23 Jun STRUCTIONS: All questions apply to thi
STRUCTIONS: All questions apply to this case study. Your responses
should be brief and to the point. Adequate space has been provided for
answers. When asked to provide several answers, they should be listed
in order of priority or significance. Do not assume information that is not
provided. Please print or write clearly. lf yourresponse is not legible, it i
will be marked as ? and you will need to rewrite it.
Scenario
J.F. is a 50-year-old married homemaker with a genetic autoimmune deficiency; she has suffered i
from recurrent bacterial endocarditis. The most recent episodes were a Staphylococcus aureus infec~ f
tion” of the mitral valve 16 months ago and a Streptococcus mutans infection of the aortic valve 1
month ago. During this latter hospitalization, an echocardiogram showed aortic stenosis, moderate
aortic insufficiency, chronic valvular vegetations, and moderate atrial enlargement. Two years ago J.F.
received an 18-month course of TPN therapy for malnutrition caused by idiopathic, relentless nausea A
and vomiting (NN). She has also had CAD for several years, and 2 years ago suffered an acute ante-
rior wall MI. in addition, she has a history of chronic joint pain.
Now, after being home for only a week, J.F. has been readmitted to your floor with endocarditis,
NN, 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, i
you note that she wears glasses and has a dental bridge. She is immediately started on TPN at 125 1
mI/h and on penicillin 2 million units lV q4h, to be continued for 4 weeks. Other medications are l
furosemide 80 mg PO qd, amiodipine 5 mg PO qd, K-Dur 40 mEq PO qd (dose adjusted according to
laboratory results), metoprolol 25 mg PO bid, and droperidol 0.25-O.5 ml lVP pm for NN. Admission
VS are 152/48 (supine) and 100/40 (sitting), 116, 22, 37.9? C. When you assess her, you find a grade
llNl holosystolic murmur and a grade lllNl diastolic murmur; 2+ pitting tibial edema but no peripheral
cyanosis; clear lungs; orientation x 3 but drowsy; soft abdomen with slight LUQ tenderness; hema-
turia; and multiple petechiae on skin of arms, legs, and chest.
1. What is the significance of the orthostatic hypotension, the wide pulse pres- O O O O 0
sure, and the tachycardia?
2. What is the significance of the abdominal tenderness, hematuria, joint pain,
and petechiae?
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