1. Case conference
감염내과
R2 문수연

2. 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

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

4. 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(-)

5. 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

6. 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(-/-)

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

8. Chest PA ’ ’

9. 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

10. #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)

11. 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

12. 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:

13. Chest PA and both lateral

15. Chest CT

16. 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

17. 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 g iv q 6 hrs
Trimethoprim/sulfamethoxazole mg iv q 6 hrs
Gancyclovir 250mg iv q 8 hrs
Ribavirin 200mg po qid

18. 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

19. Chest AP

20. 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

21. Chest AP

22. 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

23. Chest PA

24. 6th admission ’04-11-27 discharge ’04-12-07 URO OPD visit
’ bicalutamide (LHRH agonist), terazosin,
bethanechol, diazepam
’ Sputum culture for mycobacterium: 1+
’ Visited ER for dyspnea

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

26. Chest AP

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

28. 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 – – 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)

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

30. 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

31. Chest AP

32. HD13( )
#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

33. Chest AP

34. 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

35. HD27
#6. Pneumothorax d/t barotrauma
S) dyspnea(+)
O) RR 24/min  28/min
ABGA: – 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

36. Chest AP

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