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: no known allergies / adverse drug reactions attending: chief complaint: garbled speech and left hemiplegia major surgical or invasive procedure: peg tube placement history of present illness: the pt is a 76 year-old woman with htn, hl, previous embolic strokes, atrial fibrillation on asa and clopidogrel, recent pacemaker followed by mi with resultant chf who presents as a transfer from osh for acute onset of garbled speech and left hemiplegia. the patient had been admitted for constipation issues. at 0300 this morning the patient was seen well. at 0330 the patient was found with garbled speech and left hemiplegia. a nchct was done that reportedly did not show any specific findings. the patient was transferred to the osh icu and then transferred here for evaluation for possible neuro interventional procedure. past medical history: -hl -htn -previous strokes - late embolic with hemorrhagic conversion. dx with a-fib at this time and started on pradaxa -stemi - bms placed in lad; subsequent tte : ef was 30% with akinesis of anterior septum/wall, apex, and a -paf, sick sinus syndrome, prolonged qt --> pacemaker placed ; pradaxa stopped prior to pm placement -chronic dependent edema -hx of bleeding stomach ulcer -osteoporosis -recurrent utis -hx diverticulosis -ibs social history: patient had been living with her daughter up until mi in , since which she was in rehab. prior to this stroke, she was able to ambulate with a cane/walker. her two daughters are her hcp. widowed. family history: non-contributory physical exam: physical exam on admission: vitals: t: 97.8 p: 98 r: 19 bp: 111/67 sao2: 98% on 4l nc general: eyes closed, in bed. heent: nc/at, no scleral icterus, mmm neck: supple, no carotid bruits. no nuchal rigidity pulmonary: decreased breath sounds at bases bilaterally cardiac: irreg irreg, nl. s1s2, 2/6 systolic murmur abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: bilateral pitting edema skin: no rashes or lesions noted. neurologic: nih stroke scale score was: 14 1a. level of consciousness: 1 1b. loc question: 0 1c. loc commands: 0 2. best gaze: 2 3. visual fields: 0 4. facial palsy: 2 5a. motor arm, left: 4 5b. motor arm, right: 0 6a. motor leg, left: 4 6b. motor leg, right: 0 7. limb ataxia: 0 8. sensory: 0 9. language: 0 10. dysarthria: 1 11. extinction and neglect: 0 -mental status: alert, oriented x (). able to relate limited history, speaking in word phrases. inattentive, requiring repeated stimulation during interview. intact comprehension. speech was not dysarthric. able to follow both midline and appendicular commands. denies l hand as own. l neglect. r gaze preference. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. no blink to threat on left. iii, iv, vi: l gaze palsy, can overcome with ocrs. limited down vertical gaze. v: decreased facial sensation along left hemiface vii: left facial droop viii: hearing intact to finger-rub bilaterally. ix, x: palate unable to be visualized : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: full strength in right side. left side is flaccid and plegic. -sensory: decreased sensation on left hemibody. intact on right. -dtrs: tri pat ach l 2+ 2+ 2+ 2 1 r 2 2 2 2 1 plantar response flexor on right and extensor on left. -coordination: no dysmetria in rue. -gait: deferred neurologic exam on discharge: -mental status: lethargic, arouses to voice, mostly nods in response to questions but can occasionally provide word responses. inattentive, requires repeated stimulation. comprehension intact, follows some simple commands. +l neglect but identifies left hand as her own. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. iii, iv, vi: r gaze preference but able to cross midline to the left v: decreased facial sensation along left hemiface vii: left lower facial droop viii: hearing intact to voice bilaterally. ix, x: palate unable to be visualized : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: full strength in right side. left hemiplegia with no spontaneous movement observed. increased tone throughout l arm and leg. -sensory: decreased sensation on left hemibody. intact on right. -dtrs: tri pat ach l 2+ 2+ 2+ 2 1 r 2 2 2 2 1 plantar response flexor on right and extensor on left. -coordination: no dysmetria in rue. -gait: deferred pertinent results: 09:30pm ck(cpk)-33 09:30pm ck-mb-3 02:33pm urine color-yellow appear-clear sp ->1.050* 02:33pm urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.0 leuk-sm 02:33pm urine rbc-25* wbc-67* bacteria-none yeast-none epi-0 02:33pm urine wbcclump-mod 10:54am glucose-103* urea n-6 creat-0.9 sodium-141 potassium-3.7 chloride-106 total co2-26 anion gap-13 10:54am estgfr-using this 10:54am alt(sgpt)-23 ast(sgot)-18 ld(ldh)-266* ck(cpk)-34 alk phos-136* tot bili-0.5 10:54am ck-mb-3 ctropnt-0.08* 10:54am albumin-3.1* calcium-8.4 phosphate-3.3 magnesium-1.9 cholest-135 10:54am %hba1c-6.0* eag-126* 10:54am triglycer-103 hdl chol-51 chol/hdl-2.6 ldl(calc)-63 10:54am tsh-4.1 10:54am wbc-8.6 rbc-4.21 hgb-10.4* hct-35.1* mcv-83 mch-24.7* mchc-29.6* rdw-18.0* 10:54am plt count-425 10:54am pt-12.3 ptt-28.2 inr(pt)-1.1 ct/cta/ctp head/neck : impression: 1. occlusion of the right ica at its bifurcation with no evidence of intracranial flow. lack of right internal carotid atheromatous disease or dissection suggests a proximal embolic source. 