History of Present Illness:

39 y/o F, with a history of IVDU for 23 years and asthma, who presents to the ED due to abnormal lab results. Patient states she was called over a month ago and told to come to the ED, but she did not come to the ED until now. Cultures were taken on 1/28/21 while the patient was in the hospital for lower back pain and resulted on 2/1/21 after the patient was discharged, positive for enterococcus faecalis. Patient denies fever, chills, weakness, fatigue, weight loss, chest pain, palpitations, SOB, cough, abdominal pain, nausea, vomiting, changes in bowel habits, headache, dysuria or any other symptoms at this time.

PMHx: IVDU x 23 years – uses heroin twice a day, alcohol abuse, bipolar disorder, lumbar foraminal stenosis

Medications: Albuterol 2.5 mg q4h PRN, Advil 200mg PRN, Gabapentin 1 capsule three times a day

Allergies: NKDA

PSHx: C-section

PFHx: Mother COPD, Father asthma, Sister bipolar disorder

Social history: At least one alcoholic drink a day, 4-5 cigarettes a day, IV heroin use twice a day

Review of Systems:

General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills or night sweats

Skin: deniesrashes, pruritus or any changes to skin

Eyes: Denies anyvisual disturbance, blurring, diplopia, photophobia

Mouth and throat: Denies bleeding gums, sore throat

Neck: Denieslocalized swelling/lumps, stiffness or decreased ROM

Pulm: Denies SOB, cough, wheezing, hemoptysis, cyanosis, sputum production

CV: Denies chest pain, palpitations, irregular heartbeat, edema, syncope, known heart murmur, hypertension

GI: Denies change in appetite, abdominal pain, nausea, vomiting, hematemesis, jaundice, change in bowel habits, rectal bleeding

GU: Denies frequency, urgency, oliguria, polyuria, dysuria, hematuria

Nervous System: Deniesseizures, headache, loss of consciousness, sensory disturbances, change in mental status

Musculoskeletal System: Admits to back pain. Denies redness, swelling

Peripheral Vascular System: Denies claudication, coldness, edema, color change

Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE

Physical Exam:

Vitals: T 99, BP 100/50, RR 18, HR 82, O2 saturation 100%, Ht 5’4”, Wt 195 lb, BMI 33.99

Gen: Alert and oriented, in no acute distress. Well-groomed and appropriately dressed. 

Skin: multiple track marks on bilateral upper extremities. No erythema or warmth. No other lesions.

HEENT: normocephalic, atraumatic, mucous membranes moist, EOMI, PERRLA

Neck: Full ROM, supple

CV: Regular rate and rhythm. S1, S2. No murmurs or rubs appreciated.

Pulm: Clear to auscultation bilaterally

Abd: Soft, flat, nondistended, obese. No tenderness to palpation

MSK: No midline or paraspinal tenderness to palpation.

Neuro: no focal deficit

Psych: normal mood and behavior

 Assessment:

39 y/o F, with a history of IVDU for 23 years and asthma, who presents to the ED due to bacteremia from 1/28/21 with enterococcus faecalis. Patient is asymptomatic with no abnormalities appreciated on physical exam.

Differentials:

Bacteremia, infective endocarditis

Plan:

CBC

CMP

Lactate

PT/PTT

ESR/CRP

Troponin

Blood cultures

Urine HcG

EKG

CXR

Echo

Addendum:

Patient CXR with patchy right lower lobe alveolar consolidation. Lab findings significant for elevated ESR at 119, CRP at 133. Lactic acid and troponin within normal limits. Echo shows large vegetation, 1.6 cm x 1.2 cm, at tricuspid valve with mild-to-moderate regurgitation. Aortic valve cannot rule out small vegetation.

Disposition:

Admit the patient to telemetry with infective endocarditis and pneumonia. Will start the patient on IV Vancomycin and Zosyn. Will require cardiology consult and possible PICC line. 

Education:

You have a bacterial infection of one of the valves in your heart. This infection will be treated with antibiotics through an IV line. You will need IV antibiotics for several weeks and so a PICC line, which is a long catheter that can be used for long-term IV access, may be placed while you are admitted. Additionally, you have an infection in your lungs called pneumonia. This will also be treated with antibiotics while you are in the hospital.