Assignment Paper

3rd case report
A 35-year-old man presented with a 3-day history of fever ( maximal temperature 39,3° C), chills, progresing fatigue, heart palpitations and dyspnea.

Anamnesis morbi: Fever suddenly appeared 3 days ago, maximum t ° 39.3 ° C with strong chills, sweating. He have used paracetamol (1-2 tablets per day), ibuprofen (1-2 tablets per day), but the temperature dropped to 37.5 ° C for 2-3 hours. A heartbeat sensation, dyspnea during exercise, back myalgias have appeared on tha last day.

Anamnesis vitae: He cofirmed infrequent intravenous heroin use 1-2 times per week already 5 years and smoking (10 cigarettes per day 10 years). His past medical history includes mitral valve prolapse (MVP) diagnosed 15 years ago and apendectomy was performed 2 years ago.

Physical examination: the condition of the patient was serious. He was conscious, adequate, sweating. The respiration rate was 21 breaths per minute, but physical intolerance was evident – increase in dyspnea and tachypnea up to 28-30 times per minute during the al least slow movement in the bed. Sp O2 91 %. Lung auscultation revealed bibasilar crackles.Examination revealed regular heart rate 110 bpm, BP 110/65 mmHg, poor peripheral circulation – hands and feet cold, sweaty.
Her cardiovascular examination reveals a grade 2/4 pansystolic murmur that is loudest at the right upper sternal border, jugular venous distention.
Palpation revealed right upper quadrant discomfort and firm, rounding y of liver edge 2-3 cm below the costal margin.
Patient confirmed that urination was normal. t° 38,3°.
It was observed a needle track mark in left femoral vein projection without the signs of infection.

Laboratory findings (1 day):
Complete blood count: Biochemical blood tests:
WBC 19 * 109/l
Band forms 35%
Lymphocytes 8%
RBC 3,9 *1012/l
Hb 115 g/l
Ht 33%
ESR 32 mm/h
Potassium 4,2 mmol/l
Sodium 136 mmol/l
Chloride 100 mmol/l
Urea 9,8 mmol/l
Creatinine 93 mkmol/l
Bilirubin total 28,7 mkmol/l
Conjugated bilirubin 12,2 mkmol/l
ALT 78 v/l
AST 66 v/l
AF 43 v/l
GGT 21 v/l
LDH 112 v/l
Creatine kinase 267 v/l
Troponin I 1077 ng/ml
Brain natriuretic peptide 439 pg/ml
Albumin 30 g/l
CRP 321 mg/l
Procalcitonin 34 ng/l
Arterial blood gas analysis Coagulation tests
pH 7,52
paO2 84,6 mmHg
paCO2 25,5 mmHg
HCO3 20,7 mmol/l
ABE -1,7
Glucose 6,2 mmol/l
Lactate 2,2 mmol/l APTT-33s
SPA (Standardized prothrombin activity) 63%
INR 2.0
Fibrinogen 6,7 g/l

ECG

Chest X-ray

Transthoracic echocardiography Blood culture
Transthoracic echocardiography revealed large, mobile and pedunculated vegetation measuring 22 × 16 mm which was attached to the anterior leaflet of the tricuspid valve with severe regurgitation and pulmonary hypertension (mean pulmonary arterial pressure was 37 mmHg). The right ventricle and atrium were enlarged. The left ventricle valves were normal. Two blood samples were collected from different veins, analysis was performing

Treatment (day 1, day 2)
Dosage
Drug 1 day 2 day
Vancomycin 1 g infusion 15 min IV 2 2
Sol. Gentamycin 80 mg IV 3 3
Sol. Ringeri lactate 1000 ml IV 3 2
Esomeprazole 40 mg IV 1 1
Tab. Ibuprofeni 400 mg per os 3 3
Sol.Diazepami 5mg IM 2 2
Sl Heparini 10 000 VV IV infusion 24 val 1 1
Sol. HepaMerz 5g IV infusion 30 min 2 2
On day 3 laboratory confirmed that methicillin-susceptible Staphylococcus aureus was isolated in blood cultures.
On day 4 patient was operated. Routine preparation for surgery was made. Via cardiopulmonary bypass, large vegetation which was attached to the tricuspid valve was detected. The vegetation could not be removed with valve sparing. Tricuspid valve leaflets was resected and tricuspid valve was replaced with 33 no carbomedics bioprosthesis valve.
Laboratory findings (4 day):
Complete blood count: Biochemical blood tests:
WBC 29 * 109/l
Band forms 25%
Lymphocytes 18%
RBC 3,3 *1012/l
Hb 95 g/l
Ht 30%
ESR 31 mm/h

Potassium 5,2 mmol/l
Sodium 139 mmol/l
Ionized calcium 1,73 mmol/l
Chloride 110 mmol/l
Urea 21,8 mmol/l
Creatinine 323 mkmol/l
Bilirubin total 18,7 mkmol/l
Conjugated bilirubin 12,2 mkmol/l
ALT 57 v/l
AST 46 v/l
Albumin 21 g/l
CRP 278 mg/l
Procalcitonin 21 ng/l
Arterial blood gas analysis Coagulation tests
pH 7,42
paO2 100,6 mmHg
paCO2 35,5 mmHg
HCO3 20,7 mmol/l
ABE -1,7
Glucose 16,2 mmol/l
Lactate 4,2 mmol/l APTT-63s
SPA 43%
INR 2.7
Fibrinogen 7,7 g/l

Treatment (day 3, day 4)
Dosages
Drug Day 3 Day 4
Vancomycin 1 g infusion 15 min 2 2
Sol. Gentamycin 80 mgIV 2 2
Sol. Glucosae 5% 1000 ml IV 3 2
Esomeprazole 40 mg IV 1 1
Tab. Ibuprofeni 400 mg per os 2 2
Sol.Diazepami 5mg IM 2 2
Sol. Heparini 10 000 VV IV infusion 24 h 1 1
Sol. HepaMerz 5g IV infusion 30 min 2 2
The postoperative course was uneventful.
Tasks:
1. Analyze the treatment of the patient on the 1st day and the changes on 3rd day.

2. You are preparing patient for transfer to general ward – please, write the treatment recommendations.