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: bactrim / vancomycin attending: chief complaint: dyspnea major surgical or invasive procedure: central venous line placement cardiac catheterization swan ganz catheter placement picc placement intubation and extubation arterial line placement history of present illness: mrs. is a 66 year old woman with a history of copd on home o2 2-4lnc, bronchiechtasis with multiple recurrent pneumonias, dchf, a fib not on coumadin, as s/p balloon valvuloplasty who presents with acute shortness of breath and with green/yellow sputum. of note, she was recently admitted to from for acute dchf, acute copd and treated with diuresis and steroids with improvement in her symptoms. she grew pan-resistant pseudamonas but was thought to be a colonizer per id c/s. she was discharged on a long steroid taper, starting at prednisone 5 daily x 1 week, followed by prednisone 2.5 daily x 1 week, then to stop. she was still taking 5 a day when her symtptoms began 3 days prior to presentation. she first noted increasing with heavy green/yellow sputum that was new. she also noted associated dyspnea worsening with the . within 1-2 days prior to presentation she noticed increasing wheezing, orthopnea, mild weight gain (4lbs from 266->270lbs in 24 hours), pedal edema. she also complained of generalized malaise and weakness. due to this constellation of symptoms, she decided to come to the ed for further evaluation. . in the ed, her initial vitals were 99 131/99 100 18 94%3l. she was thought to be in hypercarbic respiratory failure requiring bipap with her initial abg 7.33/79/181. repeat 1 hr after bipap trial was 7.42.60/174 while on 2lnc. she was given 2 doses of albuterol nebulizer without clear improvement in her symptoms, but it did lead to thick yellow sputum clearance. her pressures remained in the 90s/40s while on bipap. after bipap her pressures improved and she was given lasix 40mg iv once for presumed pulmonary edema. she made approximately 300cc of urine after this bolus. she had a foley and 1 20 gauge iv placed. her last set of vitals were 98.6 95 100/50 26 96%2lnc. . in the micu, she continued to have a heavy with heavy secretions and remained mildly dyspneic and mildly tachypneic. she also became hypotensive to the high 70s/40s, which responded to a 250cc bolus. she was started on vancomcyin, meropenem for hap treatment, hydrocortisone for mild copd flare and relative adrenal insufficiency, and kayaxalate for hyperkalemia. bipap was started overnight for her known osa. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss. denies headache, sinus tenderness, rhinorrhea or congestion. denies denies chest pain, chest pressure, palpitations, or focal weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes past medical history: asthma: (since childhood)/copd s/p multiple intubations: 2l nc (since ) at baseline for spo2 91-95%, last pft ~1 yr ago at osh, trach previously suggested but pt refused - osa: sleep study in , recommended cpap but has not tolerated it well, unclear how compliant since last discharge (made some progress on the fit of the mask). of note, overnight oximetry "better than expected" when measured at rehab --> now 100% adherance to cpap at home - bronchiectasis: grows panresistant pseudamonas last admission thought to be colonizer - gerd - anemia (history of gi bleeding many years ago) - leukopenia, long standing, unclear etiology - hyperglycemia when previously on prednisone - diastolic heart failure, lvef > 55%, - aortic stenosis (valve area 1.0-1.2 cm^2) -->ballooned in and again in while intubated for respiratory failure - moderate to severe pulmonary htn, pcwp > 18 - atrial fibrillation (on dilt + beta blocker), no anticoagulation due to questionable history of gi bleeding - acute on chronic respiratory failure with intubation in during which she had balloon valvuloplasty for severe as and started workup for tavi vs surgical avr, was treated for resistant pseudomonas pna social history: -smoking/tobacco: quit smoking in (20 pack years) -etoh: none -illicits: none -lives at/with: sister (a nurse) in , was in rehab until ; has 3 children, 1 died @ 27 in from asthma complication, has a daughter who's a cna. -retired manager of a medical answering services family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. -mother died of cva -father died