Question

help please. questions 5-16 please

PATIENT CASE HPI Mr. H.Y. is a 63-year-old male, who presents to the ER with a two-day history of high-grade fever with chills. "I don't feel well and I think that I may have the flu," he tells the ER nurse and physician. He also complains of "some painful bumps on my fingers and toes that came on last night." He denies IVDA. When asked about recent medical or dental proce- dures, he responded: "I had an infected tooth removed about two weeks ago." He does not recall receiving any antibiotics either prior to or after the procedure Patient Case Question 1. Which type of infective endocarditis is suggested by the patient's clinical manifestations--acute or subacute? PMH Asthma since childhood Rheumatic fever as a child X 2 with mitral valve replacement 2 years ago HTN X 20 years DM type 2, x 9 years COPD X 4 years H/O tobacco abuse Alcoholic liver disease Patient Case Question 2. Which three of the illnesses in this patient's medical history may be contributing to the onset of infective endocarditis and why are these diseases considered risk factors? FH Mother died from CVA at age 59; also had ovarian cancer Father had H/O alcohol abuse; suffered AMI at age 54; DM type 2; died in his 60s from pancreatic cancer that "spread to his bones SH Married for 43 years, recently widowed and lives alone Father of 4 and grandfather of 10 One son lives in same city, but his other children live in other states Insurance salesman who retired last year Monthly income is derived from social security, retirement account, and a small life insur- ance benefit following his wife's death (breast cancer) Manages his own medications, has no health insurance, and pays for his medications himself 45 pack-year smoking history, but quit when he was diagnosed with emphysema Has a history of alcohol abuse, but quit drinking 4 years ago; continues to attend AA meet- ings regularly and is active in his church as an usher and Prayer Warrior ROS Patient denies any pain other than the lesions on his fingers and toes Denies cough, chest pain, breathing problems, palmar problems (+) for mild malaise and some loss of appetite plantar rashes, and visjon Patient Case Question 3. What is the significance of the absence of breathing problems, chest pain, rashes, and visual problems? Meds Theophylline 100 mg po BID Albuterol MDI 2 puffs QID PRN Atrovent MDI 2 pulfs BID Nadolal 40 mg po QD Furosemide 20 mg po QD Metformin 850 mg po BID Parient Case Question 4. For which nwo disease states might the patient be taking theo- phylline? Patient Case Question 5. Which medication or medications is the patient taking for abetes? Petient Case Ouestion 6, Which medication or medications is the patient taking for igh blood pressure? All Penicillin (rash, shortness of breath, significant swelling "all over") Patient Case Question 7. Why are the clinical manifestations of the penicillin allergy so significant? PE and Lab Tests Gen The patient is a significantly overweight, elderly male in moderate acute distress. His skin is pale and he is slightly diaphoretic. He is shivering noticeably Vital Signs See Patlent Case Table 7.1 Patient Case Table 7.1 Vital Signs Ht 510 BP 150/92 RR 23 and unlabered 102.5 252 lh P 118 W Patient Case Question 8. Is this patient technically considered overwelght or obese? Skin/Nails Very warm and clammy .No rashes No petechiae or splinter hemorrhages in nail beds Multiple tattoos No "track" marks Patient Case Question 9. What is the significance of the absence of "track" marks? HEENT Anicteric sclera PERRLA EOMI Conjunctiva WNI No retinal exudates TMs intact . Nares clear Oropharyax benign and without obvious lesions Mucous membranes moist Poor dentition Neck Supple (-) for lymphadenopathy, JVD, and thyromegaly Heart Tachycardia with regular rhythm Normal S, and S, Diastolic murmur along the left sternal border (not previously documented in his medical records), suggestive of aortic regurgitation Patient Case Question 10. What is the most significant and relevant clinical finding in the physical eamination so far and what is the pathophysiology that explains this clini cal sign? Chest CTA throughout Equal air entry bilaterally No wheezing or crackles Chest is resonant on percussion Abd Soft and non-tender (4) bowel sounds No organomegaly Genit/Rect Deferred Ext No CCE Reflexes bilaterally 5/5 in all extremities Small, tender nodules that range in color from red to purple in the pulp spaces of the terminal phalanges of the fingers and toes ( Osler nodes") Neuro No focal deficits noted A& 0 x 3 Laboratory Blood Test Results See Patient Case Table 7.2 Patient Case Table 7.2 Laboratory Blood Test Results 135 meg/L 145 mg/dl. Na Glu, random Bands 7% 3.7 mog/L 100 meq/L Lymphs нь 14.1 g/dl 40 % 12% C Hct Monos 1% нсо, 213.000mm 22 mey/L Plt Alb 4.0 pdL 17 mgd 10 mgdl BUN 19.500mm WBC ESR 30 mm/br Cr Neutros 80% Ca 8.9 mgdl. Parient Case Question 11. dentify five elevated laboratory test results that are consis- tent with a diagnosis of bacterial endocarditis Patient Case Question 12. Explain the pathophysiology for any three of the five elevated. laboratory results identified in Question 11 above. Patient Case Question 13. ldentify two subnormal laboratory results that are consistent with a diagnosis of bacterial endocarditis. Urinalysis The urine was pale yellow, clear, and negative for proteinuria and hematuria. A urine toxi- cology screen was also negative Patient Case Question 14. Explain the pathophysiology of proteinuria and hematuria in a patient with infective endocarditis. ECG Normal Transthoracic ECHO A 3-em vegetation on the aortic valve was observed. No signs of ventricular hypertrophy or dilation were seen Blood Cultures 3 of 3 sets (+) for Sreptococcus viridans (collection times 1030 Tuesday, 1230 Tuesday, 1345 Tuesday) Patient Case Question 15. What are the six diagnostic Modified Duke University criteria that favor a diagnosis of infective endocarditis in this patient? Patient Case Question 16. What is the appropriate pharmacologic treatment for this patient?

Answer 1

question no. 5

Antidiabetic medication that using by the patient is:

Metformin 850 mg po BID.

Metformin is an antidiabetic medication used by the type 2 diabetes patients.

question no.6

Antihypertensive drugs are Nadolol and furosemide( diuretic: increases urine output there by reducing the fluid retention)

Nadolol 40 mg po QD

Furosemide 20 mg QD

question no. 7

Clinical manifestations of penicillin allergy is so significant that a patient with hypersensitivity to penicillin should exclude from the treatment with penicillin. otherwise there are chances to develop anaphylaxis reaction with the subsequent doses of penicillin. Anaphylaxis is a fatal allergic reaction to allergens. A patient who shows allergic symptoms to penicillin can be notified to physicians so they won't prescribe the patient with another dose of penicillin antibiotics.

question number .8

patient is technically considered as Obese. His Body Mass Index is 49.2.

BMI = weight in kilograms/ ( height in meters)²

^{= 114.305/( 1.524×1.524)= 49.2 (25-29 is in the over weight range andabove 29 is obese)}

^{question no. 9}

^{absence of track marks: Track marks are the proof of drug abuse intravenously. Chronic drug abuse patients may have the track marks. Absence of track marks is very significant in patient examinations, especially patients who diagnosed with endocarditis. One of the main cause of endocarditis is Intravenous drug abuse. In the absence of track marks on patient's limbs , a physician can conclude that endocarditis is due to another reason.}

^{question no.10}

^{most significant findings in PE is diastolic murmur}

^{Diastolic murmur in the patient is indicative of Aortic regurgitation.}

^{pathophysiology: Infective endocarditis leads to the damage of valves in the heart. Inflammation of endocardium leads to the formations of blood clots at the sites of damged valves. Incompetency and partial closure of mitral valve leads to aortic regurgitation inturn leads to the diastolic murmurs.}