2. elevated mtt, low cbv, and low cbf in the entire right mca territory, suggesting completed acute infarction in this region. 3. large hypodensities of right parietotemporal and left occipital region regions, compatible with late subacute right mca and left pca infarction. 4. atheromatous plaque of left common carotid bifurcation without significant luminal stenosis. 5. large bilateral dependent pleural effusions with associated adjacent compressive atelectasis. ct head : impression: 1. progressive cytotoxic edema in the right cerebral hemisphere, compatible with evolving right mca infarction. 2. no evidence of hemorrhagic transformation at this time. 3. established left occipital and einferior right frontal infarctions with encephalomalacia. cxr : findings: in comparison with the study of , there is a slight decrease in the diffuse bilateral pulmonary opacifications, most likely reflecting some decrease in pulmonary edema despite lower lung volumes. the possibility of supervening pneumonia would have to be considered in the appropriate clinical setting. cxr : impression: 1. signficantly improved bilateral diffuse pulmonary opacities. 2. stable moderate left-sided pleural effusion and resolved right-sided pleural effusion. video swallow study : findings: video swallow examination was performed in conjunction with the speech and swallow division. multiple consistencies of barium were administered. there was moderate silent aspiration of the nectar and honey-thick barium with significantly delayed cough and swallowing reflexes. there was no aspiration or penetration with pudding, however, there was significant oral residue, but no evidence of pharyngeal residue. ct abdomen without contrast : impression: 1. large hiatal hernia. 2. equivocal perfusion defects in the kidneys, which are of uncertain significance but the possibility of infection cannot be entirely excluded by this study. correlation with clinical factors is recommended. the most distinct abnormality involves the mid to lower pole, where there is suspected volume loss which may suggest longer chronicity, and according the lesion may be due to more chronic scarring. brief hospital course: ms. was transferred from an outside hospital to our neuro icu on . upon arrival to our nicu, approximately 5.5h after the onset of her symptoms, she was awake and answered questions. her eyes were deviated to the right and she had a dense left hemiplegia along with left sided neglect. her examination was consistent with a large right hemispheric mca parietal syndrome. stat ct, ctp, and cta showed bilateral old infarcts in various arterial territories (left occipital & right frontal) and a less defined hypodensity in right parietal region extending into the deep basal ganglia. cta showed occlusive lesion and decreased flow signal in the left right ica/mca. these findings were consistent with new acute/subacute right mca infarct, likely cardioembolic due to af (untreated with oac, recent mi, and low ef). she was not a candidate for endovascular intervention/ia t- established infarction on ct. we discussed her condition with her daughters and confirmed her code status as full. we placed a dobhoff tube for feeding and provided supportive post-stroke care. she was monitored in the icu overnight and as she remained stable was transferred to the floor stroke service on . neuro: her examination has remained largely stable since being transferred to the floor on . she is appearing somewhat more awake, nodding/shaking head to questions, occasionally verbalizing a few words, and following commands. she continues to have a significant left hemiplegia. left-sided neglect is improving. she was initially continued on aspirin and plavix for secondary stroke prevention as well as cardioprotection given her recent stent. per discussion with her outpatient cardiologist dr. , plavix was stopped on (approx 1 month after bare metal stent placement) and she was transitioned to coumadin and aspirin 