Case conference 감염내과 R2 문수연

11134315 이O쇠(M/75) Adm. ’04-11-03 (5th admission via OPD) CC) Fever o/s) recent: 1 month ago remote: 5 months ago PI) 5 months ago – fever, chilling 3 months ago – prostatic cancer bilateral orchiectomy with hydrocelectomy 1 month ago – fever with chilling PMHx) DM(-) HTN(-) TB(-) hepatitis(-) Op(+) hemorrhoidectomy cataract – PE with IOL bilateral orchiectomy with hydrocelectomy

Travel history(+) for fishing 서해, 강원도, 춘천, 중랑천, 여주, 충청도 Current medication Bicalutamide 50 mg qd Terazosin 2 mg qd Bethanechol 25 mg tid PHx) Alcohol(+) social Smoking(+) 50 pack-years

Review of systems General: fever(+) chill(+) weight loss(-) fatigue(-) Head and neck: headache(-) stiffness(-) sore throat(-) Respiratory: cough(-) sputum(-) dyspnea(-) hemoptysis(-) Cardiac: chest pain(-) orthopnea(-) palpitation(-) Abdomen: abdominal pain(-) nausea(-) vomiting(-) Urogenital: dysuria(-) frequency(+) urgency(-) Musculoskeletal: myalgia(-) joint pain(-)

Physical examination V/S 130/70 mmHg – 78/min – 20/min – 36.2 ℃ General Alert consciousness Chronically ill-looking Skin No rash or pigmentation No escar Head and neck No cervical lymph node enlargement No neck vein engorgement Eyes/ENT Isocoric pupil with PLR(++/++) Pinkish conjunctiva Clear sclera

Chest Abdomen Back and extremity Clear breathing sound without crackle or wheezing Regular heart beat without murmur Abdomen Soft and flat abdomen No tenderness or rebound tenderness Back and extremity CVA tenderness(-/-) Pretibial pitting edema(-/-)

Initial Laboratory finding CBC/DC 4740/mm3 – 12.2 g/dL/36.4 % - 343000/mm3 (seg. 73.7%) Chemistry TB/DB 0.3/0.3 mg/dL Glucose 111 mg/dL AST/ALT 91/92 U/L BUN/Cr 22/0.6 mg/dL ALP 934 U/L Na/K/Cl 131/4.5/100 mmol/L Prot/Alb 6.2/3.9 g/dL PSA 0.56/0.49 ng/mL UA RBC 0-1/HPF WBC 0-1/HPF Protein (-)

Chest PA ’04-06-29 ’04-11-03

Initial problem lists #1. Fever A) Fever P) Work up plan for r/o infectious disease chest PA F/U sputum exam, throat culture, blood culture, urine culture for r/o drug fever medication history review medication hold Therapeutic plan empirical antibiotics

#2. Prostatic cancer s/p bilateral orchiectomy with hydrocelectomy Prostatic cancer s/p bilateral orchiectomy with hydrocelectomy P) Work up plan for evaluation of disease state abdominal sonography total/free PSA Therapeutic plan hormonal therapy (LHRH agonist)

Clinical course HD3(Transferred to Department of Infection) #1. Fever S) fever(+) chilling(+) cough(+) sputum(+) O) V/S 120/80 mmHg – 90/min – 28/min – 37.5 ℃ clear breath sound without crackle or wheezing A) Fever P) Work up plan for r/o pneumonia chest PA F/U, sputum exam for r/o drug fever check medication history, adverse effect of drug Therapeutic plan stop all medication

HD6 #1 Fever S) Fever(+) chill(+) cough(+) sputum(+) dyspnea(+) O) V/S 130/80 mmHg – 88/min – 20/min – 39 ℃ Clear breathing sound without crackle or wheezing Sputum culture: α-hemolytic streptococcus Sputum AFB (-) ABGA: 7.48 - 30.3 - 41.7 - 22.3 - 81.8

Chest PA and both lateral

Chest CT

A) Fever d/t pneumonia P) Work up plan for r/o atypical pneumonia Sputum exam (Gram stain & culture, AFB stain & culture) P.carinii – Gomori stain Anti-CMV antibody IgM Therapeutic plan Antibiotics Levofloxacin 500 mg iv qd Piperacillin/tazobactam 4.5 g iv q 6 hrs Trimethoprim/sulfamethoxazole 1200 mg iv q 6 hrs Doxycyclin 100 mg po bid ICU care for close observation

HD7 #1 Fever S) fever(+) chill(+) dyspnea(+) cough(+) sputum(+) O) BT 36.5 ~ 39 ℃ Coarse breathing sound without crackle or wheezing A) Fever d/t atypical pneumonia P) Work up plan Sputum exam Broncholalveolar larvage Therapeutic plan Piperacillin/tazobactam 4.5 g iv q 6 hrs Trimethoprim/sulfamethoxazole 1200 mg iv q 6 hrs Gancyclovir 250mg iv q 8 hrs Ribavirin 200mg po qid

