INFECTIVE ENDOCARDITIS

Chief Complain:

“I have been feeling feverish and short of breath all week long.”

History of Past Illness:

JC is a 53-year-old woman who presents to the ED with complaint of fever, chills, and worsening
shortness of breath. These symptoms developed approximately 2 week ago. The patient was
seen in the ED 3 months earlier for incision and drainage of a skin abscess.

Past Medical History:

 Type 2 diabetes mellitus diagnosed 10 years ago

 Hypertension diagnosed 15 years a go
 Valvular abnormalities secondary to fenfluramine use.

Family History:

Noncontributary

Social History:

No H/O IDU; denies alcohol use, smokes one pack/day and has a 10 pack-year tabacco history

Meds:

 Tylenol 650mg po Q 4-6 h PRN headaches

 Metformin 500 mg po Q 12 h
 Lisinopril 20 mg po Q 24 h

Allergy:

Penicillin (hives)

Review of system:

Noncontributory except for complaints noted in HPI

Physical Examination

Gen.: Patient is a morbidity obese Caucasian woman with mild distress

Vital signs: BP 136/84, P 188, RR 24, T 38.9 degree C; wt: 128 kg Ht 5’5”

Skin/Nails
 Splinter haemorrhage noted on the rigt thumb nail 4-6 mm painful nodular lesions noted and
right foot pads

Head, Ear, Neck & Teeth:

Anicteric sclerae, PERRLA, pink conjucttivae, dry oral mucosa, no Roth spots; poor dentition

Neck/ Lymph Nodes:

Crackles in RLL; no wheezing

Cardiovascular

RRR, normal S1 and S2, S3, present, III/VI holosystolic murmur

Abdomen

Soft with mild diffuse tendersness, liver and spleen margins difficult to assess secondary to
obesity

Genital/ Rectal

Normal: guaiac negative stool

Extremities:

Reflexes bilaterally 4/5 UE, 3/5 LE, Babinski decreased, no edema

Neuro:

Non-focal; A & O x 3, (-) asterixis

Laboratoty

Na 133 meq/L Hct 23.6%

K 5.6 meq/L Plt 180x10^3/mm^3

Cl 91 meg/L RDW 17.3%

CO2 17 meq/L MCV 89.1 micrometer^3

BUN 15 mg/dl MCH 26.3 pg/cell

SCR 1.9 mg/dL MCH 34 g/dL

Glu 185 mg/dL WBC 15.4 x 10^3 /mm^3

Hgb 8.1 g/dL Neutros 78%

 Bands 8% Monos 2%

Lymphs 12% Albumin 2.6 g/dL

INR 1.0

ESR 93/h

ECG

Nonspecific T-wave changes; increased QT c interval

2D- echo (Transthoracic)

Unable to accurately visualize heart valves

Transesophageal Echocardiogram

8 mm vegetation on the vitral valve with severe regurgitation, and no perivalvular abscess noted.
Moderate left ventricular hyperthrophy

Blood Culture

3 of 3 sets (+) for staphylococcus aureus (collection times: 1:40, 3:20, 4:15).

Assessment

53-year-old female with history of diabetes, recnt I & D of a skin abscess, valvular abnormalities
secondary to fenfluramine presents with S. auresus endocarditis (vegetation on mitral valve).

Additional problems include hyperkalemia, renal insufficiency and possible acidosis (on metformin), and
hypertension.