J.F. is a 50-year-old married homemake with a genetic autoimmune deficiency; she has suffered frim recurrent bacterial endocarditis. The most recent episodes were a Staphylcoccus aureus infection of the mitral valve 16 months ago and a Streptococcus mutans infecton of the aortic valve 1 month ago. During this latter hospitalization, an ECG showed moderate left atrial enlargement. Two years ago J.F. received an 18-month course of total parenteral therapy (TPN) for malnutrition caused by idiopathic, relentless N/V. She has also had CAD for several years, and 2 years ago suffered an acute anterior wall MI. In addition, she has history of chronic joint pain.
Now, after being home for only two weeks, J.F. has been readmitted to your floor with endocarditis, N/V, and renal failure. Since yesterday she has been vomiting and retching constantly; she also has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note she wears glasses and has dental bridge. She is immediately started in TPN at 125 mL/hr and on penicillin 2 million units IV q4h to be continued for 4 weeks. Other medications are furosemide 80 mg PO qd, amlodipine 5 mg PO qd, K-dur 40 mEq PO qd (dose adjusted according to laboratory results), metoprolol 25 mg PO bid, prochlorperazine (Compazonee) 2.5 to 5 mg IVO prn for N/V, and Tylenol 650 mg PO q6h PRN for pain. Admission VS are 152/48 (supine) and 100/40 (sitting), 116, 22 37.9 C, 95%. When you assess her, you find a grade II/VI holosystolic murmur and a grade III/VI diastolic murmur, 2+ pitting tibial edema but no peripheral cyanosis, clear lungs, orientation x 3 but drowsy, soft abdomen with slight left upper quadrant (LUQ) tenderness, hematuria, multiple petechiae on skin and arms, legs and chest, and headache pain stating 5 out of 10.
Laboratory results included, Na 135, Cl 93, BUN 25, K 3.4, HCO3 26, Cr 0.85, Glu 105, WBC 18.5, Hgb 8.8, Hct 23.7, ptt 210.