of lung ca physical exam: on admission: general: alert, oriented, morbidly obese woman in mild-mod resp distress, frequent coughing heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp difficult to discern, no lad lungs: diffuse and heavy ronchi, no rales, wheezes cv: regular rate and rhythm, normal s1 + s2, musical sm at rlsb, no rubs, gallops abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, significant bilateral le edema, tenderness to palpation diffuse, venous changes bilaterally on discharge: 99.2 p95 100-108/50-50's 26 93-100% on 2l nc able to get out of bed to bedside chair extubated, awake, alert, pleasant otherwise unchanged pertinent results: micro: blood cultures negative x1 blood cultures myco/lytic negative x1 b-glucan and aspergillus antigen negative legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. 4:05 am sputum source: expectorated. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): heavy growth commensal respiratory flora. pseudomonas aeruginosa. moderate growth. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | amikacin-------------- =>64 r cefepime-------------- 16 i ceftazidime----------- 16 i ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem------------- 4 s piperacillin/tazo----- s tobramycin------------ =>16 r legionella culture (final ): no legionella isolated. fungal culture (preliminary): yeast. 1:05 pm bronchoalveolar lavage bronchial lavage.. gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. of two colonial morphologies. piperacillin/tazobactam sensitivity testing confirmed by . non-fermenter, not pseudomonas aeruginosa. 10,000-100,000 organisms/ml.. sensitivity testing performed by microscan. amikacin & ceftriaxone >32mcg/ml. gentamicin ,tobramycin & meropenem >8mcg/ml. ceftazidime & cefepime >16mcg/ml. piperacillin >64mcg/ml. ciprofloxacin >2mcg/ml. levofloxacin >4mcg/ml. bactrim (=septra=sulfa x trimeth) <=2/38mcg/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | non-fermenter, not pseudomonas aerugin | | amikacin-------------- =>64 r r cefepime-------------- =>64 r r ceftazidime----------- =>64 r r ceftriaxone----------- r ciprofloxacin--------- =>4 r r gentamicin------------ =>16 r r imipenem-------------- 2 s levofloxacin---------- r meropenem------------- 8 i r piperacillin---------- r piperacillin/tazo----- =>128 r <=8 s tobramycin------------ =>16 r r trimethoprim/sulfa---- s viral culture: r/o cytomegalovirus (preliminary): no cytomegalovirus (cmv) isolated. 1:05 pm rapid respiratory viral screen & culture bronchial lavage.. **final report ** respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. respiratory viral antigen screen (final ): less than 60 columnar epithelial cells;. specimen inadequate for detecting respiratory viral infection by dfa testing. interpret all negative results from this specimen with caution. negative results should not be used to discontinue precautions. refer to respiratory viral culture results. recommend new sample be submitted for confirmation. reported to and read back by - 1334. studies: cxr : impression: little change from prior with continued pulmonary vascular congestion, bibasilar airspace opacities suggestive of atelectasis and probable small left pleural effusion. please note that infection within the lung bases cannot be excluded on this exam. enlargement of the hila bilaterally is suggestive of underlying pulmonary arterial hypertension. cxr : chest: there has been no significant change since the prior chest x-ray of . bibasilar consolidations are again noted with bilateral effusions. appearances are consistent with failure and possibly additional pneumonia. impression: no change. failure and possible pneumonia. ct chest without contrast findings: there is a large nodule in the left lobe of the thyroid gland measuring 3.2 x 2.4 cm. this contains coarse calficiations but is unchanged in appearance compared to the prior study. no supraclavicular lymphadenopathy is seen. moderate atherosclerotic calcification of the aortic arch and coronary arteries is seen. calcification of the mitral valve annulus is also noted. a left-sided subclavian line is in situ with its tip at the distal svc. the heart is moderately enlarged but unchanged compared to the prior study. no axillary or mediastinal lymph nodes which meet the ct size criteria for pathologic enlargement. there is a cluster