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Headache and Fever in a 73-Year-Old Female: A Case Presentation

This case presents a 73-year-old female with a chief complaint of severe headache and mild fever, which onset one week prior. She describes the pain as if being struck in the back of the head. Her medical history includes a previous skull base fracture and hypertension. Recent evaluations showed signs of bacteremia with Gram-positive cocci, leading to differential diagnoses including infective endocarditis and partially treated meningitis. The diagnostic and therapeutic plans involve echocardiography and targeted antibiotics based on blood culture results.

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Headache and Fever in a 73-Year-Old Female: A Case Presentation

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  1. IM7 Case Presentation 정0연 F/73 2007313075 손의영

  2. Chief Complain • Headache • Onset : 1 week ago • Character : 뒤통수를 망치로 가격하는 듯한 • Associated symptoms : mild fever. N/V. PNS

  3. Present Illness • 2010. 겨울에 넘어져서 Skull base fracturedura찢어지고 뇌척수액 샘 2주간 입원 치료 후 호전 • 2011.04.16오른쪽 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 referCSF tapping 시행 및 이상 없으나, PND 있어 PNS series 에서 Lt m. siusitis외래 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 : 2011.04.30 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, clear sclerae dehydrated tongue(–) JVP(–) Cervical LNE (– / –) Maxillary sinus tenderness (–) • : kernig, 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. PNS

  14. Blood culture ( )

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

  16. 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

  17. Diagnostic plan • For infective endocarditis • Transthoracic echocardiography • Transesophagealechocardiography

  18. 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

  19. Blood culture > • S.A

  20. TEE

  21. Therapeutic plan • Meningitis (IDSA guidelines, 2004)

  22. Therapeutic plan • Meningitis (IDSA guidelines, 2004)

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