Date of Admission  01/03/2022   Date of Discharge  01/17/2022   Reason for Hospitalization   facility sent for elevated ammonia levels, pt has hx, wears 2lnc at home.  hx covid from post acute care, bsg w/ ems 152  Hospital Course       Patient is a 67yo woman with a PMHx of cirrhosis 2/2 Hep C, COPD, recurrent UTIs, post-polio syndrome, and multiple recent admissions for decompensated cirrhosis & bacteremia. She was admitted to medicine on 1/3 for AMS, most likely 2/2 hepatic encephalopathy. Found to have Klebsiella growing in her urine culture & Enterococcus faecium bacteremia. Mentation improved drastically with lactulose & rifaximin. ID was consulted for abx guidance. She was started on ertepenem & daptomycin, and ertapenem was discontinued after having completed 5d course for tx of presumed UTI. Given recurrence of bacteremia. Pt underwent TEE on 1/12 which was negative for vegetation. Pt's lactulose was increased due to no BMs for 3 days on the 20g tid dosing. She continued to receive Daptomycin here as she was not agreeable to returning to facility, and due to cost, she would not have been able to return to facility anyway. On 1/16 patient's CK was noted to be elevated at 1,625, so ID was contacted. They recommended to discontinue and switch to linezolid as sensitivities permitted. She was started on linezolid 600mg bid on 1/16, with the last dose to be evening of 1/17. She tolerated the linezolid well, so she was discharged home with last dose to be taken as outpatient. Follow up was ordered with ID and PCP. Additionally, requested Hepatology appointment given Hep C with resultant cirrhosis and she does not have a hepatologist currently, nor has she ever seen one. Discharged home with walker and 24/7 assist by her husband.  Discharge Diagnoses      1. Acute encephalopathy  Enterococcus faecium bacteremia  Recent hx of E. faecalis & E. faecium bacteremia  - ID following (appreciate)    -- TEE negative for vegetation on 1/12 OPAT (outpatient parenteral antimicrobial therapy) instructions:  Antimicrobial(s) and dosing: Daptomycin 10 mg/kg daily Duration of therapy: 2 weeks  Start date: 1/3  Stop date: 1/17 Weekly labs: cbc with auto diff, cmp,  CK,             Please schedule follow-up in ID clinic the week of 1/17 Vascular access: Midline   Remove midline/PICC line by the end of therapy Fax results attention to:  - s/p daptomycin 10mg/kg q24h (1/3-1/16)  - CK 1/16 1,625  - dapto discontinued 2/2 elevation in CK on 1/16. Switched to linezolid 600mg bid for 1/16 & 1/17. Last dose to be taken at bedtime on 1/17, discharged home with 1 tablet po to complete course  - ID appointment requested  Asymptomatic Klebsiella pneumoniae bacteriuria vs. UTI  - s/p Ertapenem 1/3-1/8  Acute Hepatic encephalopathy Cirrhosis 2/2 Hepatitis C Thrombocytopenia  - Plt count 62k on last check  - INR 1  - MELD score 10 - Hep C viral load 11/8: 1.4 million copies. Genotype 1, Phenotype a - CTH & MRI brain: empty sella - AMS resolved with lactulose & rifaximin  - continue lactulose 30g tid (titrated for 3-4 soft stools per day) & rifaximin on discharge  - have been holding home spironolactone & lasix due to AKI, resume after repeat labs show continued improvement in renal function  - requested follow up to establish with Hepatology  - follow up PCP  AKI (resolved)  Likely CKD  - since November 2021, pt's creat has ranged from 1.01 - 2.37  - creat currently 1.00  - follow up with nephro