52 Year old male with infective endocarditis secondary to UTI

NOTE- this is an ongoing case, the E-LOG will be updated as and when we find new information 
This E-log has been created under the guidance of DR. Siddharth


CHIEF COMPLAINT –

A 52-year-old gentleman presented to the OPD with Cheif Complaints of
  • abdominal distension from the past 7 days
  • shortness of breath after having food from the past 7 days
HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic

2 years back the patient had a Non - Healing Ulcer Injury to the Right foot and visited the local hospital and was diagnosed with Diabetes Mellitus Type -II and was started on TAB- GLIMY-M2 PO/OD

2 years back he complained of Tingling in the upper limbs up to the palms, in the lower limbs up to the knee,

15 Days back the patient presented to the casualty with Abdominal Distension NOT associated with pain, No nausea, No Vomiting, No loose stools

He was admitted 15 Days back for Alcoholic Liver Disease, Acute Kidney Injury secondary to Urinary Tract Infection, or Chronic Kidney Disease HEPATIC encephalopathy grade-II, he was discharged on resolving complications. 

From the past 7 Days, He Complains of Abdominal Distension

For the past 5 days, he complains of Constipation and has not passed stools since

He Also complains of altered Sleep patterns from the past 5 Days

He has hiccups since today morning
HISTORY OF PAST ILLNESS

Known Case of
DM type -II
Chronic Kidney Disease
Hepatic encephalopathy Grade -I


DRUG HISTORY-
  • TAB- GLIMY-M2 PO/OD,

PERSONAL HISTORY -
  • He has been consuming alcohol for the past 20 years 150 ml daily
  • He has an altered sleep pattern for the past 5 days

FAMILY HISTORY -
  • No family history of DM, hypertension, Heart disease, or Asthma

GENERAL EXAMINATION -

  • The patient is conscious
  • Icterus is present
  • Oedema of the feet is present
  • Absence of pallor, cyanosis, lymphadenopathy, Malnutrition, Clubbing
VITALS -
  1. Temperature- Afebrile
  2. Pulse rate- 92 beats per minute
  3. Respiration Rate- 24 cycles per minute
  4. BP-100/70 mmHg
  5. SPO2 at room air-90%
  6. GRBS 76 mg%

SYSTEMIC EXAMINATION -

A. CARDIOVASCULAR SYSTEM
  • S1, S2 heard
  • No murmurs or thrills
  • JVP- normal
  • Ejection Systolic murmur is heard in all areas 
B. RESPIRATORY SYSTEM-
  • No Dyspnoea, wheeze
  • Central position of the trachea
  • vesicular breath sounds
C.EXAMINATION OF THE ABDOMEN -
  • Distended abdomen
  • Bowel sounds present
  • no tenderness, palpebral mass, free fluid
D. CENTRAL NERVOUS SYSTEM-
  • Conscious
  • normal speech
  • No signs of Meningeal irritaTION
  • No abnormality detectedd in cranial nerves, motor system, sensory system

PROVISIONAL DIAGNOSIS -

?INFECTIVE ENDOCARDITIS
?HEPATIC ENCEPHALOPATHY GRADE-I
?ALCOHOLIC LIVER DISEASE 

INVESTIGATIONS -

A. BIOCHEMICAL INVESTIGATION-



1. SERUM ELECTROLYTES



2. SERUM BILIRUBIN


3.BLOOD UREA




4. FASTING BLOOD SUGAR




5.POST LUNCH BLOOD SUGAR




6. SERUM CREATININE



7. LIVER FUNCTION TEST
 


8. RENAL FUNCTION TEST


B. PATHOLOGICAL INVESTIGATION-

1. COMPLETE BLOOD PICTURE


2. COMPLETE URINE EXAMINATION
 



3. HEMOGRAM




C. 2-D ECHO REPORT









D.ULTRASOUND REPORT

 

E. ECG 





TREATMENT

DAY 1-


  1.  INJ PAN 40mg IV
  2. .INJ MONOCEF 2g IV
  3.  INJ - VANCOMYCIN 
  4. SALT RESTRICTION <2G/DAY 
  5. FLUID RESTRICTION <1.5L/DAY
  6. INJ-LASIX 40mg IV
  7. INJ - ZOFFER 40mg IV
  8. SYRUP -LACTULOSE 1.5ml
  9. INJECTION THIAMINE IV
  10. TAB-BACLOFEN 10mg




THE PATIENT WAS REFERRED TO THE NEPHROLOGIST




on cross consultation, the following medications were prescribed -
1.INJ- LASIX 40mg IV
2.TAB NODOSIS 500mg
3. TAB. BIO -D3
4.IVF-NS-UO 30ml/hr
5. GRBS - 6th hourly


DAY 2- 

1. RENAL FUNCTION TEST 

TREATMENT - SAME AS DAY 1 

DAY 3- 
 
BACTERIAL CULTURE AND SENVITY REPORT 



MRI BRAIN PLAIN - 


Treatent - same as day 1
DAY 4 - 
  • Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr
  • Procto clysis enema
  • Inj. Pan 40 mg Iv/OD
  • Inj. Thiamine 200mg in 100ml NS /BD
  • Inj. HAI 6U S/C TID
  • Inj - Augmentin 1.2g IV / TID 
  • TAB Ecospirin 150 mg
  • Tab Clopidogrel 75mg 
  • Tab Atorvas 20 mg 
DIFFERENTIAL DIAGNOSIS - 
INFECTIVE ENDOCARDITIS  with AV VEGETATIONS
SECONDARY TO UTI
with AKI 
with  ?UREMIC ENCEPHALOPATHY?SEPTIC ENCEPHALOPATHY 
WITH ULCER OVER THE SOLE OF THE RIGHT LEG 
WITH ACUTE MULTIPLE INFARCTS IN BILATERAL CEREBRAL AND CEREBELLAR HEMISPHERES 

ADVICE AT DISCHARGE - 
  • Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr
  • Inj. Pan 40 mg Iv/OD
  • Inj. Thiamine 200mg in 100ml NS /BD
  • Inj. HAI 6U S/C TID
  • Inj. Augmentin 1.2 gm IV/TID
  • Tab. Ecospirn 150mg PO/HS/SOS
  • Tab. Clopidogrel 75mg PO/HS/SOS
  • Tab. Atorvas 20mg PO/HS/OD added
LINKS WITH RELEVANT INFORMATION - 

this article was used by me for comparison with the patient above in order to give my self a wider perspective of the case presentation of endocarditis 
 

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