IM7 Case Presentation

IM7 Case Presentation 정0연 F/73 2007313075 손의영

Chief Complain • Headache • Onset : 1 week ago • Quality : 뒤통수를 망치로 가격하는 듯한

Present Illness • 1980. Diagnosis of TB Medication 후 완치 판정 • 2001. Diagnosis of Spinal stenosis Operation • 2010. 겨울에 넘어져서 Skull base fracturedura찢어지고 뇌척수액 샘. 2주간 입원 치료 후 호전 • 2011.04.16 오른쪽 아래 어금니 충치 발치발치 후 약물 복용 안 함.이후 모심기 일정 무리하게 진행

Present Illness • 2011.04.21 Headache with fever 발생안동 local clinic 에서 manage • 2011.04.27 증상 지속되어 본원 ER refer Initial V/S, Lab, CSF tapping 시행 PND 및 cough로 PNS CT 상 Acute rhinosinusitis의심되어외래 f/u PO Augmentin처방 후 퇴실 • 2011.04.29 04.27 Blood culture 상 Gram (+) Cocci동정되어 ER 재내원 • 2011.04.30 R/O infective endocarditis로 TTE 시행 followed management 위해 입원함

Other Histories • Past Medical History • HTN(+) DM(–) Hepatitis (–) TB(+) Allergy(–) • Family History • 특이소견 없음 • Social History • Occupation : 어렸을 때부터 농사일 (경북 안동) • Alcohol : never • Smoking : never

Review of System • General weakness / Easy Fatigue ( –/ –) • Weight change (–) • fever/chill ( +/ – ) • Headache/dizziness ( + / – ) • Rhinorrhea/ cough / sputum ( –/ – / –) • Dyspnea (–) • Chest pain (–) • Palpitation (–)

Review of System • anorexia/nausea/vomiting ( – / – / – ) • abdominal pain/discomfort ( – / – ) • constipation/diarrhea ( – / – ) • hematemesis/melena/hematochezia( – / – / – ) • Urinary Sx(–) • Arthralgia(–) • Myalgia(–)

Physical Exam • V/S : 2011.04.30 20:21 • BP 154/72 mmHg PR 88 /min RR 21 /min BT 37.7℃ • G/A Acute ill-looking appearance • Mentality alert & well orientation • HEENT pinkish conjunctivae, anictericsclerae dehydrated tongue(–) JVP(–) Cervical LNE (– / –) Maxillary sinus tenderness (–)

Physical Exam • Chest symmetric expansion, regular heart beat no murmur, clear breathing sound • Abdomen Soft & Flat normal bowel sound tenderness / palpable mass (– / –) no shifting dullness • Back no CVAT no tenderness • Extremity Peripheral embolic phenomenon (–)

Lab test – 2011.04.29 • WBC▲10.3 x10³/μL • Neut.60.6% (seg.) • Mono.▲10.4% • Hb 12.7 g/dL • Hct37.9% • PLT 320,000/μL • Protein6.9 g/㎗ • Albumin3.7 g/㎗ • Globulin3.0 g/㎗ • CRP▲5.66 mg/dL • AST 31 U/l • ALT 27 U/l • ALP▲259 U/l (05.02) • BUN 8.5 mg/dL • Cr 0.74 mg/dL • BUN/Cr 11.5 • Na141 mmol/ℓ • K4.2 mmol/ℓ • Cl104 mmol/ℓ

CSF Findings • 2011.04.27 • RBC 50 /mm3 • WBC 1 /mm3 • Protein 17.9 mg/dL • Glucose 70 mg/dL (Serum: 128 mg/dL)

Chest X-ray 내원 당시 (04.27) Follow up (05.02)

Problem List #1. Headache #2. Fever #3. Blood culture – Gram positive cocci in cluster #4. Hypertension #5. Past TB history #6. Postnasal drip, cough

Initial Impression • #1, #2, #3 • r/o Infective endocarditis • r/o partially treated meningitis • r/o odontogenicrhinosinusitis • #2, #5 • r/o TB recur

Diagnostic plan • For infective endocarditis • Transthoracic echocardiography • Transesophageal echocardiography • For Meningitis • Meningeal irritation sign : kernig, brudzinski sign • CSF tapping

Therapeutic plan • Infective Endocarditis – 균 종류에 따른 치료 • Streptococci : Penicillin 내성 정도에 따라 Penicillin G, Ceftriaxone, Vancomycin, Gentamicin등을 고려 • Enterococci : Penicillin G, Ampicillin, Vancomycin • Staphylococci : Methicillin내성 정도에 따라Nafcillin, Cefazolin, Vancomycin등 Harrison's Internal Medicine 17th Ed. Table 118-4

Therapeutic plan • Meningitis (IDSA guidelines, 2004)

IM7 Case Presentation