| Jasper, Lakin |
| MRN: 186707 | Room: 425 | DOB: 9/28/1987 | Age: 38 | Gender: Male | Allergies: No known drug allergies |
| Setting | Adult Medicine Unit | ||
| Scenario | LJ is admitted to the general medical floor based on his clinical presentation. His HIV antigen/antibody test was reactive, and he is now diagnosed with acute HIV infection. Based on his chest radiograph and clinical presentation, the infectious diseases team was concerned for Pneumocystis jiroveci pneumonia (PJP). They ordered an induced sputum and a DFA stain for PJP, which is positive for Pneumocystis jiroveci. The team also asked for a room air arterial oxygen level to determine his degree of hypoxia. On physical exam, white plaques were seen in his oral cavity without any esophageal pain or dysphagia. The infectious diseases physician diagnoses the patient with PJP, acute HIV infection, and oral candidiasis, and has provided counseling on these specific infectious-related issues. Blood cultures are negative at 24 hours and the sputum culture has grown commensal flora. Given the new HIV diagnosis, LJ is worried about compliance with a potential complex antiretroviral regimen.
The team asks you to review the patient’s case and make recommendations for antibiotics, antiretrovirals, and any other suggestions regarding this patient’s care. |
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| Admission note taken on 10/19/25 | |||
| CC | "My breathing has gotten worse over the past week, especially with activity." | ||
| HPI | LJ arrived in the emergency department at 1700 on 11/30/18 via a friend because he believes "his breathing has become very labored." LJ complains of shortness of breath on exertion and subjective fevers. He reports that his symptoms started approximately a week or two ago and have progressively gotten worse. He says he just hasn’t felt like himself over the past month. He also reports having multiple sex partners over the past 18 months. He prefers to not use protection and hasn’t noticed any "signs" of a sexually transmitted infection. He states that he has woken up in the middle of the night with night sweats over the past few weeks, but figured it was just his new roommate "blasting the heat". He presented to an urgent care center about a week ago due to his subjective fevers and shortness of breath. The urgent care provider prescribed him a "Z-Pak" and some steroids for a "respiratory infection". He reports that this did not help his symptoms at all, and he now feels worse. In the ED, ceftriaxone and azithromycin were initiated for a suspected community-acquired pneumonia (CAP). The infectious diseases team was consulted given his history and progressive symptoms. The infectious diseases team was concerned for acute HIV infection and a potential opportunistic infection and ordered the appropriate diagnostic and laboratory tests for a workup. |
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| Social History |
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Family History |
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| Vaccine History |
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Surgical History |
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| Physical Exam |
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| Test Name | 10/19/25 | Range |
| Sodium (Na+) | 135 | 136-145 mEq/L |
| Potassium (K+) | 4.2 | 3.5-5 mEq/L |
| Chloride (Cl-) | 101 | 98-106 mEq/L |
| Bicarbonate (HCO3-) | 20 | 23-28 mEq/L |
| Urea nitrogen (BUN) | 12 | 8-20 mg/dL |
| Creatinine | 0.7 | 0.5-1.3 mg/dL |
| Glucose | 85 | 70-115 mg/dL |
| Hemoglobin A1c | 5.3-7.5 % | |
| Calcium,Total | 8.6 | 8.6-10.2 mg/dL |
| Phosphate | 3.1 | 3-4.5 mg/dL |
| Magnesium | 1.6 | 1.6-2.6 mEq/L |
| Protein, total | 5.7 | 5.5-9 g/dL |
| Albumin | 3.6 | 3.5-5.5 g/dL |
| Aminotransferase,aspartate (AST) | 22 | 10-40 units/L |
| Aminotransferase,alanine (ALT) | 34 | 10-40 units/L |
| Lactic dehydrogenase (LDH) | 761 | 80-225 units/L |
| Alkaline phosphatase | 115 | 30-120 units/L |
| Bilirubin, Total | 1.3 | 0.3-1 mg/dL |
| Leukocytes (WBC) | 5.8 | 4.5-11 x103/mcL |
| Red blood cells (RBC), Male | 4.4 | 3.8-5.1 x108/mcL |
| Hemoglobin, Male | 17 | 14-18 g/dL |
| Hematocrit, Male | 51 | 42-50 % |
| Mean corpuscular hemoglobin (MCH) | 30 | 27-33 picogram |
| Mean corpuscular volume (MCV) | 81 | 76-100 mcm3 |
| Platelets | 130 | 150-450 x103/mcL |
| International normalized ratio (INR) | 1.1 | 0.8-1.2 |
| Prothrombin time (PT) | 12 | 9.5-11.3 sec |
| Partial thromboplastin time,activated (aPTT) | 29 | 25-35 sec |
| Additional Labs: |
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| Medication History |
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| Patient Name: Jasper, Lakin Date of Birth: 9/28/1987 Room#: 425 |
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 | 10/19/25 |
| Ceftriaxone 1 g IV QD Rate: 100 mL/hr | 00:40 |
| Azithromycin 500 mg PO QD | 00:30 |
| Lisinopril 10 mg PO QD | 9:32 |
| Calcium carbonate 500 mg PO BID AC | 6:31 16:41 |
| Fluticasone propionate 50 mcg/spray 100 mcg EN QAM | 9:37 |
| Acetaminophen 500 mg PO Q6H PRN PRN yes, pain (1-6) or fever > 38⁰C |
| 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: Jasper, Lakin | Date of Birth: 9/28/1987 | Room: 425 |
| Medication (name/strength) | Dose | Route | Frequency | Notes |