1. CASE CONFERENCE
내분비 대사 내과 R2 박지나

2. CC : fever & myalgia o/s) 내원 3일전
김0주 (F/23) Adm
CC : fever & myalgia o/s) 내원 3일전
PI : 특이 병력 없던 환자로 내원 6일전 기도원에서 금식 기도한 후 3일전부터 fever, chilling, skin rash, generalized myalgia , nausea, vomiting, watery diarrhea 있어 local에서 manage 받았으나 증상호전 없어 큰 병원 권유 받아 ER 경유 입원

3. PMHx) DM(-) HTN(+)
Pulmonary Tb (-) Hepatitis(-)
OP Hx(-) Allergy(-)
PHx) alcohol (-)
smoking(-)

4. Family history

5. Review of system General fever (+) chill (+) fatigue (+) myalgia (+)
Skin rash(+) pigmentation(-)
Head & neck headache(+) dizziness(-) neck stiffness(-)
neck pain(+) sore throat(+)
Eye & ENT visual disturbance(-) hearing loss(-)
Breast pain(-) lump(-) discharge(-)
Respiatory cough(-) sputum(-) dyspnea(-)
Cardiac angina(-) orthopnea(-) palpiation(+)
Gastointestinal anorexia (+) nausea(+) vomiting(+)
diarrhea(+) constipaition(-) abdominal pain(-)
Genitourinary
frequency (+) urgency (+) dysuria (-)
Musculoskeletal
multiple joint pain (+) ; both knee, hand

6. Physical examination V/S 100/70mmHg –130회/min– 20회/min – 39.5°C G/A
Alert consciousness
acutely ill-looking appearance
Skin
petechiae (+) Osler’s node (+) splinter hemorrahages (+)
H/N
No cervical LN enlargement
No neck vein engorgement
Thyroid enlargement (+), tenderness (+)
neck stiffness(-)

7. Petechiae

8. Osler’s nodes

9. Conjunctival hemorrhage

10. E/E/N/T
Isocoric pupil with PLR (+/+)
subconjunctival petechiae (+)
Exophthalmosis(-)
Chest
Regular & rapid heart beat with pansystolic murmur(Gr I-II)
Clear breathing sound without crackle
Abdomen
Hyperactive bowel sound
Soft & flat abdomen
Tenderness/Rebound tenderness(-/-)

11. Back & extremities
CVA tenderness(-/-)
Pretibial pitting edema(-/-)
Both hand and knee tenderness(-), redness(-), swelling(-)
Neurology
facial palsy(-)
DTR(+/+)
mortor sensory
v v
100
100 v v

12. Laboratory findings I CBC/DC
6370/mm3 – g/dl – 36.7 % - 36k ( seg % )
PT/PTT 14.2S (INR 1.13) / 49C33
Chemistry
T/D–bilirubin / 0.51 mg/dL
AST / ALT / 138 U/L
T-protein/albumin / 2.7 g/dL
Glucose mg/dL
BUN / Cr 11/0.8 mg/dL
Na/ K /Cl / 3.2 / 100 mmol/L
CRP mg/dL
U/A
RBC 2~4 / HPF WBC 0~2 / HPF nitrite (+)
protein mg/dL pH S.G 1.025

13. EKG

14. Chest PA

15. Brain CT ( )

16. Initial assessment Infective endocarditis subcortical hematoma
R/o Thyrotoxicosis

17. Diagnostic plan Blood culture 3쌍 2-D Echocardiography
2. TFT ,TSI,TBII,TG
Thyroid scan

18. TTE ( )

19. TEE ( )

20. Brain CT ( )

21. Laboratory findings II
TFT
T (80~200 ng/dL)
free T (0.77~1.94 ng/dL)
TSH (0.3~4.0 μ /mL)
TG-Ab <50 (<100 IU/ml )
TG(S) ( <50 ng/ml )
TBII (< %)
TMS (<8 ug/ml)
단백면역
AS0 329() C3 12(88-201) C4 12(15-45)
Blood culture ; S. aureus (MSSA), S. viridans(2/19)
Urine culture ; S. aureus (MSSA)

22. <내원 기간동안의 TFT 의 변화>
PTU,Propranolol(2/4-2/15)

23. Clinical course blood culture 3쌍; MSSA , 2-D Echo; vegetation
Infective endocarditis 진단, IV antibiotics start
2. Brain CT; Rt occipital lobe ICH F/U brain CT에서
hematoma resolve되고 두통 감소.
3. 1/31 PSVT 발생 IV CCB 사용후 resolved
recurrent pulmonary edemaO2 supply및 lasix 투여
4. 2/4 TFT T3 171,FT$10.3,TSH0.04
PTU 300mg q 6hr 및 propranolol 40mg q6hr start

24. Clinical course 5. 2/15 fever(+) ANC 289PTU stop
6. F/U TFT T3 51, FT41.65, TSH 0.05
->Euthyroid state, propranolol 40mg q8hr
7. 2/26 F/U 2-D Echo에서 severe MR
OP 위해 타병원 transfer됨.

25. Clinical course(antibiotics)HD 1 2 6
22 ~
vancomycin
S. viridans (+)  vancomycin GM
cefazolin
MSSA infective endocarditis  cefazolin
ceftriaxone
Cb Hrr. d/t septic emboli  ceftriaxone d/t BBB penitration
S. viridans (+)
MSSA infective endocarditis
MSSA at Urine Cx & blood Cx ,
Cb Hrr. d/t septic emboli
Empirical Tx for infective endocarditis

26. Final diagnosis 1.Infective endocarditis : MSSA
- Sepsis d/t septic emboli
- subcortical hematoma
- Mitral regurgitation
2.Thyrotoxicosis
- d/t subacute thyroiditis ?
subclinical hyperthyroidism?