Chapter 128: Infective Endocarditis: A Symptom of the Larger Disease Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Identify major and minor diagnostic criteria for infective endocarditis.

• Select an appropriate empiric antibiotic regimen for presumed infective endocarditis.

• Design a pharmacotherapy regimen for endocarditis that takes into account patient-specific factors such as medication allergies, comorbidities, and social history.

• Recognize the psychosocial and ethical issues related to the treatment of infective endocarditis among intravenous drug users.

• Establish monitoring parameters for a selected drug therapy in the treatment of a patient with infective endocarditis.

PATIENT PRESENTATION

Chief Complaint

“Let me go home! I was just tired, nothing is wrong with me! Why am I here?”

HPI

Christina Meyer is a 27-year-old woman who presents in police custody after being found unconscious outside the local gas station. She was only minimally responsive upon arrival of EMS but became combative in the field following a dose of naloxone. Upon arrival to the emergency department, Ms Meyer remains altered but is able to relay symptoms of cough, chest pain, and shaking chills. She vehemently denies any illicit drug use.

PMH

Generalized anxiety disorder (diagnosed 5 years ago)

Chronic back pain (diagnosed 6 years ago, due to workplace-related injury)

Migraine headache (diagnosed 8 years ago)

Genital herpes (diagnosed 2 years ago)

FH

Mother: Depression, committed suicide 12 years ago

SH

Tobacco use, 1/2 ppd; “social” EtOH use; denies illicit drugs

Meds

Amitriptyline 100 mg PO QHS

Ibuprofen 200 mg, two tablets PO Q 6 H PRN back pain

Sertraline 100 mg PO QD

Valacyclovir 500 mg QD

All

Amoxicillin (unknown reaction as a child)

ROS

Constitutional: Chills. Uncertain about fevers. No weight loss or appetite change.

HEENT: No visual disturbances, nose bleeds, recent cold symptoms, or voice changes.

Respiratory: No shortness of breath, cough. No hemoptysis or wheezing.

Cardiovascular: Diffuse chest pain. No palpitations, orthopnea, or leg swelling.

GI: No diarrhea, stomach pain, nausea, vomiting, or blood in stools.

GU: No dysuria, hematuria, or frequent urination.

MS: No joint pain or swelling. No extremity weakness. (+) back pain.

Integumentary: No rash or jaundice.

Neuro: Headache, questionable syncope, mild confusion. No dizziness or seizures.

Psych: Anxious. ...