scheduled  COPD  - continue incruse ellipta  - continue duonebs  - prescribed a nebulizer as pt's machine was stolen years ago & she prefers a nebulizer        Orders:   albuterol-ipratropium, 3 mL, Hi-Flow Neb, qid, # 360 mL, Refill(s) 0, Pharmacy:  PHARMACY HOSP, bedside delivery please, 155, cm, 01/04/22 10:45:00, Height (cm), kg, 01/04/22 10:45:00, Weight (kg), 66.8  amLODIPine, 10 mg = 2 Tablet(s), form: Tablet, Oral, Daily, first dose 01/17/22 9:10:00   fluticasone-vilanterol, 1 Inhalation, Inhalation, Daily, # 1 Each, Refill(s) 0, Pharmacy:  PHARMACY  HOSP, 155, cm, 01/04/22 10:45:00, Height (cm), kg, 01/04/22 10:45:00 , Weight (kg), 66.8  furosemide, 40 mg = 1 Tablet(s), Oral, Daily, hold this medication until you see your PCP or hepatologist, # 30 Tablet(s), Refill(s) 0, other  lactulose, 30 g = 45 mL, Oral, tid, titrate for 3-4 soft stools per day. If you've already had 3 bowel movements, hold your next doses for the day, and start again the next day, # 4,050 mL, Refill(s) 0, Pharmacy: PHARMACY HOSP, bedside delivery...  linezolid, 600 mg = 1 Tablet(s), Oral, q12h, # 1 Tablet(s), Refill(s) 0, 01/18/22, Pharmacy: PHARMACY HOSP, last dose is 2100 tonight, would like to dsch. Please misecure with cost for 1 tablet to ensure affordable. Thanks!, 155, cm, 01/04/22 1...  rifAXIMin, 550 mg = 1 Tablet(s), Oral, bid, # 60 Tablet(s), Refill(s) 0, Pharmacy: PHARMACY HOSP, bedside delivery please, 155, cm, 01/04/22 10:45:00 , Height (cm), kg, 01/04/22 10:45:00 , Weight (kg), 66.8  spironolactone, 100 mg = 1 Tablet(s), Oral, Daily, hold this medication until you see your PCP or hepatologist, # 30 Tablet(s), Refill(s) 0, other  traMADol, 50 mg = 1 Tablet(s), Oral, q4h, Scheduled / PRN PRN as needed for pain, DO NOT take tramadol within 3 days of taking linezolid. Can resume on 1/21, # 1 Tablet(s), Refill(s) 0, 01/18/22, other  umeclidinium, 62.5 = mcg 1 Inhalation, Inhalation, Daily, # 1 Each, Refill(s) 0, Pharmacy: PHARMACY HOSP, 155, cm, 01/04/22 10:45:00 , Height (cm), kg, 01/04/22 10:45:00 , Weight (kg), 66.8  Basic Metabolic Panel  CBC with Auto Differential  Comprehensive Metabolic Panel  Creatine Kinase  Follow Up Appt Medicine Gastroenterology  Follow Up Appt Medicine Infectious Disease  Follow Up Appt Primary Care Provider (PCP)  PT   Other Diagnoses   Ongoing  Acute kidney injury  Bacteremia  BMI 38.0-38.9,adult  Chronic hepatitis C with cirrhosis  Degeneration of lumbar or lumbosacral intervertebral disc  Obesity  Post-polio syndrome  Spinal stenosis of lumbar region  Historical  No qualifying data    Consultants   Infectious Disease       Discharge Disposition  Home, with 24/7 assist  Medications  New, Changed, or Refilled Medications  albuterol-ipratropium (albute 3 mL, Hi-Flow Neb, qid, 360 mL, 0 Refill(s)    ergocalciferol (Vitamin D2 1. 50,000 IntUnits, 1 capsule(s), Oral, qMonday, 5 capsule(s), 0 Refill(s)    fluticasone-vilanterol (Breo 1 Inhalation, Inhalation, Daily, 1 Each, 0 Refill(s)    furosemide (Lasix 40 mg) 40 mg, 1 Tablet(s), Oral, Daily, hold this medication until you see your PCP or hepatologist, 30 Tablet(s), 0 Refill(s)  Instructions:hold this medication until you see your PCP or hepatologist  lactulose (lactulose 10 g/15 30 g, 45 mL, Oral, tid, for 30 day(s), titrate for 3-4 soft stools per day. If you've already had 3 bowel movements, hold your next doses for the day, and start again the next day, 4,050 mL, 0 Refill(s)  