Latent syphilis unspecified Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Esophageal reflux Edema Need for prophylactic vaccination and inoculation against influenza
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
All allergies / adverse drug reactions previously recorded have 
been deleted
 
Attending: ___.
 
Chief Complaint:
rash, leg swelling

 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
Mr. ___ is a ___ with no significant PMH who presents with 
rash and leg swelling. He is visiting from ___ and is 
Portugeuse speaking only. He got Tdap and MMR vaccines on ___ 
prior to coming to the ___ for a visit. Just prior to leaving 
___, he noticed a rash on his neck that was pruritic and 
erythematous. He thought it was irritation from the hot weather 
and came to the ___ during the week of ___. The rash was 
progressing, so he went to ___ urgent care on ___. At that time, 
there was concern for viral xanthem and he was referred to 
dermatology. He saw Dr. ___ on ___ and due to concern for 
syphilis vs. measles-like syndrome, RPR was sent as was measles, 
mumps and rubella serology. Fluocinonide cream was prescribed 
for the leg swelling. Pt presented to the ED due to concern for 
worsening leg swelling. Echo ws negative for an acute 
cardiomyopathy. UA showed trace protein. Patient was admitted 
for further workup and for transaminitis. 

In the ED, initial vitals: 100.8 97 158/89 18 99%  
- Exam notable for: erythematous rash on neck, chest and groin
- Labs notable for: ALT 126, AST 182, RPR + 1:64. Lactate 2.2 

On arrival to the floor, pt reports no discomfort. Rash is 
nonpainful. Denies rhinorrhea, corrhyza or mucosal lesions.

ROS: 11 point ROS is positive per HPI otherwise negative. 
 

 
Past Medical History:
GERD  
 

 
Social History:
___
Family History:
NC
 
Physical Exam:
ADMMISSION:
===========
Vitals- 98.6 87 137/86 16 97% RA  
General- Alert, oriented, no acute distress  
HEENT- Sclerae anicteric, MMM, oropharynx clear  
Neck- supple, JVP not elevated, no LAD  
Lungs- CTAB no wheezes, rales, rhonchi  
CV- RRR, Nl S1, S2, No MRG  
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness 
or guarding, no organomegaly  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro- CNs2-12 intact, motor function grossly normal 
SKIN: erythematous papules on neck, behind ears, over scalp, 
chest and groin. Few scattered papules on back. One crusted 
lesion on R neck. 

DISCHARGE:
==========
Vitals- 99.5, 98.7, 118/59, 93, 16, 99%RA 
General- Alert, oriented, no acute distress  
HEENT- Sclerae anicteric, MMM, oropharynx clear  
Neck- supple, JVP not elevated 
Lungs- CTAB no wheezes, rales, rhonchi  
CV- RRR, Nl S1, S2, No MRG  
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness 
or guarding, no organomegaly  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro- CNs2-12 intact, motor function grossly normal 
SKIN: erythematous papules on neck, behind ears, over scalp, 
chest and groin. Few scattered papules on back. One crusted 
lesion on R neck. 