of small mediastinal lymph nodes in a pretracheal and precarinal position (2:17, 10). these are similar in appearance compared to the prior study. there are bilateral small simple pleural effusions with associated compressive atelectasis. there is near-complete atelectasis of the left lower lobe. assessment for associated infection is limited by the lack of intravenous contrast. the main pulmonary artery measures 4.6 cm, increased in size compared to the prior study when it measured 4.2 cm. in addition the right main pulmonary artery measures 3.4 cm, increased from 2.9 cm and the left main pulmonary artery measures 3.1 cm, increased from 2.7 cm. there is prominence of th intrapulmonary vasculature also consistent with the patient's known pulmonary hypertension. there is persistent bronchiectasis in the right upper lobe (2:21). this has not progressed compared to the prior study. no other focal abnormalities are seen. an endotracheal tube is in situ with its tip approximately 2cm proximal to the carina. the airways are patent to subsegmental level. this study s not tailored for evaluation of the subdiaphragmatic organs, only to note there is a small amount of perihepatic simple free fluid. an ng tube lies with its tip in the stomach. the right adrenal gland is unremarkable. the left adrenal gland is not clearly seen. bony structures: no destructive lytic or sclerotic bony lesions are seen. impression: 1. left lower lobe atelectasis, superimposed infection cannot be excluded. 2. persistent pulmonary hypertension with disease progression. 3. small bilateral pleural effusions not sufficient to account for the left lower lobe atelectasis. 4. trace ascites. 5. cardiomegaly. 6. atherosclerotic calcification of the aortic arch, coronary arteries and mitral valve annulus. cardiac cath comments: 1. resting hemodynamics revealed severely-elevated left-sided filling pressures with a mean wedge pressure of 40mmhg, moderately-elevated right-sided filling pressures with a mean ra pressure of 18, and moderate pulmonary hypertension with a mean pa pressure of 44. the patient's cardiac index was perserved. final diagnosis: 1. severely-elevated biventricular filling pressures. 2. moderate pulmonary hypertension. 3. preserved cardiac output. tee left atrium: no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. right atrium/interatrial septum: dilated ra. a catheter or pacing wire is seen in the ra and extending into the rv. no asd by 2d or color doppler. left ventricle: overall normal lvef (>55%). right ventricle: dilated rv cavity. borderline normal rv systolic function. aorta: simple atheroma in descending aorta. aortic valve: ?# aortic valve leaflets. severely thickened/deformed aortic valve leaflets. significant as is present (not quantified) trace ar. mitral valve: moderate thickening of mitral valve chordae. mild (1+) mr. tricuspid valve: normal tricuspid valve leaflets. moderate tr. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. no tee related complications. the patient appears to be in sinus rhythm. resting tachycardia (hr>100bpm). left pleural effusion. conclusions no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. the right atrium is dilated. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is dilated with borderline normal free wall function. there are simple atheroma in the descending thoracic aorta 35 cm from the incisors. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are severely thickened/deformed. significant aortic stenosis is present (could not be quantified). trace aortic regurgitation is seen. there is moderate thickening of the mitral valve chordae. mild (1+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. impression: significant calcific aortic stenosis (not quantified). preserved left ventricular function. dilated right ventricle with borderline normal systolic function. tte left atrium: mild la enlargement. elongated la. right atrium/interatrial septum: mildly dilated ra. a catheter or pacing wire is seen in the ra and extending into the rv. normal ivc diameter (<=2.1cm) with <50% decrease with sniff (estimated ra pressure (5-10 mmhg). left ventricle: moderate symmetric lvh. normal lv cavity size. overall normal lvef (>55%). no resting lvot gradient. right ventricle: moderately dilated rv cavity. borderline normal rv systolic function. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. aortic valve: ?# aortic valve leaflets. severely thickened/deformed aortic valve leaflets. critical as (area <0.8cm2). mild (1+) ar. mitral valve: mildly thickened mitral valve leaflets. mild mitral annular calcification. no ms. mild (1+) mr. tricuspid valve: tricuspid valve not well visualized. moderate to severe tr. severe pa systolic hypertension. pulmonic valve/pulmonary artery: pulmonic valve not well seen. pericardium: no pericardial effusion. conclusions the left atrium is mildly dilated. the left atrium is elongated. the estimated right atrial pressure is 5-10 mmhg. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the right ventricular cavity is moderately dilated with borderline normal free wall function. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are severely thickened/deformed. there is critical aortic valve stenosis (valve area <0.8cm2). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. moderate to severe tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. impression: critical calcific aortic stenosis with mild aortic regurgitation. moderate left ventricular symmetric hypertrophy with preserved systolic function. moderately dilated rv with borderline systolic function. moderate to severe moderate tricuspid regurgitation with severe pulmonary hypertension. compared with the prior report dated (images reviewed), the degree of aortic stenosis is now quantified and appears to be critical. cxr findings: as compared to the previous radiograph, there is no relevant change. unchanged course and position of the left-sided picc line. unchanged cardiomegaly with signs of moderate pulmonary edema. unchanged bilateral basal opacities, left more than right, that are probably atelectatic in origin. the presence of small pleural effusions cannot be excluded. no newly appeared focal parenchymal abnormalities. cxr left picc line tip is at the level of superior svc. cardiomegaly is present, including severe pulmonary hypertension. the patient continues to be in pulmonary edema. right lower lobe opacity is persistent and might reflect gradual progression of infectious process. bilateral pleural effusions are redemonstrated. admission labs: 07:45pm blood wbc-4.7 rbc-3.35* hgb-9.6* hct-31.4* mcv-94 mch-28.6 mchc-30.5* rdw-17.5* plt ct-170 05:25am blood wbc-4.0 rbc-3.15* hgb-9.1* hct-28.8* mcv-91 mch-28.9 mchc-31.6 rdw-16.8* plt ct-138* 03:35am blood wbc-3.8* rbc-3.11* hgb-9.2* hct-28.4* mcv-91 mch-29.7 mchc-32.6 rdw-16.5* plt ct-139* 06:07am blood wbc-4.5 rbc-3.42* hgb-9.6* hct-31.5* mcv-92 mch-28.2 mchc-30.6* rdw-16.3* plt ct-171 07:45pm blood neuts-76.7* lymphs-16.7* monos-3.8 eos-1.7 baso-1.1 03:53am blood neuts-68.7 lymphs-23.6 monos-6.5 eos-0.8 baso-0.3 02:45pm blood hypochr-2+ anisocy-1+ poiklo-1+ macrocy-1+ microcy-normal polychr-normal ovalocy-1+ 07:45pm blood pt-12.9 ptt-23.5 inr(pt)-1.1 05:25am blood qg6pd-17.1* 03:53am blood ret aut-3.4* 05:25am blood ret aut-3.9* 07:45pm blood glucose-106* urean-55* creat-1.8* na-141 k-6.2* cl-94* hco3-33* angap-20 05:25am blood glucose-117* urean-54* creat-1.5* na-142 k-4.3 cl-96 hco3-38* angap-12 05:03pm blood glucose-101* urean-54* creat-1.6* na-140 k-4.7 cl-94* hco3-38* angap-13 03:35am blood glucose-89 urean-52* creat-1.3* na-141 k-4.5 cl-95* hco3-39* angap-12 05:03pm blood ck-mb-2 ctropnt-0.06* 05:25am blood ck-mb-2 ctropnt-0.08* 07:45pm blood probnp-3366* 05:25am blood ck(cpk)-17* 05:03pm blood ck(cpk)-21* 06:07am blood alt-7 ast-10 ld(ldh)-146 alkphos-68 totbili-0.3 03:53am blood ld(ldh)-122 totbili-0.4 07:45pm blood phos-5.2* mg-2.4 05:25am blood calcium-8.2* phos-5.0* mg-2.4 05:03pm blood calcium-8.1* phos-5.4* mg-2.5 03:53am blood caltibc-342 hapto-130 ferritn-32 trf-263 03:08am blood %hba1c-4.6* eag-85* 07:45pm blood cortsol-12.6 05:25am blood cortsol-27.8* 08:21pm blood po2-181* pco2-79* ph-7.33* caltco2-44* base xs-12 11:35pm blood po2-174* pco2-60* ph-7.42 caltco2-40* base xs-12 comment-green top 04:18pm blood type-art po2-78* pco2-126* ph-7.15* caltco2-46* base xs-9 07:50pm blood glucose-100 na-139 k-5.8* cl-88* calhco3-40* 08:21pm blood lactate-0.8 k-5.5* 04:18pm blood lactate-1.0 12:59am blood o2 sat-96 07:45pm urine color-straw appear-clear sp -1.008 07:45pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-tr discharge labs: 04:25am blood wbc-2.6* rbc-3.24* hgb-8.7* hct-26.9* mcv-83 