IM7 Case Presentation

정 0 연 F/73

2007313075 손의영

Chief ComplainHeadache

Location : Bilateral occipitalOnset : 1 week agoProdrome : No

Associated symptoms : mild fever, PND

Present Illness2009.01 겨울에 넘어져서 Skull base fracture

dura 찢어지고 뇌척수액 샘2 주간 입원 치료 후 호전

2011.04.16 오른쪽 아래 어금니 충치 발치발치 후 약물 복용 안 함 .이후 모심기 일정 무리하게 진행

Present Illness2011.04.21 Headache with fever 발생

안동 local clinic 에서 manage2011.04.27 증상 지속되어 본원 ER refer

CSF tapping 시행 및 이상 없으나 ,

PND 있어 PNS series 에서 Left maxillary rhinosinusitis 의심되어외래 f/u PO Augmentin 처방 후 퇴실

2011.04.29 04.27 Blood culture 상 Gram (+) Cocci 동정되어 ER 내원

Other HistoriesPast Medical History

HTN(+) DM(–) Hepatitis (–) TB(+, 1980) Allergy(–) Spinal stenosis Op. (2001)

Family History특이소견 없음

Social HistoryOccupation : 어렸을 때부터 농사일 ( 경북 안동 )Alcohol : neverSmoking : never

Review of SystemGeneral weakness / Easy Fatigue ( – / – )Weight change (–)Fever/chill ( + / – )Headache/dizziness ( + / – )Rhinorrhea/ cough / sputum ( – / – / – )Dyspnea (–)Chest pain (–)Palpitation (–)

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

Physical ExamV/S : 2011.04.27 19:07

BP 152/79 mmHg PR 109 /min RR 20 /min BT 37.9℃

G/A Acute ill-looking appearanceMentality alert & well orientationHEENT pinkish conjunctivae, clear sclerae

dehydrated tongue(–)JVP(–) Cervical LNE (– / –)Maxillary sinus tenderness (–)Nuchal rigidity (–)Kernig sign (–), Brudzinski sign (–)

Physical ExamChest symmetric expansion, regular heart beat

no murmur, clear breathing soundAbdomen Soft & Flat

normal bowel soundtenderness / palpable mass (– / –)no shifting dullness

Back no CVATno tenderness

Extremity Peripheral embolic phenomenon (–)

Lab test – 2011.04.29

WBC▲ 10.3 x10³/μLNeut. 60.6% (seg.)Mono.▲10.4%

Hb 12.7 g/dLHct 37.9%

PLT 320,000/μLProtein 6.9 g/ ㎗Albumin 3.7 g/ ㎗Globulin 3.0 g/ ㎗CRP▲ 5.66 mg/dL

AST 31 U/lALT 27 U/lALP▲ 259 U/l

(05.02)

BUN 8.5 mg/dLCr 0.74 mg/dLBUN/Cr 11.5Na 141 mmol/ℓK 4.2 mmol/ℓCl 104 mmol/ℓ

CSF Findings2011.04.27

RBC 50 /mm3

WBC 1 /mm3

Protein 17.9 mg/dLGlucose 70 mg/dL (Serum: 128 mg/dL)

Chest X-ray

내원 당시 (04.27) Follow up (05.02)

Brain CT

PNS

CONCLUSION:Rhinosinusitis  in  left  frontal  and  maxillary  sinuses

Blood culture

Problem List#1. Headache

#2. Fever

#3. bacteremia – Gram positive cocci in cluster

#4. Hypertension

#5. Past TB history

#6. Postnasal drip

Assessment #1, #2, #3

r/o Infective endocarditis

r/o odontogenic rhinosinusitis r/o partially treated meningitis

#4. Hypertension

#5. Past TB history

#6. Postnasal drip

Diagnostic planFor infective endocarditis

Transthoracic echocardiographyTransesophageal echocardiography

Therapeutic plan#3. For Staphylococcus aureus bacteremia

S. aureus 에 대하여 community-acquired onset empirical antibiotics

Infective Endocarditis

Harrison's Internal Medicine 17th Ed. Table 118-4 中

TEE