power point

DIFFERENTIAL CASE

PRESENTATIONS By

Regis College.

Case study presentation,

Case study presentation,

The case study is 28-year-old woman with opioid use

disorder; uses IV heroin; has PTSD; no other medical

problems or medications. She currently is single, lives with

several roommates, and has a history of legal problems

(with some jail time). Sexually active with men and

women; inconsistent use of protection.

.

Symptoms are:

•Shortness of breath

•Chest pain

•Flank pain

•Fever

PATHOPHYSIOLOGY OF THE DISORDERS FROM THE MOST

TO THE LEAST LIKELY FOR PATIENT

Case study presentation,

PATHOPHYSIOLOGY OF ENDOCARDITIS.

Infective endocarditis is an infection of the heart valves or the heart’s inner lining,

known as the endocardium. Infective endocarditis is usually caused by a bacteria or a

fungus. Intravenous Drug Abuse Endocarditis occurs in individuals who share

contaminated needles and syringes while using illegal drugs, as seen in patient history,

The infection from the site of injection (hand or arm) may enter the bloodstream (usually

resulting in bacteremia) and attack the lining of the heart or the heart valves, the mitral

valve is frequently most affected (Purohit,2018). The inflammation disrupt blood flow

and effectiveness of the ventricle, the valve may be scarred, leading to stenosis and

fibrosis (Hubert & VanMeter, 2018).

Case study presentation,

Continuation of pathophysiology of Endocarditis

Patient presented with fever, shortness of breath, flank pain and chest pain, this agrees with

Purohit (2018), the signs and symptoms of Intravenous Drug Abuse Endocarditis range from

low-grade fever, fatigue, and joint pain, to severe features that include stroke cardiac

arrhythmias, and damage to kidney and spleen leading to flank pain, chest pain may occur.

Case study presentation,

PATHOPHYSIOLOGY OF ANXIETY.

The neurochemical of anxiety has been postulated to arise from the amygdala, the brain area

that registers the emotional significance of environmental stimuli and stores emotional

memories. The efferent pathways from the central nucleus of the amygdala travel to a

multiplicity of critical brain structures, including the parabrachial nucleus (resulting in dyspnea

and hyperventilation), the dorsomedial nucleus of the vagus nerve and nucleus ambiguous

(activating the parasympathetic nervous system), and the lateral hypothalamus (resulting in

SNS activation).

Case study presentation,

Continuation of pathophysiology of anxiety

During panic attacks the fear is of imminent death; in social phobia, the fear is of embarrassment; in

posttraumatic stress disorder, the traumatic memory is remembered or re-experienced; in obsessive-

compulsive disorder, obsessional ideas recur and intrude; and in generalized anxiety disorder, anxiety is

“free-floating” (i.e., not conditioned to specific situations or triggers) Anxiety disorder most often associated

with cardiovascular symptoms of chest pain, tachycardia, and dyspnea respiratory rate with the induction of

an accompanying subjective sense of breathlessness. Patient had history of legal case and PTSD which

can predispose her to anxiety, manifested by shortness of breath and chest pain.

Case study presentation,

PATHOPHYSIOLOGY OF HEPATITIS C

Hepatitis C is Caused by the hepatitis C virus (30-60 nm RNA virus). HCV is mainly

transmitted through the skin, and most often by sharing needles and other equipment in IV

drug use. It is also a sexually transmitted disease. It is also able to be transmitted to an

infant if the mother is infected. People who undergo hemodialysis are also at risk. The

incubation period is 35-60 days. The inflammatory process is activated throughout the

whole liver, and hepatocytes are destroyed by cytotoxic cytokines and natural killer cells,

both parts of the inflammatory process. Cellular necrosis takes place. If inflammation

affects the periportal areas, cholestasis, or the interruption of the flow of bile takes

place. The liver is usually able to repair itself and regain complete function if no other

complications occur.

Case study presentation,

Continuation of pathophysiology of hepatitis c

The person feels malaise, rash, arthritis, fever and angioedema from this activation. Abnormal

proteins are also produced in the blood, termed cryogloblinemia. The person may also develop

vasculitis and glomerulonephritis (Lewis, Heitkemper, Bucher., & Camera 2011). In this scenario,

patient has history of IV drug use and unprotected sex, which might have predispose her to Hep C.

She also presented with fever which is one of the signs of hepatitis c.