HD8 #1 Fever S) fever(+) chill(+) dyspnea(+) O) BAL  clear fluid culture, AFB and TB PCR were done Urine legionella antibody(-) A) Fever d/t atypical pneumonia P) Work up plan Wait for bacterial culture and TB PCR of BAL fluid Repeat sputum exam Therapeutic plan Continue antibiotics

Chest AP

HD15 #1. Fever S) fever(+) 감소 chilling(+) 감소 cough(+) sputum(+) O) BT 36.8 ~ 38.5 ℃ coarse breathing sound withour crackle or wheezing P.carinii (-) BAL fluid – no growth A) Fever d/t atypical pneumonia P) Work up plan for r/o other causes of fever Bone marrow aspiration and biopsy Therapeutic plan Levofloxacin 500 mg iv qd Rivabirin 200 mg po qid

Chest AP

HD21 #1. Fever S) Fever(+) chilling(+) cough(±) sputum(±) O) Bone marrow aspiration and biopsy, culture were done  Aspiration: normal BM Anti-CMV antibody IgM(-) A) Fever d/t atypical pneumonia P) Work up plan wait for BM culture Therapeutic plan Continue levofloxacin 500 mg iv qd

Chest PA

6th admission ’04-11-27 discharge ’04-12-07 URO OPD visit ’04-12-13 bicalutamide (LHRH agonist), terazosin, bethanechol, diazepam ’04-12-23 Sputum culture for mycobacterium: 1+ ’04-12-30 Visited ER for dyspnea

Laboratory finding CBC/DC 2220/mm3 – 13.6 g/dL/ 39.8%- 140/mm3 (seg. 90.0%) Chemistry TB/DB 1.2/0.5 mg/dL Glucose 85 mg/dL AST/ALT 106/37 U/L BUN/Cr 79/1.1 mg/dL ALP 338 U/L Na/K/Cl 134/4.8/96 mmol/L Prot/Alb 6.1/2.2 g/dL UA RBC 0-1/HPF WBC 0-1/HPF Protein (-) ABGA 7.48 – 21 – 56 – 20 – 91

Chest AP

Problem list #1. Dyspnea #2. Tuberculosis #3. Prostate cancer s/p bilateral orchiectomy with hydrocelectomy

HD2 #1. Dyspnea S) dyspnea(+) cough(+) sputum(+) fever(+) chill(+) O) V/S 90/60 mmHg – 90/min – 24/min – 39 ℃ SaO2 <90% (resevor bag) ABGA: 7.47 – 24 – 100.5 – 17.1 – 98 (post-intubation) A) ARDS P) Work up plan Sputum TB PCR ABGA F/U Therapeutic plan Ventilator care (CMV FiO2 0.7 RR 24 TV 420mL PEEP 3)

#2. Tuberculosis S) dyspnea(+) cough(+) sputum(+) O) Sputum TB culture (1+) A) Tuberculosis P) Work up plan Sputum exam for tuberculosis Therapeutic plan Isoniazid 300 mg qd Rifampicin 600 mg qd Ethambutol 800 mg qd Pyrazinamide 1.5 g qd Pyridoxine 50 mg qd Levofloxacine 500 mg iv qd + Amikacin 500 mg iv q 12 hrs

HD8 #4. Elevated heart enzyme #5. MRSA in sputum S) cough(+) sputum(+) O) V/S 120/60 mmHg – 100/min – 24/min – 39 ℃ Sputum bacterial culture: MRSA A) Ventilator associated pneumonia P) Work up plan Sputum exam for bacteria Therapeutic plan Levofloxacin and amikacin D/C Vancomycin 1g iv q 12 hrs for 14 days

Chest AP

HD13(05-01-11) #1. ARDS #6. Pneumothorax S) dyspnea(+) aggravation O) V/S 100/60 mmHg – 90/min – 22/min – 38 ℃ RR 22/min  26/min ABGA: 7.43 – 43.8 – 64.1 – 28.8 – 93.1

Chest AP

A) Pneumothorax d/t barotrauma s/p chest tube insertion P) Work up plan Chest AP F/U Therapeutic plan chest tube drainage Ventilator care

HD27 #6. Pneumothorax d/t barotrauma S) dyspnea(+) O) RR 24/min  28/min ABGA: 7.355 – 60.2 – 75.2 – 32.9 – 94.2 A) Pneumothorax d/t barotrauma s/p chest tube insertion, bilateral P) Work up plan Chest AP F/U Therapeutic plan chest tube drainage

Chest AP

HD34 #1. ARDS #2. Tuberculosis #3. Prostatic cancer s/p bilateral orchiectomy with hydrocelectomy #4. Elevated heart enzyme #5. MRSA pneumonia #6. Pneumothorax  Expire