1. 정 0 연 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 fracture dura 찢어지고 뇌척수액 샘 2 주간 입원 치료 후 호전 2011.04.16 오른쪽 아래 어금니 충치 발치 발치 후 약물 복용 안 함. 이후 모심기 일정 무리하게 진행

4. Present Illness 2011.04.21Headache with fever 발생 안동 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 rhinosinusitis 의심되어 외래 f/u PO Augmentin 처방 후 퇴실 2011.04.2904.27 Blood culture 상 Gram (+) Cocci 동정되어 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/AAcute ill-looking appearance Mentalityalert & well orientation HEENTpinkish conjunctivae, clear sclerae dehydrated tongue(–) JVP(–) Cervical LNE (– / –) Maxillary sinus tenderness (–) Nuchal rigidity (–) Kernig sign (–), Brudzinski sign (–)

9. 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 ExtremityPeripheral 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% PLT320,000/μL 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/ℓ K4.2 mmol/ℓ Cl 104 mmol/ℓ

11. CSF Findings 2011.04.27 RBC50 /mm 3 WBC1 /mm 3 Protein17.9 mg/dL Glucose70 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 odontogenic rhinosinusitis 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, Gentamicin 등을 고려 Enterococci : Penicillin G, Ampicillin, Vancomycin Staphylococci : Methicillin 내성 정도에 따라 Nafcillin, Cefazolin, Vancomycin 등 Harrison's Internal Medicine 17 th Ed. Table 118-4

20. Blood culture > S.A

21. TEE ( 이것도 그림 그대로 )