Comments on: Rounds on a sick young man

By: Hildy

Hildy — Tue, 10 Apr 2007 09:04:57 +0000

old murmur – suggestion of congenital valvular disease / MVP / some other predisposition to endocarditis. the mitral valve appears to be incompetent causing pulmonary hypertension and a bit of backwards left failure.

Ix: blood count, electrolytes, creatinine (with that renal infarct: can you use gent / vanc in this person?), blood cultures, echo (either TTE or TOE).

By: Graham

Graham — Tue, 10 Apr 2007 02:21:15 +0000

It’s never wrong to ask for all the vital signs.

ESR/CRP?

More history? IVDU? Recent invasive procedure?

What’s up with his crit–is that from the spleen?

By: Acrobat

Acrobat — Tue, 10 Apr 2007 01:17:07 +0000

I would agree with the tests, possibly add a TEE in prep for surgery, but would suggest that it is a left sided endocarditis, i.e. mitral valve. The fact that there was no mention of pulsatile liver suggests an intact tricuspid valve. A right-sided endocarditis would require some form of right-to-left shunt in order to create a systemic embolism; otherwise seeding would be primarily pumonary first.

Ultimately, though, therapy is directed towards sepsis until cultures define the bacteria. Echo, whether TTE or TEE, will define the state of the valve(s), and whether repair/replacement is required, and when. CT abdomen should be reviewed in more detail to determine the state of the spleen and kidneys vis-a-vis futher therapy (and bloodwork to determine renal function), and to establish whether there was any other injury.

By: #1 Dinosaur

#1 Dinosaur — Mon, 09 Apr 2007 20:41:14 +0000

Sorry: 2D echocardiogram and blood cultures. Treatment (in addition to intensive supportive care) would be antibiotics and possibly a CT surgery consult in the event urgent valve replacement is needed.

By: #1 Dinosaur

#1 Dinosaur — Mon, 09 Apr 2007 20:16:54 +0000

Endocarditis, with vegetations on the tricuspid valve. Throwing left-sided septic emboli (renal and splenic infarcts) with tricuspid insufficiency causing pulmonary edema (wet rales) and pump failure (hypotensive and tachycardic despite pressors.)