Mr. K.P. is a 71-year-old female, who presents to your office with a 3-day history of more than 103F with chills. The patient reports, “I don’t feel well, and I think that I may have the flu.” 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 procedures, he responds: “I had an infected tooth removed about 2 weeks ago.” He does not recall receiving any antibiotics either prior to or after the procedure. Infective Endocarditis Discussion Forum Essay Sample

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
Urinalysis: The urine was pale yellow, clear, and negative for proteinuria and hematuria. A urine toxicology screen was also negative.

ECG: Normal

Transthoracic ECHO: A 3-cm vegetation on the aortic valve was observed. No signs of ventricular hypertrophy or dilation were seen.

Blood Cultures: 3 of 3 sets (+) for Streptococcus viridans (collection times 1030 Tuesday, 1230 Tuesday, 1345 Tuesday)

Laboratory Blood Test Results

Na 135 meq/L
K 3.7 meq/L
Cl 100 meq/L
HCO3 22 meq/L
BUN 17 mg/dL
Cr 1.0 mg/dL
Glu, random 145 mg/dL
Hb 14.1 g/dL
Hct 40%
Plt 213,000/mm3
WBC 19,500/mm3
Neutros 80%
Bands 7%
Lymphs 12%
Monos 1%
Alb 4.0 g/dL
ESR 30 mm/hr
Ca 8.9 mg/dL
Questions

1. What are the six diagnostic modified Duke University criteria that favor a diagnosis of infective endocarditis in this patient? Explain your answer.
2. Explain the pathophysiology of proteinuria and hematuria in a patient with infective endocarditis.
3. Identify four elevated laboratory test results that are consistent with a diagnosis of bacterial endocarditis. And explain the pathophysiology of the elevated values.

Discussion: Infective Endocarditis

1. What are the six diagnostic modified Duke University criteria that favor a diagnosis of infective endocarditis in this patient? Explain your answer.

This 71 year-old patient has several comorbidities that make them susceptible to developing infective endocarditis. To begin with, the advanced age and the several chronic conditions that he has lower his immunity and place him at risk of infections. These include diabetes (the hyperglycemic medium is favorable for microorganisms), valvular heart disease (the valve replacement provides a foreign body to which bacteria easily attach), and the history of rheumatic fever (Hammer & McPhee, 2018).

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The six Duke University diagnostic modified criteria in this patient that would favor the diagnosis of infective endocarditis are vegetation, microorganisms, a positive blood culture, fever, predisposing heart condition (valvular heart disease with replacement done), and evidence of endocardial involvement by the fact that he has a prosthetic valve (Durack, n.d.). The echocardiogram showed vegetation on the aortic valve. Blood culture was also positive for S. viridans and the patient had heart valves replaced by prosthetics due to rheumatic fever.

2. Explain the pathophysiology of proteinuria and hematuria in a patient with infective endocarditis.

Proteinuria is a very common finding in infective endocarditis. Together with microscopic hematuria they represent the renal complication of infective endocarditis (Hammer & McPhee, 2018). Up to 80% of infective endocarditis patients show the presence of proteinuria as a laboratory finding. Also, microscopic hematuria is usually found in about half of the patients diagnosed with infective endocarditis. Septic emboli are the cause of minute renal infarctions that affect the glomerular apparatus and compromise their efficiency. The result is proteinuria and hematuria. Usually, there is also resulting glomerulonephritis that contributes to the proteinuria and hematuria (Hammer & McPhee, 2018).

A number of factors contribute to the renal pathology caused by infective endocarditis. They include acute tubular necrosis due to septic emboli and bacterial exotoxins, renal parenchymal invasion by the infecting bacteria, cortical necrosis, and immune complex deposition amongst others (Hammer & McPhee, 2018). All these factors conspire to compromise the effectiveness of renal filtration and the result is proteinuria and hematuria.   Infective Endocarditis Discussion Forum Essay Sample

3. Identify four elevated laboratory test results that are consistent with a diagnosis of bacterial endocarditis. And explain the pathophysiology of the elevated values.

Four laboratory values that are elevated in the test results for this patient are the white blood cell count (WBC), the erythrocyte sedimentation rate or ESR, the percentage of neutrophils in the differential count, and the random blood glucose level. The normal white blood cell count in an adult is between 4.5 and 11.0 x 10⁹ while the normal erythrocyte sedimentation rate is 15 mm/ hr and below for males. This patient’s white blood cell count is grossly elevated at a whopping 19,500 mm³ of blood. On the other hand, his erythrocyte sedimentation rate is also quite high at 30 mm/ hr. The random blood sugar in a diabetic is usually 126 mg/dL and above. This patient has a medical history of diabetes and that is why his random blood sugar was found to be 145 mg/ dL. The normal differential count of neutrophils is usually between 40% and 60% (Hammer & McPhee, 2018). For this patient, the neutrophil percentage is high at 80% indicating that the leucocytosis seen in the white blood cell count is largely due to this neutrophilia. WBC count is raised because the leucocytes fight the invading bacteria while the ESR indicates an active inflammatory process.

References

Durack, D. (n.d.). Duke criteria for infective endocarditis: Diagnostic criteria for endocarditis. https://www.mdcalc.com/calc/1731/duke-criteria-infective-endocarditis

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Discussion Forum Sample

Discussion questions in NUR-631 are presented with a range of options.

Read the questions carefully and follow directions regarding whether to select one, two or answer multiple questions for the response. Present responses using the sample format provided below and include at least two citations from peer-reviewed journals published within the last 5 years or from the textbooks. References must be in proper APA format. A substantive responses must be at least 150 words in length and pertain to the topic as it relates to pathophysiology.

Sample DQ

Select one of the following discussion questions for your discussion response.

1. What did Mark Twain mean when he said, “the difference between the right word and the almost right word is the difference between lightning and the lightning bug”? Demonstrate your answer by providing an example from your own life when “almost the right word” created confusion, misunderstanding, or adversity.
2. How can knowing your fellow students and fostering a sense of community benefit your educational experience?
3. Part of effective communication involves knowing how to respond rather than react to something someone has said or written. In the online classroom format, why is it important to read a classmate’s post and assess that person’s intended message before you offer a response? How can this skill of responding help you in your career?

Sample Student DQ Response Format

What did Mark Twain mean when he said, “the difference between the right word and the almost right word is the difference between lightning and the lightning bug”? Demonstrate your answer by providing an example from your own life when “almost the right word” created confusion, misunderstanding, or adversity.

It is very important to use the right words when communicating. If you do not select your words carefully you can end up not getting your point across or miss a great opportunity. Using the right word makes sure you are understood correctly. If you are not careful about the words you use, it is easier for people to misinterpret them. This can have a negative impact in the medical field, as miscommunication affects “patients’ quality of care, health outcomes, adherence to treatment and satisfaction” and is also cited as the “most common reason for patient medical complaints” (Morgan, 2013, p. 123).

I have experienced what the difference between the “right word” and the “almost right word” can do. A couple years ago I was having a tough time. I was really busy with a lot of different things and my family could tell it was wearing me down. One day my daughter came up and handed me a picture she drew of the two of us. I was in the middle of something and just took it and said, “Oh, that’s nice, thanks.” Later, I could see she was sad. I felt terrible and thought about how much work she put into the picture for me, and how she was trying so hard to make me happy. I used almost the right words, but not the right words. We both felt much better after I took the time to express how I really felt.

Reference:

Morgan, S. (2013). Miscommunication between patients and general practitioners: Implications
for clinical practice. Journal of Primary Health Care, 5(2), 123-128.

Infective Endocarditis Discussion Forum Essay Sample