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: trach dislodgement major surgical or invasive procedure: replacement of trach history of present illness: mr. is a 77 year-old male status post tracheostomy and peg tube placement in , who presents from his nh after dislodging his trach. per ems records, he was saturating well on 100% nrb. a 3.5 cm ett was positioned in stoma prior to transfer. in ed (), t 96.7, hr 103, bp 111/69, rr 24, sat 99% on nrb. tm 100.4 in ed. his tracheostomy (#6.0 portex) was replaced with fiberoptic bronchoscope (following stoma dilation). a cxr was suspicious for a rll pneumonia. while in the ed, he required frequent toileting. for this reason, he was admitted to the icu for further care. past medical history: 1. history of botulism toxin poisoning in 2. anoxic brain injury in setting of trach plugging 3. status post tracheostomy 01/. multiple ed visits for trach replacement (, ). 4. status post peg tube placement 5. hypertension 6. hypercholesterolemia, not on medication 7. bph 8. depression 9. history of mrsa in sputum (? at nh) social history: resident at nh. mulsim. no etoh or tobacco. son lives in pa, phone #: 1- or 1-. family history: nc; no known family history of neurologic disease as per son. physical exam: vitals: t 95.6, bp 1254/66, hr 97, rr 26, sat 100% tm 6l/min gen: in nad, legs flexed up. not interactive. heent: anicteric. neck: jvp not elevated. resp: limited examination, clear to auscultation anteriorly. cvs: rrr. normal s1, s2. no s3, s4. gi: peg tube in place. soft, non-tender. ext: without edema. pertinent results: labs on admission: 08:10am blood wbc-11.1* rbc-4.45*# hgb-12.2* hct-36.8* mcv-83 mch-27.4 mchc-33.1 rdw-15.1 plt ct-375 08:10am blood neuts-71.6* lymphs-18.3 monos-5.6 eos-4.3* baso-0.2 08:10am blood pt-11.4 ptt-24.2 inr(pt)-1.0 08:10am blood glucose-98 urean-32* creat-0.8 na-136 k-4.6 cl-96 hco3-30 angap-15 05:40am blood mg-2.1 08:29am blood lactate-1.3 labs on discharge: 03:40am blood wbc-10.0 rbc-4.68 hgb-12.4* hct-37.8* mcv-81* mch-26.5* mchc-32.8 rdw-15.8* plt ct-444* 03:40am blood glucose-101 urean-18 creat-0.8 na-135 k-5.0 cl-96 hco3-33* angap-11 03:40am blood calcium-9.9 phos-2.3* mg-2.0 microbiology: 11:43 am sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): oropharyngeal flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. gram negative rod(s). moderate growth. gram negative rod #2. sparse growth. gram negative rod #3. sparse growth. bcx x 2 - ng sputum sample x 2- mixed flora _________________________________________ radiology: chest ap - the previously demonstrated tracheostomy has been dislodged in the meantime interval. the upper trachea is slightly distorted and tortuous. there is no overt pneumomediastinum. the heart size is normal. mediastinum has normal contours, width and position. the right lower lobe consolidation is new. the left lung is clear. the pleural surfaces are smooth with no pleural effusion. impression: 1) slightly irregular upper trachea after tracheostomy dislodgement. 2) new right lower lobe consolidations represent pneumonia or aspiration. ct chest without contrast - a tracheostomy was inserted in the interval, with a 2-2.5 cm intratracheal length. the trachea and the right main and right lower lobe bronchus contain a large volume of secretions with subsequent partial atelectasis of right lower lobe. lower lobe bronchiectasis is greater on the right in an area of consolidation that is likely due to atelectasis, but pneumonia cannot be excluded. recurrent aspiration is likely given diffuse distension of the esophagus with air and fluid. multiple centrilobular nodules in the upper lobes are bilateral, more on the right, representing bronchiolitis, could be due to aspiration or infection. pleural effusions demonstrated on the neck ct from have resolved. diffuse calcification of the left apical pleura most probably represents previous granulomatous infection. several mediastinal and hilar lymph nodes, most diffusely calcified, up to 1 cm in subcarinal region, 2a:56. atherosclerotic calcification involves all major coronary arteries. the heart size is normal. there is no pericardial effusion. pleural effusions demonstrated on the neck ct from has been resolved. images of upper abdomen demonstrate percutaneous gastrostomy and additional drainage for unknown purpose. the liver, the spleen, the kidneys, the adrenals, and the pancreas are unremarkable. impression: 1. tracheostomy tube shorter than usually seen. no complications. 2. central airways secretions probably responsibe for right lower lobe atelectasis. 3. mild bibasilar bronchiectasis and upper lobe bronchiolitis most probably due to recurrent aspiration, infection cannot be excluded. 4. mediastinal and hilar lymph nodes, partially calcified, and calcified pleural plaque with bilateral apical scarring could represent previous granulomatous exposure. 5. full length esophageal dilatation, suggest distal obstruction or dysfunction. chest ap -chest: ap portable upright view. the tracheostomy tube appears small, given the caliber of the trachea. previously noted opacities in the right upper, left upper, and right lower lobes are slightly improved. there is no pulmonary edema or pleural effusion. heart and mediastinum appear normal. impression: partial improvement in multifocal consolidations. chest ap . improving right lower lobe and right upper lobe consolidation. there are no pleural effusions or pneumothorax. heart size is normal. the mediastinal and hilar contours are normal. impression: improving right upper lobe and right lower lobe consolidation. tracheostomy in good position. brief hospital course: 77 year-old male with tracheostomy and prior mrsa in sputum, status post tracheostomy change in ed following accidental removal, with increased secretions/low-grade fever and bronchiectasis on repeat ct. 1. respiratory decompensation/hypoxemia pt was admitted and had copious thick secretions. ct scan showed evidence of bibasilar bronchiectasis and upper lobe bronchiolitis most probably due to recurrent aspiration. he was treated with an empiric nine day course of vancomycin and levaquin though cxr looked wholely good. he also had moderate improvement in secretions with atrovent po (not through trach) but a return of variable secretions (often thick) in upper and lower airways since then. we continued pulmonary toilet, and supplemental o2 via trach mask as needed. the possibility of decannulation was entertained but in reviewing records from both rehabilitation and in speaking with son, it was deemed that it was not plausible; this had been attempted in the past though was unsuccessful secondary to copious amounts of secretions. we also considered placing a cuffed trach in this pt to help prevent aspiration of secretions. however, pt would have to go to or as stoma is small and this was decided against. sputum recultured from is growing gnr, unspeciated at this point. on pt was started on cefepime, which he will continue for a 10 day course. it is likely that pt has bronchiectasis, is colonized, and intermittent antibiotics at a scheduled dose. 2. neuro: pt with history of botulism as well as anoxic brain injury from plugged trach. neurology service here was consulted and determined that based on their records, there were no new changes. mental status was variable, with 2 days of somnolence and mildly unresponsive period, but other days of responsive and attempting to communicate but still incoherent for us. keppra was continued. 3. htn- continued metoprolol with good hr/bp control. 4. anemia-hct remained in the 33-37 range. iron supplementation was continued. 5. fen: tube feeds: probalance full strength per nutrition recs. electrolytes were checked and monitored. 6. pt's son (; ) 7. code status- pt was dnr/dni medications on admission: jevity 1.2 at 60 ml/hr, flush with h20 200 ml q 6 hours aranesp 40 mcg qwk celexa 20 mg po qd folate 1 mg po qd zyprexa 5 mg po bid detrol 1 mg po qd colace 100 mg po bid metoprolol 25 mg po bid prevacid 15 mg po bid keppra 500 mg po bid senna 2 tabs po qhs trazodone 50 mg po qhs fleet, dulcolax, tylenol, mom, , haldol prn feso4 ?220 mg po bid ativan 0.5 mg po prn heparin 5000 units sc tid discharge medications: 1. cefepime 2 g piggyback sig: two (2) grams intravenous q12h (every 12 hours) for 10 days: start day . last day . 2. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 3. tolterodine 2 mg tablet sig: one (1) tablet po bid (2 times a day). 4. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 6. lansoprazole 15 mg susp,delayed release for recon sig: one (1) po bid (2 times a day). 7. acetaminophen 160 mg/5 ml solution sig: one (1) po q4-6h (every 4 to 6 hours) as needed. 8. albuterol sulfate 0.083 % solution sig: inhalation q4h (every 4 hours) as needed. 9. ferrous sulfate 300 mg/5 ml liquid sig: one (1) po daily (daily). 10. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 11. senna 8.8 mg/5 ml syrup sig: ten (10) ml po hs (at bedtime). 12. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed. 13. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 14. levetiracetam 100 mg/ml solution sig: one (1) po bid (2 times a day). 15. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po daily (daily). 16. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 17. haloperidol 1 mg iv bid:prn 18. citalopram 20 mg tablet sig: one (1) tablet po once a day. 19. ativan 0.5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. discharge disposition: extended care facility: manor care in lebannon,pa discharge diagnosis: primary diagnosis: tracheostomy tube dislodged tracheobronchitis bronchiectasis secondary diagnoses: anoxic brain injury hypertension hypercholesterolemia, not on medication bph depression discharge condition: stable discharge instructions: please call your doctor for increased volume of secretions, increased thickness or change in color to yellow/green secretions, fever, increased shortness of breath, or tracheostomy dislodgment. followup instructions: -f/u with primary care physician within one week of discharge. -you will need to find a pulmonologist with 1-2 weeks of arrival to nursing home. md procedure: enteral infusion of concentrated nutritional substances other bronchoscopy replacement of tracheostomy tube diagnoses: anemia, unspecified other convulsions acute respiratory failure bronchiectasis without acute exacerbation attention to tracheostomy 

Answer: The patient is high likely exposed to