1. Case Presentation
PK 1조 :: 조재완

2. 주소 (chief complaints)
열이 심해졌어요.
Onset:2wks ago
Aggravation:2days ago

3. 현병력 (present illness)
07년 11월 allergy work up 시행하여 asthma, allergic rhinitis로 본원 외래 F/U하던 환아로 08년 04월 이후 F/U loss 되었으며 입원 2주전 열감, 코막힘 증상있어 local에서 처방받고 약 먹었으나 호전의 기미를 보이던 중 하루 전 오전 9시경 부터 열, 기침 심해지고 귀 아픔을 호소하며 자면서 숨쉬기 힘들어하여 응급실 통해 입원함.

4. 과거력 (past history) 출생력: 분만 C/S, 재태 32주 출생 체중: 1.79kg (P<3%)
Vaccination:
B형 간염(3회), bCG(+), DPT(3회), 수두(+), MMR(2회) 소아마비(3회), Influenza(08년10월)
Known Asthma, Allergic rhinitis(unspecified)
IgE IU/ml, D1 class2, D2 class2
Atopic dermatitis (-)
Chronic sinusitis

5. 가족력 (family history) AD (-), AR (-), Asthma (-)
Father : Allergy (Urticaria)
Mother : Contact dermatitis

6. 계통적 병력 (review of system)
Fever(+) : 2주전부터 있다 하루 전 agg
Cough/Sputum/Rhinorrhea (+/+/+)
Poor oral intake (+), Dec activity (+)
Otalgia (+), Nasal obstruction (+)
Tachypnea (+), Cyanosis (-), Wheezy breath (+)
Nausea/Vomiting/Diarrhea/Constipation (-/-/-/-)

7. 진찰 소견 (physical exam) G/A : acute ill-looking appearance
V/S :
G/M : weight 17kg (P=75%)
[HEENT]
Conjunctiva: not anemic
TM injection (+/+), bulging (+/+), effusion (-/+)
Throat injection (+), PTH (+, Grade 2 w/o exudates)
Cervical enlargement (-)
Facial tenderness (+)

8. 진찰 소견 (physical exam) [Chest] [Abdomen] Symmetric expansion (+)
Chest retraction (+)
Heart beat regularity : regular
Presence or absence of murmur : heart beat w/o murmur
Quality of breath sound: coarse
Presence or absence of crackle : crackle at inspiration
Character and location of crackle : on both lung field
Presence or absence of wheezing : wheezing at expiration
Character of wheezing : m-p on both lung field
[Abdomen]
Active bowel sound : normo
Hepatosplenomegaly (-)
Palpable mass (-)

9. Problem list Know asthma, AR Fever Cough Sputum Rhinorrhea
Nasal obstuction
Otalgia
Wheezy breath
Tachypnea
TM injection, bulging, effusion
Breath sound with crackle, wheezing

10. Problem list Date # Active Inactive 09.04.14 1 Asthma 2
Allergic rhinitis 3
Chronic sinusitis 4
Fever, Cough, Sputum, Rhinorrhea 5
Wheezy breath sound, Tachypnea 6
Fever, Otalgia, TM P/E → AOM

11. Impression Known Asthma, AR S/P Chronic sinusitis Acute otitis media
R/O Pneumonia
R/O Asthma attack

12. 초기 계획 (initial plan)
#1. Asthma : F/U loss 기간 동안의 임상양상과 치료력 조사, 환아 나이(3세)에 맞는 천식 재평가
#2. Allergic rhinitis : 과거에 하지 못한 Skin prick test를 통한 반응 검사
#3. Chronic sinusitis : PNS series로 현 상태에 대한 재평가

13. 초기 계획 (initial plan) #4. Fever, Cough, Sputum, Rhinorrhea
R/O pneumoniae : 진단을 위해 Routine lab, Blood culture, CXR을 시행하고 Emperical Antibiotics, Fluid therapy, Antipyretics를 사용하여 증상을 조절한다. BT 2시간, V/S 6시간 단위로 check한다.

14. 초기 계획 (initial plan) #5. Wheezy breath sound, tachypnea
R/O pneumoniae : #4. 참조
R/O Asthma attack : #1. 참조, 속효성 b2-agonist를 사용하고 Steroid사용을 고려한다. RR, SO2를 monitoring 하면서 Nasal O2 inhalation을 추가한다.

15. 초기 계획 (initial plan) #6. Acute otitis media
Antibiotics를 사용하며 경과를 관찰하며 수술여부를 판정

16. BT, RR, 02 saturation monitoring
Date
Time BT RR O2 비고
0414
03:00
39.8 66
93%
Maxibupen
O2 inhal
04:00 52
98%
07:00
40.5 48
99%
10:00
38.2 44
100%
10:45
39.7
13:00
37.6
15:55
39.3
17:40
37.5
20:20
37.8
21:45
38.7
0415
00:30
37.0
02:50 40
05:40 32
06:40
38.8
08:20
37.4
Chilling
Date
Time BT RR O2 비고
0415
15:10
38.6
Maxibupen
20:20
37.3
0416
00:00
37.0 38
94%
수면시 88~94%
00:45
38.2 40
90%
O2 1l
03:00
36.9
99%
08:20
36.7 30
97%
16:00 36
96%
O2 D/C
20:30
37.4
98%
0417
00:50
36.3
05:30
36.4 32
09:00
36.8 34
15:40
36.6
0418
00:10 24
이후 BT 36.0~36.8, RR 24~30 큰 변화 없음

18. 경과 기록 (progress note) 2009-04-14 (HD #1)
#1. Asthma, #2. Allergic rhinitis
S : 그 동안 특별한 치료 없이 괜찮았어요. 숨쉬기 많이 힘들어해요.
O : RR, O2 saturation – 표 참고
A : R/O Asthma attack, R/O Non-asthmatic
P : Mast-food, IgM, IgG, IgA, IgE
F1, F2, D1, D2
Eosinophil Cationic Protein
Oxygen inhalation 1l/day
Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr

19. 경과 기록 (progress note) 2009-04-14 (HD #1)
#4. Fever, Cough, Sputum, Rhinorrhea, #6. AOM
S : 추워하지는 않아요.
O : Body temperature - 표 참고
Mycoplasma pneumoniae IgM (287u/ml),
Electrolyte
CRP 3.41mg/dl
WBC 12.4k/ul (Neutrophil 90.1%)
CXR
A : Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Rulid-D 50mg/TAB 1TB Bid
Augmentin 1gr Q8hr
Prospan syrup 2.5ml Tid
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

20. 0414 Chest X-ray

21. 경과 기록 (progress note) 2009-04-14 (HD #1)
#3. Chronic sinusitis
S :
O : PNS series
A : pansinusitis
P : #4 참조

22. 0414 PNS series

23. Problem list Date # Active Inactive 09.04.14 1 Asthma 2
Allergic rhinitis 3
Chronic sinusitis
→(04.14) Pansinusitis 4
Fever, Cough, Sputum, Rhinorrhea
→(04.14) Pneumonia 5
Wheezy breath sound, Tachypnea
→(04.14) Asthma attack 6
Fever, Otalgia, TM P/E → AOM

24. 경과 기록 (progress note) 2009-04-15 (HD #2)
#1. Asthma, #2. Allergic rhinitis
S : 숨쉬기 조금 힘든 듯 해요.
O : RR, O2 saturation – 표 참고
A :
P : Oxygen inhalation 1l/day
Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr
Theoclea dry syrup 0.2gr Bid

25. 경과 기록 (progress note) 2009-04-15 (HD #2)
#3. Pansinusitis
#4. Pneumoniae
#6. AOM
S : 큰 변화 없어요.
O : Body temperature - 표 참고
A : Pansinusitis, Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Rulid-D 50mg/TAB 1TB Bid
Augmentin 1gr Q8hr
Prospan syrup 2.5ml Tid
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

26. 경과 기록 (progress note) 2009-04-16 (HD #3)
#1. Asthma, #2. Allergic rhinitis
S : 숨쉬는 것 많이 나아졌어요.
O : RR, O2 saturation - 표 참고
Chest retraction (-), Wheezy breath (+)
Mast-food - Total IgE 2 & all negative
IgM 88 mg/dl, IgG 782 mg/dl
IgA 66 mg/dl, IgE mg/dl
Eosinophil Cationic Protein 6.73 ug/L
A :
P : Oxygen inhalation 1l/day
Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr
Theoclea dry syrup 0.2gr Bid

27. 경과 기록 (progress note) 2009-04-16 (HD #3)
#3. Pansinusitis
#4. Pneumoniae
#6. AOM
S :
O : Body temperature - 표 참고
WBC 3.3K/ul (Neutrophil 38.3%)
CRP 0.39 mg/dl
A : Pansinusitis, Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Rulid-D 50mg/TAB 1TB Bid
Augmentin 1gr Q8hr
Prospan syrup 2.5ml Tid
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

28. 경과 기록 (progress note) 2009-04-17 (HD #4)
#1. Asthma, #2. Allergic rhinitis
S : 코 막힘이 있어요.
O : RR, O2 saturation - 표 참고
Skin prick test (His 3.65/20.30, All negative)
A :
P : Oxygen inhalation D/C
Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr
Theoclea dry syrup 0.2gr Bid
Sudafed oral sol. 3mg/ml 5ml Tid

29. 경과 기록 (progress note) 2009-04-17 (HD #4)
#3. Pansinusitis
#4. Pneumoniae
#6. AOM
S : 밤 사이 열 나지 않았어요.
O : Body temperature - 표 참고
WBC 3.3K/ul (Neutrophil 38.3%)
CRP 0.39 mg/dl
A : Pansinusitis, Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Augmentin 1gr Q8hr
Rulid-D 50mg/TAB 1TB Bid
Prospan syrup 2.5ml Tid
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

30. 경과 기록 (progress note) 2009-04-18 (HD #5)
#1. Asthma, #2. Allergic rhinitis
S :
O : RR, O2 saturation - 표 참고
A :
P : Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr
Theoclea dry syrup 0.2gr Bid
Sudafed oral sol. 3mg/ml 5ml Tid

31. 경과 기록 (progress note) 2009-04-18 (HD #5)
#3. Pansinusitis
#4. Pneumoniae
#6. AOM
S : 밤사이 열 나지 않았어요.
O : Body temperature - 표 참고
Decreased crackle
Chest X-ray
A : Pansinusitis, Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Augmentin 1gr Q8hr
Gomcillin 500mg/Cap 0.5cap Tid
Prospan syrup 2.5ml Tid
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

32. 0418 Chest X-ray

33. 경과 기록 (progress note) 2009-04-19 (HD #6)
#1. Asthma, #2. Allergic rhinitis
S : 숨 쉬는 것 안 힘들어해요.
O : Wheezy breath (-)
A :
P : Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr
Theoclea dry syrup 0.2gr Bid
Sudafed oral sol. 3mg/ml 5ml Tid

34. 경과 기록 (progress note) 2009-04-19 (HD #6)
#3. Pansinusitis
#4. Pneumoniae
#6. AOM
S :
O :
A : Pansinusitis, Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Amocla duo syr 8.5ml Bid
Gomcillin 500mg/Cap 0.5cap Tid
Prospan syrup 2.5ml Tid
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

35. 경과 기록 (progress note) 2009-04-20 (HD #7)
#1. Asthma, #2. Allergic rhinitis
S :
O :
A :
P : Ventolin 0.4ml Q2hr
Hokunalin 1mg/pat 1PAT Qd
Pulmicort Respules 0.5mg inha. 1Am Q6hr
Theoclea dry syrup 0.2gr Bid
Sudafed oral sol. 3mg/ml 5ml Tid

36. 경과 기록 (progress note) 2009-04-20 (HD #7)
#3. Pansinusitis
#4. Pneumoniae
#6. AOM
S :
O :
A : Pansinusitis, Pneumoniae, Acute otitis media
P : Maxibupen 7ml Qd
Amocla duo syr 8.5ml Bid
Gomcillin 500mg/Cap 0.5cap Tid
Prospan syrup 2.5ml Tid
Discharge & OPD F/U (D1, D2, F1, F2 결과확인)
Negative <770 Units/ml
Low Positive 770~950 Units/ml
Positive >950 Units/ml
Roxithromycin
Amoxicillin

37. F1(white egg) - class 0 (<0.35 kUa/I)
F2(milk) - class 1 (0.4 kUa/I)
D1(D.peteronyssinus) - class 0 (<0.35 kUa/I)
D2(D.farinae) - class 0 (<0.35 kUa/I)