Instructions:titrate for 3-4 soft stools per day. If you've already had 3 bowel movements, hold your  linezolid (linezolid 600 mg) 600 mg, 1 Tablet(s), Oral, q12h, 1 Tablet(s), 0 Refill(s)    oxyCODONE (oxyCODONE 5 mg) 5 mg, 1 Tablet(s), Oral, q6h, for 3 day(s), PRN: Pain, Breakthrough, 12 Tablet(s), 0 Refill(s)    rifAXIMin (rifAXIMin 550 mg) 550 mg, 1 Tablet(s), Oral, bid, 60 Tablet(s), 0 Refill(s)    spironolactone (spironolacton 100 mg, 1 Tablet(s), Oral, Daily, hold this medication until you see your PCP or hepatologist, 30 Tablet(s), 0 Refill(s)  Instructions:hold this medication until you see your PCP or hepatologist  traMADol (traMADol 50 mg) 50 mg, 1 Tablet(s), Oral, q4h, DO NOT take tramadol within 3 days of taking linezolid. Can resume on 1/21, PRN: as needed for pain, 1 Tablet(s), 0 Refill(s)  Instructions:DO NOT take tramadol within 3 days of taking linezolid. Can resume on 1/21  umeclidinium (Incruse Ellipta 62.5 mcg, 1 Inhalation, Inhalation, Daily, 1 Each, 0 Refill(s)      Medications to be Continued  acetaminophen (acetaminophen 650 mg, 2 Tablet(s), Oral, q4h, not to exceed 3000 mg/day, PRN: as needed for pain, 0 Refill(s) Comments: as needed for pain/fever Instructions:not to exceed 3000 mg/day  amLODIPine (amLODIPine 10 mg) 10 mg, 1 Tablet(s), Oral, Daily    cetirizine (cetirizine 10 mg) 10 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    dicyclomine (dicyclomine 10 m 10 mg, 1 capsule(s), Oral, qid, PRN: stomach pain    melatonin (melatonin 5 mg) 5 mg, 1 Tablet(s), Oral, At Bedtime, PRN: Sleep    ondansetron (ondansetron 4 mg 4 mg, 1 Tablet(s), Oral, q6h, PRN: Nausea/Vomiting, 0 Refill(s)    pantoprazole (pantoprazole 40 40 mg, 1 Tablet(s), Oral, Daily, 30 Tablet(s), 0 Refill(s)    polycarbophil (FiberCon 625 m 1,250 mg, 2 Tablet(s), Oral, Daily, PRN: Diarrhea    polyethylene glycol 3350 (Mir 17 g, Oral, Daily, PRN: Constipation    senna (senna 8.6 mg) 17.2 mg, 2 Tablet(s), Oral, bid, PRN: as needed for constipation, 0 Refill(s)    tamsulosin (tamsulosin 0.4 mg 0.4 mg, 1 capsule(s), Oral, qEvening      Discontinued Medications  pregabalin (Lyrica 25 mg) 25 mg, 1 capsule(s), Oral, tid, 90 capsule(s), 0 Refill(s)       Physical Exam at Discharge  Vitals & Measurements  T: 36.4 °C  TMIN: 36.2 °C  TMAX: 36.4 °C  HR: 83  RR: 18  BP: 146/77  SpO2: 100%      Constitutional: Patient sitting upright in bed in no acute distress. Alert & oriented x4. HEENT: Oral mucosa moist. Conjunctiva without injection. Pulm: Regular respiratory rate & effort. Breath sounds clear in all anterior lung fields. No rales, rhonchi, wheezing. CV: RRR. Grade II/VI systolic murmur heard best at LUSB. GI: Normoactive bowel sounds. Soft, non-tender, non-distended. MSK: moves all extremities. Skin: Warm, dry, intact. Neuro: No focal deficits Psych: Cooperative. Appropriate mood & affect.  Time Spent   38 minutes spent. 50% or greater of time spent counseling and/or coordination of care.   Collaborating physician agreement: Dr      Follow Up Appointments     Follow Up Appt Medicine Gastroenterology, Clinic Name/Phone: Other - see comments, Provider Name: MD, Within 1 Month, Laboratory Tests, Reason for Exam establish, cirrhosis 2/2 Hepatitis C, Comments Hepatology clinic Follow Up Appt Medicine Infectious Disease, Provider Name: MD, Within 3 Days, Laboratory Tests, Reason for Exam f/u enterococcus bacteremia Follow Up Appt Primary Care Provider (PCP), Within 7 Days, Laboratory Tests