2011.09.22 MGR 좌측 수부 통증을 주소로 내원한 26세 남자 환자 감염내과 R2 김동현 / Prof. 문수연

History Chief complaint Present illness Lt hand pain o/s> 내원 1일 전. 12219064 이 O 한 (M/26) Adm. : 11. 08. 21 Chief complaint Lt hand pain o/s> 내원 1일 전. Present illness M/26, 내원 전일 오전 8시 길을 걷던 중 다가오는 오토바이 피하면서 넘어졌으며 이 때 왼쪽 손으로 땅을 짚었으나 유리에 왼쪽 손바닥을 수상 하여 타 병원 방문하였다가 큰 병원 진료 받을 것을 권유 받고 ER 경유하 여 입원함.

Past Medical History DM/HTN/TBc/Hepatitis(-/-/-/-) Medication Hx (-) Op Hx(-) 다음슬라이드로

Personal History Family History Alcohol (+) Smoking (-) None 소주 1병, 1~2회/wk. Smoking (-) Family History None

Review of System 1. General Generalized weakness(-) Fever(-) Chill(-) Myalgia(-) Weight change(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) Itching(-) 3. HEENT Headache(-) Dizziness(-) Otalgia(-) Otorrhea(-) PND(-) Nasal obstruction(-) Rhinorrhea(-) Sore throat(-) Swallowing difficulty(-) 4. Respiratory Dyspnea(-) Cough(-) Sputum(-) Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-) DOE(-) Palpitation(-)

Review of System 6. Abdominal A/N/V/D/C(-/-/-/-/-) Dysphagia(-) Bowel habit change(-) Abdominal. Pain(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-) Hematuria(-) Nocturia(-) 8. Musculoskeletal Pain(+) : Lt hand Swelling(+) Weakness(+) Backpain(-) Myalgia(-) Numbness(+) 9. Nervous Dizziness(-) Syncope(-) Seizure(-)

Physical Examination Height : 180 cm Weight : 85 kg BMI : 26.2 kg/m2 Vital Sign : 120/80 mmHg - 84/min - 20/min – 36.4℃ 1. General appearance Alert consciousness Not so ill looking appearance 2. Head & neck Normocephaly, LN enlargement(-), Neck vein engorgement(-) 3. E/ENT Isocoric pupil c PLR(++/++) Pinkish conjunctiva, whitish sclera Pharyngeal injection(-), PTH(-/-)

Physical Examination 4. Chest 5. Abdomen 6. Back & Extremities Symmetric chest expansion Clear breathing sound without rale/wheezing Regular Heart Beat without murmur 5. Abdomen Soft /Flat abdomen Normoactive bowel sound Tenderness(-), Rebound Tenderness(-) Palpable mass(-), Hepatomegaly(-) 6. Back & Extremities CVA Td(-/-) Pretibial pitting edema(-/-) Pressure sore(-) 7. Neurologic exam Sense : Lt 1st, 2nd , 3rd, 4th finger radial side sense dull Motor : 2nd & 3rd finger flexion (-) d/t tendon rupture

Initial Lab Finding 1.CBC/DC 2.Chemistry 3.UA 6760/㎕ – 13.2 g/㎗ – 38.3 % - 326,000 /㎕ (seg : 61.6%) aPTT 31.6 sec PT INR 0.93 2.Chemistry TB / DB 1.06 / 0.39 mg/㎗ BUN/Cr 17 / 0.8 mg/dL Protein/Albumin 7.7 / 4.6 g/㎗ Na/K/Cl 138 / 3.9 / 100 mEq/L AST/ALT 27 / 32 U/L Ca/P/Mg 8.2 / 2.9 / 2.2 mg/dL ALP/rGT 63 / 20 U/L Uric acid 6.6 mg/dL CRP < 0.3 mg/dL 3.UA RBC 0~1/HPF WBC 0~1 /HPF Blood - Protein - Glucose - Bilirubin -

Initial Chest PA Bony thorax intact Cardiomegaly : none Lung parencyme : nonspecific

Initial ECG Normal sinus rhythm Rate : 90회 가량 Axis : normal

Initial Problem Lists #1. Complete rupture FDS, FDP of 2nd & 3rd finger & rupture of proper digital nerve 2nd, 3rd & 4th finger, Lt hand 이상의 증상 및 검사 소견을 바탕으로 다음의 problem list를 설정하였습니다. flexor digitorum superficialis/profundus

Initial Assessment and Plan #1. Complete rupture FDS, FDP of 2nd & 3rd finger & rupture of proper digital nerve 2nd, 3rd & 4th finger, Lt hand ◆ Treatment plan 1. Emergent operation (Tenorraphy & Neurorraphy of damaged portion)

Clinical Course 임상경과 보시겠습니다.