 
Pertinent Results:
ADMISSION:
==========

___ 02:45PM   ALT(SGPT)-116* AST(SGOT)-96* LD(LDH)-206 ALK 
PHOS-96 TOT BILI-0.4
___ 03:40AM URINE  HOURS-RANDOM
___ 03:40AM URINE  HOURS-RANDOM
___ 03:40AM URINE  UHOLD-HOLD
___ 03:40AM URINE  GR HOLD-HOLD
___ 03:40AM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 03:40AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 
LEUK-NEG
___ 03:40AM URINE  RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE 
EPI-<1
___ 03:40AM URINE  MUCOUS-RARE
___ 02:44AM   LACTATE-2.2* K+-4.1
___ 02:00AM   GLUCOSE-116* UREA N-11 CREAT-0.8 SODIUM-131* 
POTASSIUM-7.3* CHLORIDE-98 TOTAL CO2-23 ANION GAP-17
___ 02:00AM   estGFR-Using this
___ 02:00AM   ALT(SGPT)-126* AST(SGOT)-182* ALK PHOS-93 TOT 
BILI-0.3
___ 02:00AM   LIPASE-37
___ 02:00AM   proBNP-99*
___ 02:00AM   TOT PROT-7.7 ALBUMIN-3.9 GLOBULIN-3.8 
CALCIUM-9.5 PHOSPHATE-4.6* MAGNESIUM-2.0
___ 02:00AM   CRP-41.1*
___ 02:00AM   WBC-10.0 RBC-4.37* HGB-13.4* HCT-41.1 MCV-94 
MCH-30.7 MCHC-32.7 RDW-14.4
___ 02:00AM   NEUTS-73.4* LYMPHS-14.8* MONOS-5.6 EOS-5.4* 
BASOS-0.8
___ 02:00AM   PLT COUNT-315

DISCHARGE:
==========

___ 06:15AM BLOOD WBC-14.2* RBC-4.47* Hgb-13.7* Hct-41.7 
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.3 Plt ___
___ 06:15AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-137 
K-4.3 Cl-101 HCO3-29 AnGap-11
___ 06:15AM BLOOD ALT-108* AST-72* LD(LDH)-192 AlkPhos-105 
TotBili-0.6
___ 06:15AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9
___ 02:00AM BLOOD HCV Ab-NEGATIVE
___ 04:45PM BLOOD HIV Ab-NEGATIVE
___ 02:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE

___ 10:03 am SEROLOGY/BLOOD

   RPR w/check for Prozone (Final ___: 
      REACTIVE. 
      Reference Range: Non-Reactive. 

   QUANTITATIVE RPR (Final ___: 
      REACTIVE AT A TITER OF 1:64. 
      Reference Range: Non-Reactive. 

   TREPONEMAL ANTIBODY TEST (Preliminary):    SENT TO STATE. 

IMAGING:
========
___ CXR
FINDINGS:    
The lungs are well inflated and clear. The cardiomediastinal 
silhouette, hila contours, and pleural surfaces are normal. 
There is no pleural effusion or pneumothorax. 
  
IMPRESSION:  
No evidence of acute cardiopulmonary process. 

 
Brief Hospital Course:
Mr. ___ is a ___ with no significant PMH who presents with 
rash and leg swelling.  

# Syphilis, leg swelling: In the setting of transaminitis, 
positive RPR, concerning for secondary syphilis. Leg swelling 
has unclear relation but began in this setting. He was treated 
with a test dose of penicillin 500mg on ___ and tolerated this 
without difficulty. He received 2.4 million units of penicillin 
IM on the morning of ___, was observed for several hours and 
then discharged home. FTA-abs are still pending at the ___ lab 
at the time of discharge.

# Tachycardia: Had episode of tachycardia to 150s while 
ambulating, asymptomatic. Received 1 L NS with resolution.
 
# GERD: continued omeprazole
  
TRANSITIONAL ISSUES:
-will be returning to ___, but will need follow up to ensure 
resolution of symptoms

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY 
2. Fluocinonide 0.05% Cream 1 Appl TP BID 

 
Discharge Medications:
1. Fluocinonide 0.05% Cream 1 Appl TP BID 
2. Omeprazole 20 mg PO DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: secondary syphilis
Secondary: GERD

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Mr. ___,

It was a pleasure taking care of you during your hospitalization 
at ___. You were admitted with a rash and leg swelling. Your 
rash was found to be caused by syphilis infection. You were 
given a test dose of penicillin and treated with a full dose 
once you tolerated the test. Your leg swelling is of uncertain 
cause, but may be related to the syphilis. You should follow up 
with your doctor in ___. Make sure to use condoms when having 
sex as this will protect you against syphilis and other 
infections.

Wishing you the best,
Your ___ Care Team
 
Followup Instructions:
___

{'rash': ['secondary syphilis'], 'leg swelling': ['secondary syphilis']}