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IM7 Case Presentation

emiko avatar
emiko
21 diapositives · 334 Views · Aug 31, 2014

This case presentation discusses a 73-year-old female patient who presented with bilateral occipital headache and mild fever that started a week prior. Past medical history includes hypertension and a history of skull base fracture following a fall in 2009. The patient has no significant past surgical procedures apart from spinal stenosis. During the evaluation, blood cultures revealed Gram-positive cocci, raising suspicion for infective endocarditis and odontogenic rhinosinusitis. Further diagnostics and therapeutic plans are outlined for effective management.

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IM7 Case Presentation
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  1. IM7 Case Presentation 정0연 F/73 2007313075 손의영

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

  3. Present Illness • 2009.01 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

  4. Present Illness • 2011.04.21 Headache with fever 발생안동 local clinic 에서 manage • 2011.04.27 증상 지속되어 본원 ER refer CSF tapping 시행 및 이상 없으나, PND 있어 PNS series 에서 Left maxillary rhinosinusitis의심되어외래 f/u PO Augmentin처방 후 퇴실 • 2011.04.29 04.27 Blood culture 상 Gram (+) Cocci동정되어 ER 내원

  5. 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

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

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

  8. Physical Exam • V/S : 2011.04.27 19:07 • BP 152/79 mmHg PR 109 /min RR 20 /min BT 37.9℃ • G/A Acute ill-looking appearance • Mentality alert & well orientation • HEENT pinkish conjunctivae, clear sclerae dehydrated tongue(–) JVP(–) Cervical LNE (– / –) Maxillary sinus tenderness (–)Nuchalrigidity (–)Kernig sign (–), Brudzinski sign (–)

  9. 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 (–)

  10. Lab test – 2011.04.29 • WBC▲ 10.3 x10³/μL • Neut. 60.6% (seg.) • Mono.▲10.4% • Hb 12.7 g/dL • Hct 37.9% • PLT 320,000/μL • Protein 6.9 g/㎗ • Albumin 3.7 g/㎗ • Globulin 3.0 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 • Na 141 mmol/ℓ • K 4.2 mmol/ℓ • Cl 104 mmol/ℓ

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

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

  13. Brain CT

  14. PNS

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

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

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

  18. Diagnostic plan • For infective endocarditis • Transthoracic echocardiography • Transesophageal echocardiography

  19. 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, Gentamicin등을 고려 • Enterococci : Penicillin G, Ampicillin, Vancomycin • Staphylococci : Methicillin내성 정도에 따라Nafcillin, Cefazolin, Vancomycin등 Harrison's Internal Medicine 17th Ed. Table 118-4

  20. Blood culture > • S.A

  21. TEE (이것도 그림 그대로)