| Baker, Jasper |
| MRN: 157691 | Room: 345 | DOB: 4/20/1970 | Age: 55 | Gender: Male | Allergies: Amoxicillin (trouble breathing), Citalopram (GI upset) |
| Setting | Adult Medicine Unit | ||
| Scenario | JB is admitted to a general medical ward and diagnosed with infective endocarditis after meeting 2 of the major Modified Duke criteria. He does not have neurologic or CNS complications and will not be undergoing invasive surgical procedures for this infection. He will be managed medically with antibiotic therapy. He was started on empiric oseltamivir and moxifloxacin upon admission for a presumptive respiratory infection, which has now been ruled out. Today (two days after his admission) the very busy microbiology lab reported the minimum inhibitory concentrations (MIC) without interpretation for the organism growing in JB’s blood culture. The first-year medical resident noticed the lack of interpretation for these MIC values and tried to call the microbiology lab who said that the technologist had left for the day. The medical resident then asks you to review the patient’s report and make recommendations for definitive antibiotic therapy as well as any other suggestions regarding this patient’s care. | ||
| Admission note taken on 10/19/25 | |||
| CC | "I have a fever and chills, my muscles hurt all over, I don’t feel like eating, and I was too weak to get out of bed this morning." | ||
| HPI | JB presented to an express medical clinic complaining of progressive muscle pains, intermittent fevers, and loss of appetite which he described as feeling like “the flu” that have been persistent for the past 3 weeks. He was treated for what was believed to be acute bronchitis and was prescribed doxycycline 100 mg twice daily for 7 days. His symptoms progressed despite taking the doxycycline as prescribed. Two nights ago he became so weak he was unable to get out of bed to go to the bathroom. In the emergency department, JB presented as somnolent but alert and oriented to person, place, and time. Upon further review of his medical history, JB reported that he was treated two months ago for a dental abscess which was surgically drained. He was prescribed an antibiotic to take prior to the procedure; however, he forgot to have this filled. He was given fluid resuscitation for dehydration and acetaminophen for his fever. He felt slightly better but his fevers have persisted after transfer to the General Medicine Service. | ||
| PMH |
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Family History |
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Surgical History |
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| Physical Exam |
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| Test Name | 10/20/25 | 10/19/25 | Range |
| Sodium (Na+) | 134 | 129 | 136-145 mEq/L |
| Potassium (K+) | 3.6 | 3.5 | 3.5-5 mEq/L |
| Chloride (Cl-) | 104 | 104 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 26 | 25 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 17 | 17 | 8-20 mg/dL |
| Creatinine | 0.7 | 0.7 | 0.5-1.3 mg/dL |
| Glucose | 95 | 94 | 70-115 mg/dL |
| Hemoglobin A1c | 5.6 | 5.3-7.5 % | |
| Calcium,Total | 8.5 | 8.2 | 8.6-10.2 mg/dL |
| Phosphate | 3.3 | 3.2 | 3-4.5 mg/dL |
| Magnesium | 1.8 | 1.9 | 1.6-2.6 mEq/L |
| Protein, total | 4.7 | 4.6 | 5.5-9 g/dL |
| Albumin | 2.8 | 2.8 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 20 | 20 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 19 | 18 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 135 | 137 | 80-225 units/L |
| Alkaline phosphatase | 52 | 51 | 30-120 units/L |
| Bilirubin, Total | 0.8 | 0.8 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 16.5 | 17 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 4.2 | 4.2 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 9.0 | 8.9 | 14-18 g/dL |
| Hematocrit, Male | 28.5 | 29.4 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 29 | 29 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 78 | 75 | 76-100 mcm3 |
| Platelets | 115 | 113 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.6 | 1.6 | 0.8-1.2 |
| Prothrombin time (PT) | 14 | 14.1 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 23.3 | 23 | 25-35 sec |
| Additional Labs: |
Other (yesterday)
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| Cultures: | Blood Culture Results (yesterday)
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| Imaging Studies: |
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| Medication History |
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| Patient Name: Baker, Jasper Date of Birth: 4/20/1970 Room#: 345 |
Allergies: |
Immunization History: |
| Community Rx Info: Rx Insurance: |
Social History: |
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| Additional Notes: | ||
STRENGTH DF |
ROUTE FREQ |
DOSE (date/time) |
EFFECTS |
ACTION |
REASON |
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|---|---|---|---|---|---|---|---|---|
| Action Key: C = Continue, D = Discontinue*, H = Hold*, M = Modify* *must provide reason |
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| Medication | 10/20/25 | 10/19/25 |
| Moxifloxacin 400 mg IV QD Rate: 250 mL/hr | 07:44 | 07:38 |
| Oseltamivir 75 mg PO QD | 09:28 | |
| Sodium Chloride 0.9% 75 mL/hr IV continuous infusion | 9:49 | |
| Simvastatin 10 mg PO QD | 21:57 | |
| Aspirin 81 mg PO QD | 09:42 | |
| Sertraline 100 mg PO QD | 09:48 |
| 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: Baker, Jasper | Date of Birth: 4/20/1970 | Room: 345 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |