Medical Grand Round R2 이설라 /Prof. 이미숙

Chief Complaints Headache & voiding difficulty Headache & voiding difficulty onset ) 2 wks ago Present Illness 특이 병력 없는 54 세 남환으로 내원 한달 전부터 generalized weakness 발생하고 2 주전 headache, fever & chill 증상 있어 개인 의원 방문 후 약물 치료 실시하였으나 증상 호전 없으며 내원 3 일전 부터 voiding difficulty 발생하여 응급실 방문 후 실시한 residual urine check 상 1000cc 확인되어 further evaluation 위해 비뇨기 과 입원. 최 O 석 (M/54) Adm

Past medical Hx DM/HTN/Hepatitis/Tbc ( - / - / - / - ) Family Hx :None Personal Hx - smoking (-) - alcohol (+) : social drinking

Review of the systems General Fatigue(-) weight loss(+ : 10kg/3month) Fever(+) chills(+) Skin Rash(-) pigmentation(-) Itching(-) Head & neck Headache(+) neck stiffness(-) Otorrhea(-) otalgia(-) Rhinorrhea(-) nasal obstruction(-) Soreness (-) hoarseness (-) Respiratory Cough(-) sputum(-) dyspnea(-) hemoptysis(-) Circulatory Chest discomfort(-) Exertional dyspnea (-) Orthopnea(-)

Review of the systems Gastro-intestinal Odynophagia (-) dysphagia(-) Anorexia (-) nausea(-) vomiting(-) diarrhea(-) Abdominal pain(-) bloating (-) constipation(-) Genito-urinary Dysuria(-) frequency(+) nocturia(-) Residual urine sense (+) hesitancy (+) Musculoskeletal Pain(-) weakness(-) Neurologic Dizziness(-) weakness(-) tingling sense(-)

PHYSICAL EXAMINATION V/S: 130/80 mmHg - 80/min - 22/min ℃ Height : 174cm Weight : 65kg General appearance Alert mental status with acute ill-looking appearrance Head & neck Normocephaly No thyroid enlargement No palpable thyroid mass No palpable enlarged lymph node No neck vein engorgement Eye & ENT Isocoric pupils with PLR (++/++) Pinkish conjunctiva Whitish sclera

Chest Symmetric chest expansion Clear breath sound without rale or wheezing Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound No hepatosplenomegaly Abdominal Tenderness/Rebound tenderness (-/-) Genitourinary DRE : tenderness(-) heating sense (-) Back & Extremities CVA Td(-/-) pretibial pitting edema(-/-) PHYSICAL EXAMINATION

Initial lab. finding CBC/DC 8800/mm g/dL – 37.7 % - 340,000/ ㎣ (Seg %) Chemistry Pro/Alb 7.6/4.3 g/dL TB/DB 0.79/0.29mg/dL T-cholesterol 156 mg/dL AST/ALT 39/30 U/L ALP/rGT 65/194 U/L BUN/Cr 17/0.6 mg/dL Glucose 159 mg/dL CRP 1.5 mg/dL Na/K/Cl 119/3.6/81 mmol/L Urine analysis RBC 5~9/HPFWBC 2-4/HPF PH 6.5 S.G Protein (-) Glucose (-) O.B.(-) ketone (-)

Chest X-ray

Electrocardiography

1. Headache 2. Voiding difficulty 3. Hyponatremia Initial problem list

1. Headache d/t common headache syndromes meningoencephalitis space occupying lesion 2. Voiding difficulty d/t BPH acute prostatitis bladder tumor 3. Hyponatremia d/t True volume defect SIADH Hypothyroidism Adrenal insufficiency Pseudohyponatremia (hyperglycemia, hyprlipidemia, mannitol) Initial assessment

Diagnostic & therapeutic plan Diagnostic & therapeutic plan 1. Headache  Pain control Brain CT Lumbar puncture - CSF exam. if needed Brain MRI, EEG 2. Voiding difficulty  Abdomen sono TRUS PSA check Blood & urine culture 3. Hyponatremia  Plasma osmolality Urine osmolality Urine sodium concentration Thyroid function test Serum cortisol and ADH level

Additional lab. finding PSA(total/free) : 1.09/0.15ng/ml Osmolality(serum/urine) : 254/545mOsm/kG Urine Na : 47mmol/L T3 : 61ng/dL free T4 : 1.36ng/dL TSH : 0.15μU/mL

2008 – ( HD #2) S : fever & chill O : altered mentality : confusion with irritability BT ’C Na/K/Cl : 131/3.4/96mmol/L Brain CT & Diffusion MRBrain CTDiffusion MR CSF study : Grossly clear appearance RBC 2 / ㎣ WBC 306 / ㎣ (Neutrophil 5% Lymphocyte 73% Monocyte 22%) Protein 1700mg/dL Glucose 58mg/dL Cloride 103mmol CSF VDRL Negative ADA 46.7IU/L A : Encephalitis (R/O Tb encephalitis) P : Transfer to NR

Clinical course Mental : alert CSF study report TB PCR (+) & QFT gold (-) H.influenzae (-) N.meningitidis (-) S.pneumoniae(-) Herpes IgM (-) HSV PCR(-) VZV IgM (-) VZV PCR(-) Mumps IgM (-) Measle IgM (-) EBV VCA IgM (-) Cysticercosis (-) P.westermani (-) Chest & abdomen CT Anti-TB medication 8/4 8/12 NS transfer For emergency OP(EVD) 8/5 mentality CT F/U 8/10 8/13

Chest CT ( )

Abdomen CT ( )

Clinical course EVD removal AST/ALT Anti-TB medication 8/14 8/25 8/18 9/1 60/11050/100 36/6532/39 4mg qd 9/6 Anti-TB medication 8/4 Methylprednisolone 250mg bid 8/7 Methylprednisolone 4mg tid 8/11

Clinical course 8/28/68/138/188/259/2 Na Cl uOsm sOsm uNa Electrolyte imbalance SIADH d/t Tb encephalitis & Hydronephrosis  water restriction & Na supply Voiding difficulty after Foley remove (8/24) TRUS : normal finding Urodynamic study : Detrusor underactivity & decreased bladder filling sensation  neurogenic bladder  CIC 유지

Final Diagnosis - Tb encephalitis with Hydrocephalus - Miliary Tb - SIADH - Neurogenic bladder Treatment - Anti Tb medication for 12 month - methylprednisolon 4mg qd until 9/14 ( 4mg tid x 3 weeks  4mg qd x 1 week ) Final Diagnosis & treatment

Brain CT (08-8-3) Brain CT (08-8-3)

Brain MR (08-8-3) Brain MR (08-8-3)

Chief Complaints Chest discomfort Chest discomfort onset ) 2 wks ago Present Illness 특이 병력 없는 66 세 여환으로 내원 약 2 주전 fever,cough, sputum 증상 있어 local 의원 방문 후 URI 의심하 약물 치료 실시하 였으나 증상 호전 없으며 facial swelling & chest discomfort 등의 증세 동반되어 local 방사선과 방문 후 pericardial effusion imp. 하 에 further evaluation 위해 외래 통해 입원 이 O 례 (F/66) Adm

Past medical Hx DM/HTN/Hepatitis/Tbc ( - / - / - / - ) Family Hx :None Personal Hx - smoking (-) - alcohol (-)

Review of the systems General Fatigue(+) weight loss(+ : 6~7kg/2month) Fever(- : 내원 당시는 subside 된 상태 ) chills(-) Skin Rash(-) pigmentation(-) Itching(-) Head & neck Headache(-) neck stiffness(-) Otorrhea(-) otalgia(-) rhinorrhea(-) nasal obstruction(-) Soreness (-) hoarseness (-) Respiratory Cough(+) sputum(-) dyspnea(-) hemoptysis(-) Circulatory Chest discomfort(+) : Substernal, continuous, tightness, aggrevated by meal & external compression, relieved by none Exertional dyspnea (+: class II) orthopnea(-)

Review of the systems Gastro-intestinal Odynophagia (-) dysphagia(-) Anorexia (+) nausea(-) vomiting(-) diarrhea(-) constipation(-) Abdominal pain(-) bloating (+) Genito-urinary Dysuria(-) frequency(-) nocturia(-) RU sense (-) Musculoskeletal Pain(-) weakness(-) Neurologic Dizziness(-) weakness(-) tingling sense(-)

PHYSICAL EXAMINATION V/S: 130/70 mmHg - 78/min - 20/min ℃ Height : 145cm Weight : 45kg General appearance Alert mental status with not so ill-looking appearance Head & neck Normocephaly No thyroid enlargement, No palpable thyroid mass No palpable enlarged lymph node Neck vein enlargement (+) Eye & ENT Isocoric pupils with PLR (++/++) Pinkish conjunctiva Whitish sclera Oral ulcer(-)

Chest Symmetric chest expansion Clear breath sound without rale or wheezing Slightly decreased but Regular heart beat without murmur Abdomen Soft & flat abdomen Normoactive bowel sound No hepatosplenomegaly Abdominal Tenderness/Rebound tenderness(-/-) Genitourinary Genital ulcer (-) condyloma (-) Back & Ext. CVA Td(-/-) pretibial pitting edema(-/-) PHYSICAL EXAMINATION

Initial lab. finding CBC/DC 4400/mm g/dL – 29.7 % - 295,000/ ㎣ (Seg %) Chemistry Pro/Alb 6.3/3.6 g/dL TB/DB 0.8/0.32mg/dL T-cholesterol 156 mg/dL AST/ALT 24/34 U/L ALP/rGT 369/59 U/L BUN/Cr 10/0.4 mg/dL Glucose 97 mg/dL Na/K/Cl 138/3.6/99 mmol/L Urine analysis RBC 0-1/HPFWBC 2-4/HPF PH 5.0 S.G Protein (-) Glucose (-) O.B.(-) ketone (-)

Chest X-ray

Electrocardiography

1. Exertional dyspnea with chest discomfort 2. Weight loss with anorexia Initial problem list

1. Pericardial effusion d/t infectious pericarditis  viral infection (Coxsackievirus, Echovirus, hepatitis, HIV) Tuberculosis other infection (syphilis) d/t noninfectious pericarditis  Myocardial infarct Uremia hypothyroidism neoplasm d/t hypersensitivity reaction  Rheumatoid arthritis, SLE Initial assessment

Pericardial effusion d/t 1. infectious pericarditis viral marker study (Coxsackievirus, Echovirus, hepatitis, HIV) AFB stain, gram stain,Tb-PCR, culture 2. noninfectious pericarditis  ECG, Heart enzyme & Echocardiography BUN/Cr check Thyroid function test Tumor marker study Chest & abdomen CT 3. hypersensitivity reaction  RF, ANA, drug use Diagnostic & therapeutic plan

Additional lab. finding Heart enzyme CK/CK-MB 165/1.1 ng/ml TnI <0.04ng/ml NT-ProBNP 112.1ng/ml Thyroid function test T3 61ng/dl free T4 1.14ng/dl TSH 2.82mIU/l Tumor marker AFP 3.5ng/ml (~8.1) CA U/ml (~35) CA U/ml (~27) CEA 1.6ng/ml (~5)

Echocardiography ( )

Chest CT ( )

Pericardial window OP ( ) Pericardial fluid RBC 10/ul WBC 700/ul (lymphocyte 87%) ADA 80IU/L Gram stain & culture (-) AFB stain culture (-) TB PCR(-) Pericardial biopsy Chronic granulomatous inflammation, consistent with tuberculosis

Diagnosis - Tb pericarditis Treatment - Anti Tb medication - Steroid Therapy with tapering Diagnosis & treatment

Clinical course Admit & Echo Anti-TB medication 5/16 5/18 5/21 5/23 Window OP 5/27 Discharge 6/10 Prednisolon 30mg bid 9/1 Stop Anti-TB medication 6/11 7/8 7/22 7/29 30mg qd 8/6 15mg qd 5mg qd 10mg qd Dyspnea

Echocardiography (08-9-1) Cardiology consult : Pph edema & Dyspnea aggrevation 시 medication 필요

Final Diagnosis - Tb Pericarditis with complicated constrictive pericarditis Treatment - Anti Tb medication 유지 - Close observation of constrictive pericarditis Final Diagnosis & treatment