with iv fluids and allow her time to recover. she gradually, over a week, improved her po intake. at the time of discharge she is approximately taking sufficient calories (calorie count ongoing) and is having good urine output. she is no longer refusing meals, but is taking in less than baseline per her family. #dispo: the family has endorsed a plan to give ms. a further week of trying po medicaions. if she is not making substantial improvement by that time (i.e., taking a majority of her oral medications at all scheduled times), the family will at that time decide on peg placement vs. opting to not treat her hypertension and atrial fibrillation. though ms. is aphasic and her comprehension is variable, we believe she has given clear and emphatic indication that she does not want peg placement. we are not convinced that she has lost competence for this decision, though competence in other realms of care are clearly compromised. medications on admission: - plavix 75mg - asa 325mg - colace 100mg - mvi - lasix 20mg - lisinopril 20mg - clonidine 0.2mg - hydralazine 25mg - metoprolol 50mg - doxazosin 4mg discharge medications: 1. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. insulin lispro 100 unit/ml solution sig: sliding scale subcutaneous qhs and qac. 3. glucagon (human recombinant) 1 mg recon soln sig: one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) nebulization inhalation q6h (every 6 hours) as needed for wheezing . 5. acetaminophen 650 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain, fever. 6. bisacodyl 10 mg suppository sig: suppositorys rectal daily (daily) as needed for constipation. 7. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 8. docusate sodium 50 mg/5 ml liquid sig: one hundred (100) mg po bid (2 times a day). 9. metoprolol tartrate 15 mg iv q6h hold for sbp < 140 or hr < 55 10. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 11. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 12. hydralazine 10 mg iv q6h:prn sbp>180 13. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 14. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 15. clonidine 0.2 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qsun (every sunday). 16. warfarin 5 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 17. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po tid (3 times a day): attempt po route prior to giving iv antihypertensives. 18. heparin (porcine) 10,000 unit/ml solution sig: 1000 (1000) units/hr injection asdir (as directed). 19. metoprolol tartrate 15 mg iv q6h prn for systolics > 170 prn, attempt po meds first hold for sbp < 140 or hr < 55 discharge disposition: extended care facility: for the aged - macu discharge diagnosis: possible small left temporoparietal infarction producing a mixed receptive and expressive aphasia hypertension requiring iv and transdermal medications discharge condition: neurological exam: non-fluent dense aphasia, mixed receptive and expressive with wernike's features dominant. unable to follow multi-step commands. left hemiparesis from remote stroke (roughly 5- throughout l. side, difficult to assess since she is unable to follow commands). left pronator drift. discharge instructions: you were admitted for evaluation of your changed speech and weakness on your right side. following transfer from to , it was recognized that you had multiple rib fractures secondary to a recent fall, and that these fractures had produced a laceration to your spleen. due to ongoing blood loss you required a splenectomy, which was completed without complications. during the first days of your assessment it appears that your area of stroke progressed, meaning that an at-risk area around the site of your stroke progressively lost blood flow, enlarging the size of your stroke and your clinical deficits. your neurological problems have been steady from that point on, suggesting that the damage is completed and should not progress further. over the last week your oral intake of food and liquids has been poor but improving. however, your refusal to take oral medications has forced us to change many of your medications to iv formulations. we have agreed upon a plan with your family that you should have one more week, following transfer to rehab, to be taking a majority of your medications by mouth and continuing to make progress. if this condition is not met, your family will then decide whether to place a peg tube or change your status to comfort measures only and opt to not treat your high blood pressure and atrial fibrillation. you must know that this situation (not taking anti-hypertensives and blood thinners) will markedly increase your likelihood of stroke or heart attack. an oral medication regimen is provided, with option of iv alternatives if she does not take her oral drugs. followup instructions: neurology: provider: , md phone: date/time: 10:30 md, procedure: venous catheterization, not elsewhere classified total splenectomy diagnoses: urinary tract infection, site not specified unspecified essential hypertension occlusion and stenosis of carotid artery without mention of cerebral infarction personal history of noncompliance with medical treatment, presenting hazards to health surgical or other procedure not carried out because of patient's decision occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction cerebral artery occlusion, unspecified with cerebral infarction aphasia home accidents injury to spleen without mention of open wound into cavity, laceration extending into parenchyma closed fracture of six ribs fall resulting in striking against other object streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group a 

Answer: The patient is high likely exposed to