Case presentation in internal medication examination. See description.

1. 內科專科口試 107年度
姜冠宇 醫師

2. 題號 性別、年齡 主 述 診 斷 CASE有圖片，請
打勾(V)
是本人照顧，請打勾(V)
CASE 1. 41 y/o male; Dyspnea in 2 days. (V) ( )
Acute myopericarditis
CASE 2. 44 y/o Male ; Suddenly onset abdominal pain (V) (V)
Acute pancreatitis with acute respiratory failure
CASE 3. 44 y/o male ; Progress shortness of breath for 1 week (V) (V)
1. Pulmonary tuberculosis with cavitation
2. Acute respiratory distress syndrome
CASE 4. 66 y/o female ; general weakness for 5 days (V) (V)
Hyponatremia
CASE 5. 56 y/o female ; Fever up to 40’C with chills for 1 day (V) ( )
Infective endocarditis of mitral valve, Staphylococcus aureus(MRSA)
CASE 6. The 57-year-old female ; consciousness disturbance and fever for 1 day (V) ( )
Type II diabetes mellitus with hyperglycemic hyperosmolar state

3. Case 5
56 y/o female
Fever up to 40’C with chills for 1 day

4. CASE 5. 病例摘要
主訴：
Fever up to 40’C with chills for 1 day
簡單病史：
This 56 years old female patient with Barlow mitral valve with underlying Severe mitral regurgitation status post mitral
valve repair and 34mm band annuloplasty on 4/28/2015 , complicated right hemothorax and multiple oozing s/p reopen on
4/29/2015 2. Moderate tricuspid regurgitation 3. Atrial fibrillation was just discharged from neurology department for
Acute ischemic stroke with left hemiparesis & hypoesthesia on 2/28, and complained fever up to 40'C soon after discharge.
Chills was also mentioned, along with weakness, dizziness, chest tightness, and epigastric pain. Constipation was also
mentioned, along with nausea vomiting episodes. She then visited ER again, and low blood pressure was observed with
shock condition. CXR showed no active lung lesion while Abdominal CT reported No definite surgical acute abdomen is
found. Blood culture reported GPC in cluster, while echocardiogram showed no evidence of vegetation. She was then
admitted for sepsis with shock status.

5. Chief complain
Fever up to 40’C with chillness for 1 day
Past history
1. Severe mitral regurgitation
s/p mitral valve repair and band annuloplasty on 2015/04/28
2. Atrial fibrillation
Patient

6. Patient illness
Acute ischemic stroke with left hemiparesis & hypoesthesia
→ Discharge from neurology department
Fever, chills, general weakness, dizziness, chest tightness,
nausea/vomiting
→ Visit to our ER
2017/02/22-28
2017/03/01

7. ER course
Con’s : Clear. HEENT : No special finding. Lymphadenopathy (-)
Chest : Symmetric expansion. Breathing sound clear
Heart : Irregular beat. Pansystolic murmur over MV and TV region,
grade III/Vl
Abdomen : Soft, no tenderness, normoactive. No limb edema
BP SBP 106 / DBP 63mmHg
HR 124 /min
RR 20 /min
BT 39.2 ℃
Sp02 98
Vital sign
Physical
examination

8. CXR

10. Lab data (3/01-3/02)

11. Shortness of breath with cold sweating, Shock
PSVT(200bpm), adenosine was loaded 6mg X2
→ Afib with RVR
B/C MRSA
Ward Under Easydopa
Give Teicoplanin
ER Blood Culture: GPC in cluster* II
Echocardiogram: No evidence of vegetation.
Normal LA & LV size; good LV contractility (EF:77%)

12. Lab data (3/04)

13. 3/06
→ Bipap support.
→ Consulted CVS for TEE and evaluation
→ ICU admission on 3/06.

18. ICU
→ Weaning ventilator smoothly, then extubation
→ Taper off levophed was hemodynamic stable
OP
ICU
Fosfomycin 4000 mg Q12H
TEE
MVR with 27mm Sorin Mitroflow bovine xenograft

19. Final Diagnosis
1. Infective endocarditis of mitral valve, Staphylococcus aureus(MRSA)
2. Pulmonary edema with pleural effusion
3. Septic shock with impending respiratory failure, resolved
4. Atrial fibrillation with rapid ventricular response
5. Recent ischemic stroke , with left hemiparesis