Question

There are two stories to read and answer questions on in this week's discussion assignment.

Case #1: Use the following story to complete the questions below:

Jessica is a 50-year-old married woman with a genetic autoimmune deficiency; she has had recurrent infective endocarditis. The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus viridans infection of the aortic valve 1 month ago. During the recent hospitalization, an echocardiogram showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago, Jessica received an 18-month course of total parenteral nutrition (TPN) for malnutrition caused by idiopathic, relentless nausea and vomiting (N/V). She has had coronary artery disease for several years and 2 years ago had an acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint pain.

Now, after having been home for only a week, Jessica has been readmitted to your floor with infective endocarditis (IE), N/V, and renal failure. Since yesterday, she has been vomiting and retching constantly. She also has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has dentures. Intravenous (IV) access is obtained with a double-lumen peripherally inserted central catheter (PICC) line. Other orders and your assessment are shown in the box.

Admission Orders

STAT blood cultures (aerobic and anaerobic) × 2, 30 minutes apart

STAT CMP & CBC

Begin TPN at 85 mL/hr

Piperacillin sodium/tazobactam sodium (Zosyn) 2.25 g q6h

Vancomycin (Vancocin), renal dosing per pharmacy, IVPB q12h

Furosemide (Lasix) 80 mg PO daily

Amlodipine (Norvasc) 5 mg PO daily

Potassium chloride (K-Dur) 40 mEq PO daily

Metoprolol (Lopressor) 25 mg PO bid

Ondansetron 4 mg IV every 6 hours PRN

Transesophageal echocardiogram ASAP

Admission Assessment

Blood pressure

152/48 (supine) and 100/40 (sitting)

Pulse rate

116 beats/min

Respiratory rate

22 breaths/min

Temperature

100.2°F (37.9°C)

Oriented × 3 to person, place and time, but drowsy.

Grade III/VI murmur.

Lungs clear bilaterally.

Abdomen soft with slight left upper quadrant tenderness.

Multiple petechiae on skin of arms, legs, and chest; splinter hemorrhages under the fingernails, hematuria noted in voided urine.

Laboratory Test Results

Na

138 mEq/L (138 mmol/L)

K

3.9 mEq/L (3.9 mmol/L)

Cl

103 mEq/L (103 mmol/L)

BUN

85 mg/dL (30.3 mmol/L)

Creatinine

3.9 mg/dL (345 mcmol/L)

Glucose

165 mg/dL (9.2 mmol/L)

WBC

6700/mm3 (6.7 x 109/L)

Hct

27%

Hgb

9.0 g/dL (90 g/L)

What is the specific pathophysiology of Jessica’s infective endocarditis?

What assessment data above supports this diagnosis?

How are you going to specifically monitor the following anatomy for and how? (i.e. monitor coronary arteries for signs of angina, MI, heart failure, and cardiac dysrhythmias through EKG, BNP, pulse, blood pressure, respiratory rate, cardiac enzymes, and patient’s description of chest pain.)

a. Cerebral:

b. Extremities:

c. Spleen:

d. Kidneys:

e. Bowels:

Answer 1

1.  the age of this women 50 yr and she has genetic autoimmune deficiency , which can laeds to easy bacetrial infection in blood either through minor abrasions occuring while brushing teeth , or small cut injury , from respiratory tracts, urinary tracts ... commonly caused by bacteria. but virus and fungai also causes.

peoples at risk for developing infective endocarditis include

those with congenital heart disease , artificial heart valves , heart valve disease , damaged heart valves ,history of endocarditis ,valve prolapse or regurgitation history , immunodeficiency states .

so this patient is having multie risk factors . tricuspid valve is most comonly involved. the bacteria may colonize initially sterile vegetation composed of fibrin and platlets . bactrerial growth enlarges the vegetation , further impending blood flow and increasing inflammation that involves the vegetation and adjacent endothelium. the vegetations are held together by agglutinating antibodies produced by bacteria. as inflammation increases , ulceration may results in erosion or perforation of valve cusps, leads to valvular incompetance ,damages to conductive pathway . DUKE criteria used for diagnosis ,. major criteria are 1. positive blood culture

2, evidence of endocardial involvment

minor criteria are 1. predisoising valvular or heart abnormality

2. IV drug abuse

3. pyrexia >38 degree celcius

4. vascular phenomina

5. immunological phenomina

6. microbiologuical evidence

clinical diagniosis criteria- 2 major criteria or

1 major and 3 minor criteria or

3 minor criteria

  

2. the data which supports this diagnosis are past history of similar illness , history of multiple risk factors , typical symptoms like fever , chills , rigors , left upper abdomen pain due to spllenomegaly, joint pain , nausea , vomiting. And examination findings shows fever,multiple petachia over the abdomen , arms, legs , chest ... spinter hemorhage under the finger nails . hematuria. soft abdomen and left upper qudrant tenderness . patient is consious but drowsy may be due to repeated vomiting, and on cardiogy examination shows grade 3 murmur due to the valve abnormalities caused by vegetations.. investigations shows high BUN may be due to kidney injury either due to high bp or as a result of abnormal heart function. hemoglobin also low level either due to autoimmune hemolysis or mechanical hemolysis.

3. things to monitor systematc basis in this patient are

cerebral   - monitor patients level of consiousnerss anddeveloping new syptoms of embolic stroke like headache, numbness of any body parts and its progression , muscle weakness , slurring of speach , difficulty in closuure of eyes , deviation of angle of mouth ... and do ct csan head or angiogram to rule out any intracranila problems and do appropriate managment.

extremeties - also look for absent of peripheral pulses and compare with other side , periphery coldness , pale , absence of sensatios ... to rule out any embolism and do appropriate drugs treatment, splinter hemorhages ,

spleen - look for enlarment , increasing tenderness , hemoglobin , hematocrite

kidney - monitor urine output , abdominal pain , edema arond eyelids , lower part of legs , colour of urine , sefrum creatine , BUN ,

bowels- monitor bowel movements , nausea , vomiting , diarrhoea , abdominal pain , cramps . bowel sounds . tendenes of abdomen ....

cardiac system - monitor for pulse rate , bp , development of new murmur , chestpain , palpitation. ecg , cardiac enzyme monitoring