Iind international faculty

Ankit kumar patel

Group no: 415b
SUBGROUP: 27

Clinical task 9 Management of patient with cardiomegaly

Clinical task.
Theme 9. Management of patient with cardiomegaly
A 27-year-old intravenous drug user presents to the emergency department with 4 weeks of
fever, productive cough, and pleuritic chest pain. He has had intermittent chills and drenching
night sweats. He reports a decreased appetite and a 5 kg weight loss.
Anamnesis. He has had no sick contacts. The patient has also noted occasional blood in his
urine. He denies any medical history and takes no prescription medications. He injects heroin
daily, smokes tobacco and marijuana, but does not drink alcohol. He is unemployed and has
had no recent travel.
Objective examination. On examination, the patient is febrile to 38,5°C, heart rate is 115 beat
per minute, and has a blood pressure of 92/65 mmHg. An oxygen saturation on room air is
90%. Respiratory rate is 23 per minute. He is thin and ill-appearing. His mucous membranes are
dry and he has poor dentition. His sclerae are slightly icteric. Neck exam reveals 6 cm of jugular
venous distention above the sternal angle. The pulmonary exam reveals bronchial breath
sounds over the right upper and left lower lobes. The cardiac exam reveals tachycardia, regular
rate, a normal SI and S2, and a blowing holosystolic murmur best heard at the left lower sternal
border. His abdomen is soft and nontender with normal bowel sounds. Skin exam reveals
findings, presented in the Figure 1.1, and needle marks on both upper extremities.
Investigations.
Complete blood count: red blood cell – 3,2*109/L, hemoglobin – 100 g/L, white blood cell –
15*109/L, eosinophils – 1%, band neutrophils – 11%, segmented neutrophils – 60%,
lymphocytes – 18%, monocytes – 8%, platelet – 180*109/L, ESR – 35 mm/h.
Biochemical analysis:  general protein – 68 g/L, albumin – 38 g/L, aspartate aminotransferase
– 106 IU/L, alanine aminotransferase – 118 IU/L, alkaline phosphatase - 88 IU/L, total bilirubin –
40 µmol/L, conjugated bilirubin – 32 µmol/L, creatinine – 132 µmol/L, urea – 5,4 mmol/L, total
cholesterol - 4,1 mM/L.
C-reactive protein – 110 mg/L (reference interval - < 5 mg/L).
Procalcitonin test – 4 ng/mL (reference interval - <0.10 ng/mL).
Urine analysis: color - deep amber, clarity – clear, specific gravity – 1020, рН – 7,5, protein –
protein – 0,66 g, leukocytes - 5 /hpf, erythrocytes - 0-4 /hpf, casts – none, crystals – none.
A blood culture was positive for methicillin sensitive staphylococcus aureus in blood sampling
during admission.
A 12-lead electrocardiogram is shown in Figure 1.2 below the task.
A transesophageal echocardiogram is shown in Figure 1.3 below the task.
Figure 1.1. Wrists of the patient

Figure 1.2. ECG

 Figure 1.3. Transesophageal echocardiogram

 
Questions to Task 1:
1. Make a rationale for diagnosis.
The patient above has
A high temperature.
Chills.
Night sweats.
Headaches.
Shortness of breath, especially during physical activity.
Cough.
Tiredness (fatigue)
Muscle and joint pain.
So the Diagnosis is right sided endocarditis
 2. Make a clinical diagnosis. Is it emergency? If yes, what emergency, how you must treat
it before proceeding through diagnosis?
Infective endocarditis (IE) is a serious disease that requires prompt recognition and early
treatment to minimize morbidity and mortality.
3. Make a differential diagnosis with proving of your choice.
Endocarditis must be differentiated from other causes of a fever of unknown origin (FUO) such
as pulmonary embolism, deep vein thrombosis, lymphoma, drug fever, cotton fever, and
disseminated granulomatoses.
4. What is “Duke criteria”, list them.
Persistently positive blood cultures, defined as recovery of a microorganism consistent with
infective endocarditis from: 2 blood cultures drawn 12 hours apart or all of 3 or most of 4 or
more separate blood cultures, with first and last drawn at least one hour apart.
5. Assign additional investigation according to a protocol.
Tests used to help diagnose endocarditis include:
Blood culture test. This test helps identify germs in the bloodstream. …
Complete blood count.
Echocardiogram.
Electrocardiogram (ECG or EKG).
Chest X-ray.
Computerized tomography (CT) scan or magnetic resonance imaging (MRI).
6. What findings on the echocardiogram will prove the diagnosis?
TTE = 60% sensitive, TOE = 90-99% sensitive, specificity of 90%
Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets,
or on implanted material in the absence of an alternative anatomic explanation
Abscess, or
New partial dehiscence of prosthetic valve
7. Decipher ECG according to general rules, and make a conclusion.
On EKG, endocarditis may be characterized by conduction abnormalities, low QRS
voltage, ST elevation, heart block, ventricular tachycardia, and supraventricular
tachycardia.

8. What are “Osler’s nodes”, “Janeway lesions”, “Roth`s spot”, “splinter hemorrhages”.
Which from these are presented in the Figure 1.1
Osler’s nodes are split pea–sized, erythematous, tender nodules located principally on the pads
of the fingers and toes.
Janeway lesions are irregular, nontender hemorrhagic macules located on the palms, soles,
thenar and hypothenar eminences of the hands, and plantar surfaces of the toes.
Roth Spots are defined as a white centered retinal hemorrhage and are associated with
multiple systemic illnesses, most commonly bacterial endocarditis.
Splinter hemorrhages can occur with infection of the heart valves (endocarditis). They may be
caused by vessel damage from swelling of the blood vessels (vasculitis) or tiny clots that
damage the small capillaries (microemboli).
9. Make a conclusion about all laboratory analysis presented in the task.
Marked leukocytosis is present.
An elevated erythrocyte sedimentation rate is present.
A positive serum rheumatoid factor may be present and is present in approximately 50% of
patients with the subacute disease.
The serum BUN and creatinine may be elevated if glomerulonephritis is present.
10. Make a rationale for patient`s treatment (group of drugs, pharmacological name,
dosage, route, time a day).
MANAGEMENT

Overview

Resuscitation
Specific therapy: IV antibiotics +/- surgery
Supportive care and monitoring
Treat underlying cause and complications
Consults: infectious diseases, cardiology, cardiothoracic surgery
IV antibiotics
Empiric treatment for community acquired disease with a native valve:
Benzylpenicillin 1.8 g (child: 45 mg/kg up to 1.8 g) IV, 4-hourly
+ flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 4-hourly
+ gentamicin 4 to 6 mg/kg (child <10y: 7.5 mg/kg; 10y+: 6 mg/kg) IV, for 1 dose, then
determine dosing interval for a maximum of either 1 or 2 further doses based on renal
function)
Empiric treatment for hospital acquired disease OR a prosthetic valve OR penicilin
hypersensitity OR suspected CA-MRSA:
Vancomycin 1.5 g (child <12y: 30 mg/kg up to 1.5 g) IV, 12-hourly
+ gentamicin 4 to 6 mg/kg (child <10y: 7.5 mg/kg; 10y+: 6 mg/kg) IV, for 1 dose, then
determine dosing interval for a maximum of either 1 or 2 further doses based on renal
function)
Duration: usually for at least 1 to 2 weeks (low risk patients may qualify for home-based
therapy)
Gentamicin is is given q24h and is usually stopped after 3 doses unless proven streptococcal or
enterococcal endocarditis (give q8h and continue)