You’re overseeing the discharge of a 26-year-old woman from the hospital after she had stayed in the hospital for 3 days for pulmonary embolism. As you prepared her discharge instructions, the floor nurse came and informed you that the patient developed a severe headache, sudden trouble seeing in one eye, dizziness, loss of balance and right sided weakness. Patient reports that her symptoms started suddenly while she was straining at the stool during a bowel movement. You suspected a stroke in this patient and wondered how such a young woman all of a sudden could get a stroke. You glanced over her medical record. She has no history of hypertension, diabetes or prior stroke or transient ischemic attacks. She does not smoke but drinks occasionally. She is sexually active. She works as a bank executive and four days ago, she returned home taking a 17-hour long transcontinental flight after attending a financial conference in Singapore. She developed chest pains 3 days ago, came to the emergency department, eventually diagnosed with pulmonary embolism, admitted and treated for it. Her current medications include a combination pill for contraception, colace for constipation, and a low-molecular weight heparin for the treatment of pulmonary embolism. On physical examination, you notice right sided weakness and normal heart examination. Which of the following is a risk factor for paradoxical emboli-associated cryptogenic stroke in this patient?