Case study presentation,

SYNOPSIS OF MOST LIKELY DIAGNOSIS

Endocarditis is most likely the culprit for patient complaints because signs and symptoms of

endocarditis such as fever, chest pain, flank pain, and shortness of breath is what the patient

is manifesting, also she also have history of IV drug use which could predispose her to

endocarditis. Infective endocarditis (IE) is defined as an infection of the endocardial surface

of the heart, which may include one or more heart valves, the mural endocardium, or septal

defect. It effects include severe valvular insufficiency which leads to CHF and myocardial

abscesses (Brusch, 2019)

Case study presentation,

Diagnostic test includes

Blood and urine studies: Complete blood count, electrolytes, creatinine, blood urea nitrogen

(BUN), glucose, coagulation panel to the lab for testing which could baseline studies.

Blood culture: A blood culture test is used to identify any bacteria or fungi in your

bloodstream.

Echocardiography: This test is often used to check for signs of infection.

Radiography: X-ray images to see if endocarditis has caused your heart to enlarge or if any

infection has spread to your lungs

C

Case study presentation,

Treatment plan:

The major goals of therapy for infective endocarditis (IE) are to eradicate the infectious

agent from the thrombus and to address the complications of valvular infection. Based on

the results of the blood tests, appropriate antibiotic or combination of antibiotics to fight

the infection, Cause this patient has a history of intravenous drug, nafcillin and

gentamicin may be use to cover for methicillin-sensitive staphylococci. (Brusch, 2019)

Case study presentation,

Anticoagulation therapy: If an established reason for anticoagulation (e.g, deep venous

thrombosis, presence of a mechanical prosthetic valve) exists, a standard regimen of

anticoagulation should be followed. Evidence indicates patients who are anticoagulated

have worse outcomes than those who are not anticoagulated (Brusch, 2019)

Surgical intervention.

Establish Indications for surgery includes valvular dysfunction and heart failure,

advanced invasive disease (including perivalvular cellulitis, abscesses or

pseudoaneurysms, and intracardiac fistulae), prosthetic valve endocarditis, difficult-to-

treat organisms (such as Pseudomonas species and fungi), persistent bacteremia, large

vegetations, and emboli, Surgery would be considered early, rather than late (Rekik,

Trabelsi, Znazen, Maaloul, Hentati, Frikha, & Kammoun, 2009).

Case study presentation,

Case study presentation,

Referral would be to multidisciplinary team such as the “Endocarditis team” with

knowledge in cardiology, infectious diseases, microbiologists, imaging,

neurologists, (if surgery is indicated neurosurgeons, and cardiothoracic should

provide decisions regarding the indication and timing of surgery) for adequate

management and follow-up (Baddour, Wilson, Bayer, Fowler, Tleyjeh, Rybak,

et al, 2011).

My original off- the-cuff differential diagnoses for the patient were hepatitis B, Respiratory failure and

Endocarditis. Having researched, using the symptoms and patient history, anxiety and hepatitis C,

replace respiratory failure and Hepatitis B. Hepatitis C is chosen to replace B because is more

common with individuals use IV heroine. Hep. B have a vaccination which helps to reduce the

incidence of the infection but Hep. C do not have. Also, anxiety is chosen over respiratory failure

because signs and symptoms presented by the patient pointed more to anxiety attack than

respiratory failure coupled with the fact that the patient had history of PTSD and legal issues which

may lead to panic/ anxiety attack

Case study presentation,

REFERENCES

Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, et al.

Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of

Complications: A Scientific Statement for Healthcare Professionals From the American

Heart Association. Circulation. 2015;132(15):1435-1486. DOI: 10.1161/

CIR.0000000000000296

Brusch, J. L. (2019, November 11). Infective Endocarditis: Practice Essentials,

Background, Pathophysiology. Retrieved from

https://emedicine.medscape.com/article/216650-overview

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., Camera, I. M.

(2011). Medical-surgical nursing: Assessment and management of clinical problems (8th

ed.). St. Louis, MO: Mosby.

Rekik, S., Trabelsi, I., Znazen, A., Maaloul, I., Hentati, M., Frikha, I., Kammoun, S.

(2009). Prosthetic valve endocarditis: management strategies and prognosis: A ten-year

analysis in a tertiary care centre in Tunisia. Netherlands heart journal : monthly journal of

the Netherlands Society of Cardiology and the Netherlands Heart Foundation, 17(2), 56–

60. doi:10.1007/bf03086218 Case study presentation,