| Foster, Daniel |
| MRN: 100716 | Room: 376 | DOB: 8/10/1974 | Age: 51 | Gender: Male | Allergies: Adhesive allergy (rash) |
| Setting | Adult Medicine Unit | ||
| Scenario | It is currently hospital day #2 and you are standing outside the patient’s room with Dr Miller and the multidisciplinary team. The CSF VDRL has just come back positive from the lab. Dr Miller is confident in her diagnosis of neurosyphilis. | ||
| Admission note taken on 10/19/25 | |||
| CC | headache, light sensitivity, blurry vision, and general “uneasiness” | ||
| HPI | DF was referred to the emergency department (hospital day (HD) #1) by his primary care physician (PCP) for evaluation of his acute symptoms. He presented to his PCP with a mild but persistent headache, light sensitivity, blurry vision, and general “uneasiness.” DF also had experienced chills on the night prior and in the morning. The patient stated that he travels regularly for work, with the most recent trip being 3 days prior in Florida. A CT scan was performed and had no abnormal findings. A lumbar puncture was performed to rule out bacterial meningitis and empiric antibiotics were started. Upon further questioning, the patient confirmed that he did not engage in sexual relations during the last trip. However, he admitted to contracting STDs in the past, for which he received treatment. DF was tested for sexually transmitted infections (STIs) including: gonorrhea, chlamydia, hepatitis B virus, and syphilis. An EKG showed normal sinus rhythm. On HD #2, DF begins to complain of chills, nausea, and “tossing and turning” all night. The cerebrospinal fluid (CSF) showed no growth. The serum VDRL test came back 1:128. A this time a second LP was done with a CSF VDRL and herpes simplex viral DNA PCR being sent for analysis with the standard CSF work up. The CSF VDRL results came back that afternoon as a 1:64 titer. | ||
| PMH |
|
||
| Social History |
|
Family History |
|
| Vaccine History |
|
Surgical History |
|
| Physical Exam |
|
||
| Test Name | 10/20/25 | 10/19/25 | Range |
| Sodium (Na+) | 139 | 141 | 136-145 mEq/L |
| Potassium (K+) | 4.2 | 4.3 | 3.5-5 mEq/L |
| Chloride (Cl-) | 105 | 103 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 23 | 22 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 21 | 22 | 8-20 mg/dL |
| Creatinine | 2.7 | 2.6 | 0.5-1.3 mg/dL |
| Glucose | 107 | 104 | 70-115 mg/dL |
| Hemoglobin A1c | 6.3 | 5.3-7.5 % | |
| Calcium,Total | 9.3 | 9.3 | 8.6-10.2 mg/dL |
| Phosphate | 3.9 | 3.9 | 3-4.5 mg/dL |
| Magnesium | 2.1 | 2.1 | 1.6-2.6 mEq/L |
| Protein, total | 5.6 | 5.5 | 5.5-9 g/dL |
| Albumin | 4.0 | 3.9 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 47 | 46 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 30 | 32 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 175 | 178 | 80-225 units/L |
| Alkaline phosphatase | 82 | 82 | 30-120 units/L |
| Bilirubin, Total | 0.6 | 0.5 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 8.0 | 7.8 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 3.6 | 3.7 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 14.0 | 14.4 | 14-18 g/dL |
| Hematocrit, Male | 38 | 39 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 29 | 29 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 91 | 88 | 76-100 mcm3 |
| Platelets | 350 | 375 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.0 | 0.9 | 0.8-1.2 |
| Prothrombin time (PT) | 10.1 | 10.4 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 30.3 | 30 | 25-35 sec |
| Additional Labs: |
Other (yesterday)
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Cultures: | (collected yesterday)
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Imaging Studies: |
|
| ||||||||||||||||||||||||||||||||||||||||||
| Medication History |
|
| Patient Name: Foster, Daniel Date of Birth: 8/10/1974 Room#: 376 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
|
| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
|||
|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
||||||||
| Medication | 10/20/25 | 10/19/25 |
| Vancomycin 1.5 g IV BID Rate: 300 mL/hr | 08:23 20:31 | |
| Trimethoprim-Sulfamethoxazole 480 mg-2400 mg IV QID Rate: 333 mL/hr | 08:13 12:23 16:46 20:18 | |
| Dexamethasone 14 mg IV QID Rate: 100 mL/hr | 08:27 12:32 16:15 20:47 | |
| Hydrochlorothiazide 12.5 mg PO QD | 08:17 | |
| Acetaminophen 1,000 mg PO Q4H PRN PRN yes, pain (1-5) | 08:19 13:37 22:30 |
| Hospital Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Previous Home Medications | ||||||
| Medication | Instructions | Comments | Continue | Modify | Discontinue | New Rx sent |
| Patient Name: | ||
| Admission Date: | Discharge Date: | Service: |
| Principle Diagnosis on Admission: | ||
| Secondary Diagnosis: | ||
| Allergies: | ||
| Medications ADDED this visit: (begin taking these) |
Medications CHANGED this visit: (modify what you were taking) |
Medications STOPPED this visit: (stop taking these) |
| Final Discharge Medication List | |||||
| Medication/Route/Dosage/Frequency/Duration | Comments | Morning | Afternoon | Evening | Bedtime |
| As Needed Medications | |||||
| Patient Name: Foster, Daniel | Date of Birth: 8/10/1974 | Room: 376 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |