Mr. Byrd, a 55 year old gentleman, submitted a sick call slip yesterday complaining of fatigue, headache, and joint aches. He states that he was seen in NSC about a month ago before being transferred to this facility, and was diagnosed with a “virus thing.” He was told to follow-up if there was no improvement, and so he submitted the sick call slip to be seen.
Nursing Sick Call Evaluation
SUBJECTIVE
Mr. Byrd states the symptoms began 2 to 3 months ago. He thinks he has had a fever but has not asked to check his temperature. Tylenol has not helped. His muscle and joint aches are diffuse. There is no joint swelling or erythema. His headache is in the temple and occipital region; the pain is constant; and Mr. Byrd denies photophobia and phonophobia. He denies any recent injuries and there is no one else sick in his unit (that he knows).
Allergies: No known drug allergies; no known food allergies.
Medications: Acetaminophen 650 mg every 12 hours PRN for aches and fever
OBJECTIVE
Vitals: T 100.6°F, P 102, R 20, BP 149/89, WT 136 lbs, HT 5’ 10”, BMI 19.5.
General: Alert, oriented x4, well-nourished, cooperative male, ill-looking.
Lungs: clear to auscultation without adventitious sounds
Heart: S1 S2, RRR, abnormal “swoosh” sound heard
Abdomen soft, non-tender to palpation, + bowel sounds all 4 quadrants
Musculoskeletal: no joint swelling or erythema noted; palpation of joints elicited no pain, except for bilateral knee areas.
Neurologic: A&O×4; cranial nerves II to XII are grossly intact.
CORRECTIONAL NURSE ACTIONS
Because Mr. Byrd was febrile, and the record indicated that he had been seen for this issue at the previous facility, and because in general he appeared ill, you decide to have the Provider evaluate him.
Mr. Byrd is then seen by the Provider.
PROVIDER ACTIONS
Review of Systems
The ROS is positive for a reported 15-lb weight loss over the past 2 months and swollen lymph nodes in his groin and armpits. The ROS was negative for chills, sweats, nausea and vomiting, rash, SOB, chest pain, abdominal pain, and weakness.
Relevant History
The patient’s medical history is positive for hypertension, for which he currently is not taking any medication. He has no surgical history. His social history includes social drinking and IV drug use, last time was “years ago.” He denies tobacco use. His family history is positive for mother dying at age 65 due to renal failure as a complication of diabetes; his father died at age 72 from an MI. His brothers are alive and well at ages 58 and 60.
Provider Physical Examination
Vitals: as above, as the patient was evaluated in Provider Sick Call immediately. Repeat temperature: 101.0 repeat blood pressure: 156/92
General: A 55-year-old man who appears older than his stated age; he appears tired, thin, and without energy.
Psychiatric: Appears tired but no signs of depression or anxiety.
Skin, Hair, and Nails: Skin is warm and dry; fingernails are smooth and shiny, transparent, and normally curved; Splinter hemorrhages are noted under the fingernails.. Hair distribution shows male pattern baldness; remaining hair is thick with normal luster.
Eyes: Corneas are clear. Conjunctivas are moist and without discharge; small red spots are seen on conjunctiva. Disc margins are sharp, arterioles are bright red with a narrow light reflex, and there is no tapering or nicking noted. There are no hemorrhages or exudates.
ENT/Mouth: Auricles are non-tender. Canals are patent; the tympanic membranes are intact; no bulging or erythema is noted. Oral examination unremarkable; a few dental caries noted.
Neck: There is no swelling or tenderness noted in the pre- or post-auricular nodes and posterior cervical, anterior cervical, or supraclavicular nodes.
Lungs: Breath sounds are heard throughout the lungs; are symmetric and vesicular. Breath sounds are low pitched and of soft intensity. No adventitious sounds are noted.
Heart: S1, S2; a loud S3 and audible S4; RRR. There is a grade IV/VI holosystolic murmur in the mitral region that radiates to the left axilla.
Abdomen: symmetric; skin smooth and soft without striae. No bulges, peristalsis, or pulsations are visible; non-tender to palpation; normative bowel sounds auscultated in all quadrants; no referred pain or rebound tenderness.
Lymphatic: There are several tender lymph nodes in the axilla bilaterally and there are approximately 2 cm, tender inguinal lymph nodes bilaterally.
Musculoskeletal: There are no areas of heat, tenderness, or soft tissue thickening; no fluid in the joints. Some tenderness is noted with movement of the knees.
Neurologic: A&O×4; cranial nerves II to XII are grossly intact.
Differential Diagnoses for Mr. Byrd
Tuberculosis is caused by Mycobacterium tuberculosis. Patients may be asymptomatic or present with dyspnea, hemoptysis, fever, chills, night sweats, and weight loss. The patient’s symptoms and social history indicate this could be a possible diagnosis. The presence of a new cardiac murmur makes this diagnosis unlikely.
Connective Tissue Disease is any disease that has connective tissues of the body as a primary target of pathology. Symptoms vary depending on etiology, but generalized symptoms include fever, arthralgias, myalgias, and rash. The presence of a new cardiac murmur makes this diagnosis unlikely.
Endocarditis is a bacterial infection of the endocardium and heart valves. Infective endocarditis presents with low back pain, and arthralgia or myalgia are common. A fever that rarely exceeds 103°F is also common. Other symptoms may include night sweats, chills, headache, and severe loss of appetite resulting in weight loss. The patient’s symptoms and finding of a new cardiac murmur strongly suggest endocarditis.
Lyme Disease is caused by the organism Borrelia burgdorferi and is transmitted by the bite of the deer tick. It presents with a rash and flu-like symptoms, followed by joint, musculoskeletal, neurologic, and cardiac manifestations. The patient’s symptoms make this a possible diagnosis. The presence of a new cardiac murmur and lack of the typical rash noted in Lyme disease make this diagnosis unlikely.
Lymphoma is a cancer that originates in the lymphocytes. The most common symptoms are painless peripheral lymphadenopathy, fever, night sweats, and weight loss. Common physical examination findings are fever, lymphadenopathy, hepatomegaly, splenomegaly, and abdominal pain. The diagnostic study of choice is a lymph node biopsy. The presence of a new cardiac murmur makes this diagnosis unlikely.
Most Likely Diagnosis: Endocarditis
The two most common forms of endocarditis are infective endocarditis and non-infective endocarditis. Infective endocarditis is an infection of the lining of the heart (endocardium) and often involves the valves of the heart as well as any areas with abnormal connections between the chambers of the heart or its blood vessels. It occurs when bacteria in the bloodstream clump on previously injured heart valves. Risk factors for endocarditis include injection drug use; compromised immune system; congenital heart defects; having a prosthetic (artificial) heart valve, pacemaker, or defibrillator; and deteriorated heart valves due to the aging process. It may be acute or subacute. Acute bacterial endocarditis usually begins suddenly with a high fever, tachycardia, and fatigue. Rapid and extensive heart valve damage occurs as a result. Subacute bacterial endocarditis occurs gradually, causing symptoms like fatigue, low-grade fever, tachycardia, weight loss, diaphoresis, and anemia.
Non-infective endocarditis occurs when blood clots that do not have bacterial contamination form on the heart valves and endocardium. It can progress to infective endocarditis if bacteria enter the bloodstream and attaches to the clots. In both infective and non-infective endocarditis blood clots can break free from the endocardium and heart valves, causing blockage of the arteries at major organs and stroke.
Diagnostic Tests/Imaging
A CBC was ordered with a CMP, Erythrocyte Sedimentation Rate (ESR), and Rheumatoid Factor (RF).
An Echocardiogram was ordered for the next day through the mobile x-ray company
PATHOPHYSIOLOGY
While bacteria are not usually found in the blood, an injury to the skin, lining of the mouth, or gums can allow a small number of bacteria to enter the bloodstream. Infections like those of the skin, gums and other areas of the body can also introduce bacteria into the bloodstream, as can certain dental, medical and surgical procedures. Individuals with normal heart valves typically are not affected by this small number of bacteria in their bloodstream, as the body’s immune system activates and quickly destroys the bacteria. For those individuals with damaged heart valves, the bacteria may clump on the valves (called vegetations), lodge in the endocardium, and begin to multiply. Sepsis can also introduce a large number of bacteria in the bloodstream, effectively overwhelming the immune system, from which endocarditis can develop even in individuals with normal heart valves. If the cause of infective endocarditis is associated with the injection of drugs or prolonged use of intravenous lines, the tricuspid valve (which opens from the right atrium into the right ventricle) is most often infected. With most other causes of endocarditis, the mitral valve or the aortic valve is infected.
PLAN
Obtain labs
Order echocardiogram for newly auscultated murmur
Monitor vital signs daily
**When the critical lab results were called in to the facility that afternoon, Mr. Byrd was sent to the emergency department for further diagnostics and treatment. He was diagnosed with Endocarditis and was admitted for intravenous antibiotics and monitoring.
PATIENT EDUCATION TOPICS
Any medication ordered and potential side effects
The treatment plan developed for the patient.
Pathophysiology of Endocarditis and the importance of prophylaxis for future medical interventions
Red flags to report, including shortness of breath,
COMMENTS
After completing 6 weeks of therapy, the follow-up echocardiogram and cultures were negative. The patient was instructed on the need for long-term prophylactic treatment with high-risk procedures.
REFERENCES
Cahill TJ, Prendergast BD. Infectious endocarditis. Lancet. 2016;387(10021):882–893. doi:10.1016/s0140-6736(15)00067-7
Medscape. Duke criteria for endocarditis: diagnose endocarditis. https://reference.medscape.com/calculator/endocarditis-diagnostic-criteria-duke
Mgbojikwe N, Jones SR, Leucker TM, Brotman DJ. Infectious endocarditis: beyond the usual tests. Cleve Clin J Med. 2019;86(8):559–567.
Pierce D, Calkins BC, Thornton K. Infectious endocarditis: diagnosis and treatment. Am Fam Physician. 2012;85(10):981–986.
Wijesinghe, Sampath. (2021). 101 Primary care case studies: A workbook for clinical and bedside skills. Springer Publishing Company. Kindle edition.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
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