Morning ReportThursday, September 1st, 2011José Luis González, MD

• CC: productive cough x 1 month

HPI: 44 yo AA homeless male presents with persistent cough productive of yellow sputum for 1 month. He denies shortness of breath, dyspnea on exertion, or chest pain. He admits to having fevers, chills and night sweats 1 day prior to admission.

In addition, he complains of nausea and vomiting for 2 weeks duration. He has no diarrhea or abdominal pain. He complains of headache that began 2 weeks ago as well. He also denies neck rigidity, photophobia, gait instability, muscle weakness or confusion.

HPI continued

• He admits to a history of “Valley Fever” meningitis diagnosed at an outside hospital 2 years ago for which he was treated. At that time, a VP shunt was placed and he has been taking fluconazole since then until 2 weeks ago due to running out.

• He is homeless and lives on the streets. He denies any known sick contacts, and he has had no recent travel outside of Southern California.

• PMH: HTN, h/o cocci meningitis• PSH: VPS Shunt placed in Palm Springs in

2009• FH: father’s history unknown, mother with

hypertension• SH: has been homeless for 5 years, lives on

the streets• Etoh: 1 beer per day x 25 years• Tobacco: 1-2 cigarettes/day x 25 years•Drugs: snorts cocaine, last use was 1 week ago

• Meds: fluconazole 200mg po BID, labetolol 200mg po BID (ran out of meds 2 weeks ago)

• NKDA

• ROS: per HPI

Physical Exam• T 101.8ºF HR 89 RR 19 BP 148/80 pain 0/10 98%RA• Gen: laying in bed, AA&O x 4, in NAD• HEENT: normocephalic w/ non-bulging VP shunt site, anicteric

sclerae, no cervical lymphadenopathy, no oral lesions, dry mucous membranes

• CV: RRR, S1 & S2, no M/R/G• Resp: decreased BS and dullness to percussion at RLB. Diffuse

crackles throughout. No ronchi or wheezing. • Abd: well-healed midline scar, +BS, soft, diffusely tender to

palpation, no rebound, no guarding.• Ext: no clubbing, cyanosis or edema• Neuro: no nuchal rigidity, negative Kernigs and Brudzinski, all CNS

intact, good tone / bulk, strength 5/5 throuhgout. DTRs: 1+ throughout, sensation intact to LT, pinprick, prioprioception, coordination: finger to nose, heal to shin and rapid alternating movements intact, but slow. Gait is normal.

Labs, Studies & Imaging

CXR EKG CBC BMP UA

1 2 3 4 5

6 7 8 9 10

11 12 13 14 15

16 17 18 19 20

EKG

CBC w/ differential

• WBC 10.5• RBC 3.66• Hgb 11.0• HCT 31.7• MCV 86.7• MCH 30.1• MCHC 34.8• RDW 14.0• PLT 521• MPV 7.8

• Neutrophil 74.8• Lymphocyte 10.9• Monocyte 13.2• Eosinophil 0.1• Basophil 0.3• ANC 11.2• Abs Lymph 1.6• Abs Mono 3.1• Abs Eos 0.0• Abs Baso 0.0

BMP• Na+ 130• K+ 5.2• Cl- 92• CO2- 27• BUN 12• Cr 1.14• Glucose 83• Ca2+ 8.8

Urinalysis• Specific Gravity: 1.015 • pH: 7.0

• Protein: * 30 mg/dL• Glucose: NEGATIVE • Ketones: Negative• Bilirubin: Negative• Blood: Small• Urobilinogen: 1.0• Leukocytes: Negative• Nitrite: Negative

Liver FUNction Tests

• Alkaline Phosphatase• Total Protein• Albumin• Bilirubin, total• AST• ALT

Coagulation Profile

•PT 14.7•INR 1.14•PTT 36.4

Urine Drug Screen

• UDS• Amphetamines negative• Barbiturates negative• Cocaine positive• Opiates positive• PCP negative• Benzodiazepines negative

Lumbar PunctureCell Count:Color: colorlessClarity: clearRBC: 7WBC: 8PMNs: 11Lymphocytes: 73Monocytes: 76

Culture: no grown to date

Cultures:Sputum Fungal Culture: - KOH prep: no fungi seen- Culture: No fungus isolated after 3 weeks

Sputum Culture: - 2+ polys, 1+ monos, 3+ epis- 1+ G+ Cocci in clusters, 3+ G+ cocci in chains, 3+ G+ Rods, 1+ G-

diplococci- Cancelled: excessive oral contamination

Blood Cultures: No Growth to Date x 2Fungal Blood Cultures: No Growth to Date x 2

HIV 1&2

negative

CT Head w/o contrast:

No evidence of mass, shift or bleed. Stable size of ventricles compared to 1/21/2011 exam.

Hospital Course: In ED, LP was performed but no fluid was able to be aspirated into syringe. Omaya resivoir was tapped by NSG w/ only 2cc of clear fluid collected.

Pt was given cefepime 2gm IV q8º, Vancomycin 1gm IV q12º, fluconazole 400mg IV q24º. ID was consulted.

Nausea and Vomitting resolved, Headache improved by second day. However, pt continued to complain of productive cough and to spike occasional fevers.

Infectious Disease Recommendations:

Patient reports having run out of daily fluconazole. No e/o superimposed meningitis on top of chronic coccidiodes infection based on history, exam and LP results.

Pt likely with R lower lobe PNA with small effusion likely also cocci associated infection vs less likely community acquired PNA.

Recommend increasing fluconazole to 400mg po BID and discontinuing all other antibiotics. Recommend R lateral decubitis film.

AFBs and PPDPPD:

8/13 negative

AFBs:

8/18: 2+ AF Bacilli

8/23: 3+ AF Bacilli

Culture: There is high probability that this isolate is M. Tuberculosis

Hospital Course Continued

The patient was started on treatment for Tb. Although he remained asymptomatic, his liver enzymes underwent a fivefold increase for which his fluconazole was changed to amphotericin and his pyrazinamide was switched for levaquin.

After approximately 1 week of treatment, the patient eloped during a smoke break.