mch-26.7* mchc-32.2 rdw-15.7* plt ct-135* 03:08am blood wbc-2.9* rbc-3.26* hgb-8.7* hct-27.1* mcv-83 mch-26.6* mchc-31.9 rdw-15.3 plt ct-121* 04:09am blood wbc-2.3* rbc-2.94* hgb-8.1* hct-25.1* mcv-85 mch-27.5 mchc-32.3 rdw-15.2 plt ct-107* 04:39am blood neuts-55.7 lymphs-36.3 monos-6.8 eos-1.0 baso-0.2 03:08am blood pt-13.4 ptt-29.6 inr(pt)-1.1 04:25am blood glucose-91 urean-24* creat-0.7 na-140 k-3.3 cl-95* hco3-39* angap-9 03:08am blood glucose-101* urean-28* creat-0.7 na-143 k-3.6 cl-100 hco3-38* angap-9 05:05pm blood glucose-176* urean-31* creat-0.8 na-142 k-4.6 cl-99 hco3-37* angap-11 04:09am blood glucose-87 urean-31* creat-0.7 na-146* k-3.8 cl-103 hco3-38* angap-9 03:12pm blood glucose-121* urean-34* creat-0.8 na-146* k-4.8 cl-101 hco3-39* angap-11 03:08am blood albumin-3.2* calcium-8.3* phos-3.1 mg-2.0 05:05pm blood calcium-8.5 phos-3.3 mg-2.0 04:08am blood calcium-8.8 phos-3.8 mg-2.1 02:25pm blood type-art temp-37.8 o2 flow-3 po2-82* pco2-67* ph-7.37 caltco2-40* base xs-9 comment-nasal 03:52pm blood type-art peep-5 po2-118* pco2-69* ph-7.35 caltco2-40* base xs-9 intubat-intubated 05:14am blood type-art po2-84* pco2-73* ph-7.36 caltco2-43* base xs-11 11:09pm blood type-art po2-141* pco2-75* ph-7.35 caltco2-43* base xs-12 brief hospital course: ms. is a 66 year old woman with a history of copd on home o2 2-4lnc, bronchiechtasis with multiple recurrent pneumonias, diastolic heart failure, atrial fib not on coumadin, aortic stenosis s/p balloon valvuloplasty who presents with acute shortness of breath and productive . 1. respiratory failure: patient presented initially to the icu with clinical and abg evidence of hypercarbic respiratory failure that improved with bipap however ultimately she necessitated intubation. etiology was ? multifactorial including hcap (has history of mutliple recurrent pna's, and both sputum and bal grew out a resistant pseudomonas, see below), pulmonary edema from severe as (see below) and uncontrolled atrial fibrillation), and copd exacerbation. she was treated with iv diuresis and was about 13l negative through los; this was occasionally limited by low blood pressures. she was treated with bronchodilators and steroids, which are currently being weaned off (currently at 20 mg daily, switch to 10 mg daily on for 3 days, and should go down to 5mg indefinitely thereafter until pulmonology f/u. of note, pt is on dapsone for pcp prophylaxis which could be stopped once pt is weaned down to 5mg daily prednisone. most importantly, while intubated pt had tee (55%, significant calcific as, dilated rv with borderline systolic fxn, 1+ mr, 2+ tr) and tte (65-70%, critical as, mild ar, rv as above, 3+ tr, severe pulmhtn -> as now critical) and pt then underwent cardiac cathterization which confirmed severe as. swan ganz catheter was placed which showed pcwp's in the 40's, and pap 60/40, at which point pt was started on iv lasix gtt guided by swan. she then underwent aortic valvuloplasty which did improve her transaortic gradient from mid 50's to low 30's. she was diuresed with iv lasix gtt and was 13l negative by discharge and last measured pcwp was 14. she was also given 3d of acetazolamide for elevated hco3. pt was evaluated by cardiology and csurg for evaluated of aortic valve replacement vs research protocol transarterial aortic valve replacement. this workup was ongoing and pt has follow up scheduled for with csurg, dr. . pt was eventually weaned from ventilator and extubated without difficulty. she was weaned down to 2l nc by discharge, and should receive bipap at night. her lasix gtt was off by discharge however she was discharged just before transitioning her to po diuresis which she was taking before admission (60 mg in the am and 20 mg in the pm, and 50 mg daily spironolactone). she was placed back on torsemide prior to discharge. patient will need daily evaluation of fluid status with goal for further diuresis of 1l if bp/hr tolerate and patient not symptomatic. 2. pseudomonas aeruginosa pna: id consulted, unclear if this was colonization vs active pna, however given pt with acute on chronic respiratory failure, id was consulted and recommended treatment with a 14d course of merrem (was intermediate to merrem and resistant to basically everything else). her last dose of merrem should be around 8pm of which will be given at ltac. she was also empirically treated with a course of vancomycin until her wbc count and plts began to drop; at which point this was stopped and only continued on meropenem without any change in clincal status. a 14 day course of meropenem was completed at the recommendation of id. 3. hypotension: initially during presentation; this responded with ivf's. this was early in her course and not further clinically relevant, she was never on pressors. 4. acute on chronic renal failure: cr 1.8 on admission, up from baseline of 1.2-1.3. unclear etiology, possibly due to poor forward flow from severe as. this improved slowly with diuresis and pt's cr was 0.7-0.8 by discharge. 5. atrial fibrillation: rate well controlled not on anticoagulation bleed history. she was noted to have rapid ventricular rate, and was initially on diltiazem gtt that was transition to oral diltiazem which provided good rate control and should be continued. continued on asa 325mg daily. however, she continued to have fast rates, requiring dilt gtt. 6. osa: reports 100% adherence. she was given nocturnal bipap after extubation. 7. leukopenia: this has been previously noted, with heme onc consultation note in . her wbc 4.7 on admission decreased to trough of 1.5 which was thought possibly due to vancomycin, and so this was stopped without any clinical deterioration and vancomycin was added to her allergy list for ? leukopenia and thrombocytopenia. 8. anemia: hct 31.4 on admission trended down through admission to 26.9 on discharge. she was not transfused. iron studies consistent with iron deficiency anemia however supplementation was deferred to outpatient providers. of note patient had heme-positive stool throughout admission. 9. thrombocytopenia: plts 170 on admission, trended down to 135 through admission, possibly also thought due to vancomycin. on discharge, plts remained 135. 10. follow up issues: she will need to follow up with cardiology (dr. ), csurg (dr. , pulmonology (has not seen in 1.5 yrs due to cancelling appts), sleep medicine (dr. ) medications on admission: 1. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po bid (2 times a day). 2. 60 mg tablet sig: one (1) tablet po once a day. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 5. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 8. prednisone 5 mg tablet sig: one (1) tablet po daily (daily) for 7 days. :*7 tablet(s)* refills:*0* 9. prednisone 2.5 mg tablet sig: one (1) tablet po once a day: until you follow-up with your new lung doctor. :*30 tablet(s)* refills:*0* 10. combivent 18-103 mcg/actuation aerosol sig: two (2) puffs inhalation four times a day. 11. diltiazem hcl 180 mg capsule, extended release sig: one (1) capsule, extended release po bid (2 times a day). 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 13. torsemide 20 mg tablet sig: three (3) tablet po qam (once a day (in the morning)). 14. torsemide 20 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 15. spironolactone 50 mg tablet sig: one (1) tablet po once a day. 16. guaifenesin 600 mg tablet extended release sig: one (1) tablet extended release po twice a day. discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: please do not exceed 4gm in 24 hours. 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day): this is for ppx while in bed and in the hospital. 4. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 5. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 6. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 7. calcium carbonate 200 mg calcium (500 mg) tablet, chewable sig: two (2) tablet, chewable po daily (daily). 8. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 9. dapsone 100 mg tablet sig: one (1) tablet po daily (daily) for until doses: this is for pcp prophylaxis until prednisone is at 5 mg per day then okay to stop. 10. insulin lispro 100 unit/ml solution sig: one (1) injection as per ss subcutaneous asdir (as directed): until stop high doses of prednisone. 11. diltiazem hcl 60 mg tablet sig: one (1) tablet po tid (3 times a day): please hold for hr<60. 12. prednisone 20 mg tablet sig: one (1) tablet po daily (daily) for 1 doses: last day on (on prednisone ). 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 15. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia: please hold for sedation and rr<12. 