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0 F/73 2007313075

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Chief Complain Headache Onset : 1 week ago Quality :

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Present Illness 1980. Diagnosis of TB Medication 2001. Diagnosis of Spinal stenosis Operation 2010. Skull base fracture dura . 2 2011.04.16 .

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Present Illness 2011.04.21Headache with fever local clinic manage 2011.04.27 ER refer Initial V/S, Lab, CSF tapping PND cough PNS CT Acute rhinosinusitis f/u PO Augmentin 2011.04.2904.27 Blood culture Gram (+) Cocci ER 2011.04.30R/O infective endocarditis TTE followed management

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Other Histories Past Medical History HTN(+) DM() Hepatitis () TB(+) Allergy() Family History Social History Occupation : ( ) Alcohol : never Smoking : never

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

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

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Physical Exam V/S : 2011.04.30 20:21 BP 154/72 mmHg PR 88 /min RR 21 /min BT 37.7 G/AAcute ill-looking appearance Mentalityalert & well orientation HEENTpinkish conjunctivae, anicteric sclerae dehydrated tongue() JVP() Cervical LNE ( / ) Maxillary sinus tenderness ()

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Physical Exam Chestsymmetric expansion, regular heart beat no murmur, clear breathing sound AbdomenSoft & Flat normal bowel sound tenderness / palpable mass ( / ) no shifting dullness Backno CVAT no tenderness Extremity Peripheral embolic phenomenon ()

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Lab test 2011.04.29 WBC10.3 x10/L Neut. 60.6% (seg.) Mono.10.4% Hb 12.7 g/dL Hct 37.9% PLT320,000/L Protein 6.9 g/ Albumin 3.7 g/ Globulin 3.0 g/ CRP 5.66 mg/dL AST31 U/l ALT27 U/l ALP 259 U/l (05.02) BUN8.5 mg/dL Cr 0.74 mg/dL BUN/Cr11.5 Na141 mmol/ K4.2 mmol/ Cl 104 mmol/

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CSF Findings 2011.04.27 RBC50 /mm 3 WBC1 /mm 3 Protein17.9 mg/dL Glucose70 mg/dL (Serum: 128 mg/dL)

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

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

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

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

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Therapeutic plan Infective Endocarditis Streptococci : Penicillin Penicillin G, Ceftriaxone, Vancomycin, Gentamicin Enterococci : Penicillin G, Ampicillin, Vancomycin Staphylococci : Methicillin Nafcillin, Cefazolin, Vancomycin Harrison's Internal Medicine 17 th Ed. Table 118-4

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Therapeutic plan Meningitis (IDSA guidelines, 2004)

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Therapeutic plan Meningitis (IDSA guidelines, 2004)