IM 7 Case Presentation 0 F73 2007313075 Chief

IM 7 Case Presentation 정 0연 F/73 2007313075 손의영

Chief Complain �Headache �Location : Bilateral occipital �Onset : 1 week ago �Prodrome : No �Associated symptoms : mild fever. N/V. PND

Present Illness � 2011. 04. 21 � 2011. 04. 27 � 2011. 04. 29 Headache with fever 발생 안동 local clinic 에서 manage 증상 지속되어 본원 ER refer CSF tapping 시행 및 이상 없으나, PND 있어 PNS series 에서 Left maxillary rhinosinusitis 의심되어 외래 f/u PO Augmentin 처방 후 퇴실 04. 27 Blood culture 상 Gram (+) Cocci 동정되어 ER 내원

Other Histories �Past Medical History � HTN(+) DM(–) Hepatitis (–) TB(+. 1980) Allergy(–) �Spinal stenosis Op. (2001) �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. 27 19: 07 � BP 152/79 mm. Hg �G/A �Mentality �HEENT PR 109 /min RR 20 /min BT 37. 9℃ Acute ill-looking appearance alert & well orientation pinkish conjunctivae, clear sclerae dehydrated tongue(–) JVP(–) Cervical LNE (– / –) Maxillary sinus tenderness (–) Nuchal rigidity (–) Kernig sign (–), Brudzinski sign (–)

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 x 10³/μL �Neut. 60. 6% (seg. ) �Mono. ▲ 10. 4% �Hb 12. 7 g/d. L �Hct 37. 9% �PLT 320, 000/μL �Protein 6. 9 g/㎗ �Albumin 3. 7 g/㎗ �Globulin 3. 0 g/㎗ �CRP▲ 5. 66 mg/d. L �AST �ALP▲ �BUN �Cr �BUN/Cr �Na �K �Cl 31 U/l 27 U/l 259 U/l (05. 02) 8. 5 mg/d. L 0. 74 mg/d. L 11. 5 141 mmol/ℓ 4. 2 mmol/ℓ 104 mmol/ℓ

CSF Findings � 2011. 04. 27 �RBC �WBC �Protein �Glucose 50 /mm 3 17. 9 mg/d. L 70 mg/d. L (Serum: 128 mg/d. L)

Chest X-ray 내원 당시 (04. 27) Follow up (05. 02)

Brain CT

PNS

Blood culture (2011 -04 -29 14: 52: 33)

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

Assessment �#1, #2, #3 � r/o Infective endocarditis � r/o odontogenic rhinosinusitis � r/o partially treated meningitis #4. #5. #6. Hypertension Past TB history Postnasal drip

Diagnostic plan �For infective endocarditis �Transthoracic echocardiography �Transesophageal echocardiography

Therapeutic plan �#1. S. A 에 대하여 commun onset -> empirical MSSA �Infective Endocarditis – 균 종류에 따른 치료 �Streptococci : Penicillin 내성 정도에 따라 Penicillin G, Ceftriaxone, Vancomycin, Gentamicin 등을 고려 �Enterococci : Penicillin G, Ampicillin, Vancomycin �Staphylococci : Methicillin 내성 정도에 따라 Nafcillin, Cefazolin, Vancomycin 등 Harrison's Internal Medicine 17 th Ed. Table 118 -4

Blood culture > �S. A