16. spiriva with handihaler 18 mcg capsule, w/inhalation device sig: one (1) capsule inhalation once a day. 17. albuterol sulfate 0.63 mg/3 ml solution for nebulization sig: one (1) neb inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. sodium chloride 0.9 % solution sig: three (3) ml topical q8h (every 8 hours) as needed for line flush. 19. meropenem 1 gram recon soln sig: one (1) recon soln intravenous q8h (every 8 hours) for 1 days: last day of meropenem is in the evening . 20. prednisone 10 mg tablet sig: one (1) tablet po once a day for 3 days: start on - for a total of 3 days. then decrease to 5mg qday. 21. prednisone 5 mg tablet sig: one (1) tablet po once a day: start on . 22. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 23. spironolactone 50 mg tablet sig: one (1) tablet po once a day: start on - hold for sbp<95. 24. torsemide 20 mg tablet sig: three (3) tablet po once a day: qam and hold for sbp<95. 25. torsemide 20 mg tablet sig: one (1) tablet po at bedtime: please hold for sbp<95. 26. folic acid 1 mg tablet sig: one (1) tablet po once a day. 27. iron 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: hospital for continuing medical care - ( center) discharge diagnosis: primary: - pseudomonas pna - dchf - as, s/p balloon valvuloplasty - copd exacerbation - pulmonary htn secondary: - acute renal failure - a-fib discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with max assistance (pt has been in bed in the icu for several days. was not able to walk this am.) discharge instructions: dear mrs. . it was a pleasure taking care of you. you came in to for increase in sob and respiratory distress. you had to be intubated (have a tube placed to help you breath). your respiratory failure was thought to be due to numerous causes: copd, heart failure, valve stenosis and pseudomonas pneumonia. you were treated for all of these with antibiotics for the pneumonia, iv lasix (diuretics) for your heart failure and you also had a balloon valvuloplasty for your aortic valve stenosis. you are also in the process of being evaluated by cardio-thoracic surgery for possible valve replacement surgery. you have done well and you were able to be extubated with no complications. you are now breathing more comfortable on liters of oxygen via nasal canula. you will need to have follow-up appointments with the cardio-thoracic surgeon and pulmonologist as listed below. the following changes were made to your medications: - meropenem 1000 mg iv every 8 hours (last dose tonight on ) - restart torsimide home dose 60mg every am and 20mg every pm, start tomorrow and adjust as needed - spirolactone 50mg orally daily - dapsone until prednisone is down to 5mg daily then stop - diltiazem changed from 240mg extended release daily to 60 mg po/ng tid (it may be increase as tolerated) - start on insulin, humolog sliding scale while on prednisone - prednisone 20mg orally until , then decrease to 10mg for 3 days (from ) and 5mg daily (from ) weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: cardiac surgery when: tuesday at 3:00 pm with: , md building: lm campus: west best parking: garage department: adult specialties, pulmonologist when: wednesday at 4:20 pm with: , md building: (, ma) campus: off campus best parking: parking on site department: adult specialties when: thursday at 3:30 pm with: , md building: (, ma) campus: off campus best parking: free parking on site md procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more combined right and left heart cardiac catheterization diagnostic ultrasound of heart closed [endoscopic] biopsy of bronchus pulmonary artery wedge monitoring right heart cardiac catheterization percutaneous balloon valvuloplasty diagnoses: hyperpotassemia obstructive sleep apnea (adult)(pediatric) congestive heart failure, unspecified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified acute on chronic diastolic heart failure aortic valve disorders other chronic pulmonary heart diseases chronic kidney disease, unspecified acute and chronic respiratory failure pneumonia due to pseudomonas alkalosis blood in stool morbid obesity chronic obstructive asthma with (acute) exacerbation hyperosmolality and/or hypernatremia other specified antibiotics causing adverse effects in therapeutic use bronchiectasis without acute exacerbation tricuspid valve disorders, specified as nonrheumatic other lymphedema 

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