1. Thursday, September 1st, 2011 José Luis González, MD

2. 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.

3. 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.

4. 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

5. 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.

6. CXREKGCBCBMPUA 12345 678910 1112131415 1617181920

10. WBC 10.5 RBC 3.66 Hgb11.0 HCT 31.7 MCV86.7 MCH30.1 MCHC34.8 RDW14.0 PLT521 MPV7.8 Neutrophil 74.8 Lymphocyte10.9 Monocyte13.2 Eosinophil0.1 Basophil0.3 ANC11.2 Abs Lymph1.6 Abs Mono3.1 Abs Eos0.0 Abs Baso0.0

11. Na+ 130 K + 5.2 Cl - 92 CO 2- 27 BUN12 Cr1.14 Glucose83 Ca 2+ 8.8

12. 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

13. Alkaline Phosphatase Total Protein Albumin Bilirubin, total AST ALT

14. PT 14.7 INR 1.14 PTT 36.4

15. UDS Amphetamines negative Barbituratesnegative Cocainepositive Opiatespositive PCPnegative Benzodiazepinesnegative

16. Cell Count: Color: colorless Clarity: clear RBC: 7 WBC: 8 PMNs: 11 Lymphocytes:73 Monocytes:76 Culture: no grown to date

17. 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 2 Fungal Blood Cultures: No Growth to Date x 2

18. negative

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

20. 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.

21. 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.

22. PPD: 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

23. 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.