81mg daily. lipid panel revealed tg 103/hdl 41/ldl 63 and hba1c was 6. she was continued on her home rosuvastatin. blood pressure was initially allowed to autoregulate and she was slowly started back on her home antihypertensives and diuretics. pt, ot, and speech therapy were consulted. she continued to have persistent dysphagia and remained npo despite multiple repeat swallow evaluations. a dobhoff tube was placed for feeding but came out on and was unable to be replaced. peg tube was subsequently placed on . she has been tolerating tube feeds well but remains npo. cv: she was maintained on telemetry monitoring during her admission. she was continued on aspirin and plavix as well as amiodarone, digoxin, and carvedilol. lasix was initially held but was then restarted at her home dose of 40mg daily due to concerns for volume overload with pulmonary edema. her respiratory status improved with diuresis. spironolactone was also restarted on . a tte performed at the outside hospital prior to her transfer revealed ef of 30% and no evidence of a cardioembolic source (although could not fully assess for thrombus). on she was noted to be tachycardic to 120-140's. her pacemaker was interrogated and revealed abnormal sensing. a cxr confirmed rv lead migration. pacemaker settings were adjusted. our cardiology team spoke with the patient's daughters about potentially removing the rv lead but it was decided to hold off as her tachycardia resolved with adjustment of the pacemaker settings. her tachycardia improved once peg was placed and she was started back on her home medications. per discussion with her outpatient cardiologist dr. , plavix was stopped on (approximately 1 month after bare metal stent placement) and she was transitioned to coumadin 5mg daily and aspirin 81mg daily. id: she had one episode of fever to 101 overnight on . cxr was concerning for pulmonary edema as well as potential aspiration pneumonia. ua and cultures were negative, and blood cultures were negative as well. she was started on vanc/zosyn and completed an 8-day course. she remained afebrile throughout the rest of her admission. on she was noted to have some vaginal discharge and was started on miconazole cream for presumed candidiasis. pulm: she was restarted on lasix 40mg daily due to concerns for pulmonary edema on a cxr . her respiratory status improved and repeat cxr showed signficantly improved bilateral diffuse pulmonary opacities. she was continued on lasix and her respiratory status remained stable. spironolactone was also restarted on . endo: she was maintained on finger sticks qid and insulin sliding scale with a goal of normoglycemia. hgba1c was 6. gi/nutrition: she continued to have significant dysphagia and remained npo despite multiple repeat swallow evaluations. a dobhoff was placed and tube feeds were initiated. the dobhoff was lost on and unable to be replaced. per discussion with ms. and her family the decision was made to place a peg tube. surgery was consulted and recommended a ct of her abdomen, which showed a large hiatal hernia. initially it was thought that this may preclude the option of a peg, and the possibility of an open j-tube placement was discussed with the pt and her family. ultimately it was determined that peg placement would be the preferred option if possible. she was taken to the or on and underwent successful placement of a peg tube. she was started on tube feeds on which she has been tolerating well. prophylaxis: she was maintained on subq heparin for dvt prophylaxis. she was maintained on a bowel regimen and a ppi for gi prophylaxis. fall and aspiration precautions were maintained. code status: her daughters and (health care proxies) confirmed her code status as full during this admission. dispo: she was discharged to rehab in good condition on . transitional care issues: she was started on coumadin 5mg daily on . this was decreased to 3mg daily on due to rapidly increasing inr. inr was 2.9 upon discharge. ***coumadin should be held and inr should be rechecked on .*** inr should be closely monitored until stable at goal . she will also need to remain on aspirin 81mg daily. she will need intensive pt and ot as well as speech therapy. nutrition should also be involved for adjustment of her tube feeds. she has a follow-up appointment scheduled with dr. in neurology clinic on at 2:30pm. medications on admission: amiodarone 200mg po daily ampicillin 500mg cap - to be completed for uti aspirin 325mg po daily coreg 3.125mg po bid vitamin b12 1000mcg digoxin 0.125mg tab docusate 100 famotidine 20 ferrous sulfate 325 po daily folic acid 1mg po daily furosemide 40mg po daily lactulose daily lisinopril 2.5mg po daily proctofoam hc rectal foam crestor 40mg po daily spironolactone 12.5mg po daily acetaminophen 650mg po q6hr milk of magnesia 30ml daily prn discharge medications: 1. docusate sodium 50 mg/5 ml liquid sig: one (1) po bid (2 times a day): hold for loose stools. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 3. cyanocobalamin (vitamin b-12) 500 mcg tablet sig: two (2) tablet po daily (daily). 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 5. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 6. acetaminophen 650 mg/20.3 ml solution sig: six y (650) mg po q6h (every 6 hours) as needed for pain. 7. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). 8. insulin regular human 100 unit/ml solution sig: one (1) unit injection asdir (as directed): as per insulin sliding scale. 9. rosuvastatin 20 mg tablet sig: two (2) tablet po daily (daily). 10. senna 8.8 mg/5 ml syrup sig: one (1) tablet po bid (2 times a day): hold for loose stools. 11. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: five (5) ml po daily (daily). 12. miconazole nitrate 2 % cream sig: one (1) appl vaginal hs (at bedtime) for 3 days: through . 13. digoxin 125 mcg tablet sig: one (1) tablet po daily (daily). 14. famotidine 20 mg tablet sig: one (1) tablet po bid (2 times a day). 15. spironolactone 25 mg tablet sig: 0.5 tablet po daily (daily). 16. modafinil 100 mg tablet sig: 0.5 tablet po qam (once a day (in the morning)). 17. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm: ****hold . recheck inr .****. 18. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po once a day. 19. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 20. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed for thrush. discharge disposition: extended care facility: - discharge diagnosis: right mca (middle cerebral artery) stroke pneumonia dysphagia discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. neurologic: pupils equal and reactive, r gaze preference but able to cross midline toward left. +left neglect but recognizes hand as her own. left lower facial droop. left hemiplegia with increased tone in upper and lower extremity, no spontaneous movement. moves right side spontaneously anti-gravity with full strength. left toe upgoing. discharge instructions: dear ms. , you were admitted to on for left sided weakness. you were found to have a stroke in the right side of your brain. your stroke is likely related to your atrial fibrillation, in the context of your recent heart attack and pacemaker placement. per discussion with your cardiologist your plavix was stopped and you were changed to aspirin and coumadin to help reduce your future risk of stroke. you were also treated for pneumonia with iv antibiotics. you were found to have difficulty swallowing due to your stroke. a nasogastric tube was placed initially to provide you with nutrition and medications. as you continued to have difficulty swallowing, a peg (percutaneous endoscopic gastrostomy) tube was placed. you will need intensive pt, ot, and speech therapy after your discharge to regain your strength and hopefully your ability to swallow as well. we made the following changes to your medications: started coumadin 3mg daily (**should be held . inr should be rechecked .**) started modafinil 50mg daily to help increase your alertness and energey level started celexa 20mg daily to help with depression you should continue to take the rest of your medications as prescribed. if you experience any of the below listed danger signs, please call your doctor or go to the nearest emergency department. it was a pleasure taking care of you during your hospital stay. followup instructions: you have the following appointment scheduled with dr. in our stroke clinic: provider: , md phone: date/time: 2:30 sc clinical ctr, neurology unit cc8 (sb) procedure: enteral infusion of concentrated nutritional substances injection or infusion of thrombolytic agent percutaneous [endoscopic] gastrostomy [peg] diagnoses: congestive heart failure, unspecified unspecified essential hypertension atrial fibrillation candidiasis of mouth diaphragmatic hernia without mention of obstruction or gangrene other and unspecified hyperlipidemia pneumonitis due to inhalation of food or vomitus osteoporosis, unspecified late effects of cerebrovascular disease, hemiplegia affecting unspecified side cerebral embolism with cerebral infarction acute on chronic systolic heart failure candidiasis of vulva and vagina acute myocardial infarction of unspecified site, subsequent episode of care other late effects of cerebrovascular disease, dysphagia dysphagia, unspecified 

Answer: The patient is high likely exposed to