Harrison‘s Principles of Internal Medicine, 17th ed Clinical Course ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 일요일 OP. Harrison‘s Principles of Internal Medicine, 17th ed Anti-HIV titer 가 양성으로 나온 상태로 대개 titer는 10~20 가량으로 낮게 나오거나 200이상으로 높게 나오게 되는 데 낮게 나오는 경우 위양성의 가능성, 특히 자가면역 질환을 가지고 있거나 임산부의 경우 그 가능성이 있으나 높게 나오는 경우는 거의 확진 검사에서 양성을 보이게 됩니다. Repeat order of Anti-HIV : X

Clinical Course ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP.

#2. Anti-HIV Ab (+), High titer (About 300) Clinical Course ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP. #2. Anti-HIV Ab (+), High titer (About 300) ◆ Diagnosis 1. Check confirm test result (About 2weeks needed) 2. Keep secret to patient about screening result → But, already informed ◆ Etc. 1. Consider occupational exposures of medical team

Occupational exposures Clinical Course ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP. Occupational exposures ◆ Fellow (Operator) : Surgical glove but torn during the operation Sleep disorder d/t HIV fear ◆ Scrub nurse : Preg. 15wks, direct exposure (-) Prior op. needle injury. So indirect exposure suspected

Who is indicated for post-exposure prophylaxis ? Clinical Course ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP. Who is indicated for post-exposure prophylaxis ? ◆ Percutaneous exposure to blood : 0.3 % ◆ Mucous membrane exposure : 0.09 % N Engl J Med 2009;361:1768-75 또한 이번 간호사와 같이 Skin defect 와 같은 intergrity의 장애가 생긴 경우 통계적으로 나온 확률은 없지만 그 전염성 정도는 두번째의 0.09%보다도 훨씬 낮다고 알려져 있습니다. 2009년에 발표된 PEP 과련 저널에서는 0.1% 이상의 Transmission 확률을 갖는 경우에 PEP를 시행하자고 함.

Who is indicated for post-exposure prophylaxis ? Clinical Course ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP. Who is indicated for post-exposure prophylaxis ? ◆ Percutaneous exposure to blood : 0.3% ◆ Mucous membrane exposure : 0.09 N Engl J Med 2009;361:1768-75 다음은 실제로 진행하는 PEP의 알고리듬입니다,

Clinical Course Who is indicated for post-exposure prophylaxis ? ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP. Who is indicated for post-exposure prophylaxis ? ◆ Percutaneous exposure to blood : 0.3% ◆ Mucous membrane exposure : 0.09 N Engl J Med 2009;361:1768-75 None of them but fellow is possible if needed

Clinical Course 2. Patient counselling Re-history taking ◆ PMHx ‘11 8/21 8/23 8/25 Adm Anti-HIV (+) Titer : 300 II consult 일요일 OP. 2. Patient counselling Re-history taking ◆ PMHx : ‘10 Acute hepatitis A : Drug(including iv drug) & Transfusion Hx. (-) ◆ Personal Hx. : Sexual contact (+), Unprotected, ‘11 4월

Clinical Course But F/U loss ‘11 8/21 8/23 8/25 9/6 Adm Anti-HIV (+) Titer : 300 II consult D/C Western-blot (+) 일요일 But F/U loss OP. N Engl J Med 2005;353:1702-10. (Anti-CMV IgG) (Toxoplasma IgG) (TB Quantiferon) (CD3/4/8) 9/6 확진검사인 Western blot에서 최종적으로 HIV 양성을 확인 하였으며. 이후 Staging 및 현재 다른 Co-infection 여부 확인을 위해 다음과 같은 검사를 진행하기로 하였습니다.

HIV infection, Unknown stage Final Diagnosis HIV infection, Unknown stage