X295484

PC: Mrs AH, 70F, Dublin, px 1 month ago with 1W hx of a lump on right chest, chest pain, fever and flu
like symptoms with a background pacemaker insertion.

HPC
1 month ago she presented with 1W hx of a small lump on the right side of chest, it was at the insertion
site of pacemaker. The lump was about 2x4cm in size, painful to touch, no discharge or skin changes.
She also has fever with it. She said the lump was progressively getting bigger and painful.

Together with it, she also had chest pain which was also progressively worse. She said the chest pain
was at right side of chest near the lump, it was constant in nature. She describes the pain as dull pain, no
radiation, nothing makes it worse or better and she rate as 4/10.

Other than that, she also had non specific flu like symptoms such as muscle pain, joint pain, fatigue, dry
cough and low grade fever.

She denied any recent weight loss, night sweats, SOB, orthopnoea, PND or palpitations.

Risk factors
Pacemaker was inserted in June 2016 where she had 3 cardiac events in the hospital. she was admitted
for severe cellulitis of left hand. This is the reason she had pacemaker on right side instead of left side of
chest.

She is diabetic. Diagnosed 18yo. Well controlled on insulin, no macro or microvascular complications.

No prosthetic heart valve or any problem with heart valves.

PMH:
DM, cellulitis
No HTN, C, personal hx of vascular events

PSH:
Cholecystectomy in 2003.

Med:
Insulin
NKDA

SH
never smoke, social drinker
Lives with husband, need home help as left arm is weak due to severe cellulitis which she was admitted
for 8W previous year which her heart problem started. She had 3 cardiac arrest at the same admission.

FH: Positive family hx of vascular problem where

-mum had stroke, DM
brother has angina

SR: Nil

In summary this is AS, 70F, px 1 month ago with 1W hx of a lump on right chest, chest pain, fever and flu
like symptoms with a background pacemaker insertion.
IX: Dukes criteria
Major

1. TOE
looking for any vegetation, dehiscence, abscess or new valve regurgitation

2. BC 3-6 sets from different peripheral venous sites, repeat 12-24H later with 3 sets
-Positive blood culture for typical Infective Endocarditis organisms (strep viridins or bovis, HACEK,
staph aureous without other primary site, enterococcus), from 2 separate blood cultures or
-2 positive cultures from samples drawn > 12 hours apart, or
-3 or a majority of 4 separate cultures of blood (first and last sample drawn 1 hour apart)

Minor

1. IVDU
2. Fever 38
3. Emboli phenomenon
4. Immunological phenomenon
5. +ve ECHO or BC that do not meet major criteria

2major, 1 major 3 minor, 5 minor

GOLD: pathological assessment of resected valvular tissue

FBC: anaemia
U&E: renal fc
Urinalysis: microscopic haematuria
Fundoscopy: roth spot
Crp: high
ECG: heart block
Glucose; DM

CTPA, MRI/CT brain: embolic phenomenon

CXR: r/o infection, heart failure

MX
ABC
IV access
O2
Diuretics, nitrate, dopamine, morphine
ABX
-native/ivdu: benzylpenicillin + gentamicin flucloxacillin (acute/ivdu)
-prosthetic/mrsa: vancomycin + gentamicin + rifampicin

Replacement of infected valve

-uncontrolled infection on active ABX meds
-haemodynamically unstable
-valvular dysfc
-ECHO features:increase in vegitation size despite tx, valve rupture/perforate, new heart block