정 0 연 f/73 2007313075 손의영. chief complain headache location : bilateral occipital onset :...
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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