J.F. is a 50-year-old married homemaker with a genetic autoimmune defi ciency; she has suffered from
recurrent bacterial endocarditis. The most recent episodes were a Staphylococcus aureus infection of
the mitral valve 16 months ago and a Streptococcus mutans infection of the aortic valve 1 month ago.
During this latter hospitalization, an ECG showed moderate aortic stenosis, moderate aortic insuffi -
ciency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago J.F. received
an 18-month course of parenteral nutrition (PN) for malnutrition caused by idiopathic, relentless nausea
and vomiting (N/V). She has also had coronary artery disease (CAD) for several years, and 2 years ago
suffered an acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint
Now, after being home for only a week, J.F. has been readmitted to your fl oor with endocarditis,
N/V, 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,
you note that she wears glasses and has a dental bridge. She is immediately started on PN at 85 ml/hr
and on penicillin 2 million units IV piggyback (IVPB) q4h, to be continued for 4 weeks. Other medications
are furosemide (Lasix) 80 mg/day PO, amlodipine 5 mg/day PO, potassium chloride (K-Dur)
40 mEq/day PO (dose adjusted according to lab results), metoprolol 25 mg PO bid, and prochlorperazine
(Compazine) 2.5 to 5 mg IV push (IVP) prn for N/V. On admission vital signs (VS) are 152/48
(supine) and 100/40 (sitting), 116, 22, 100.2° F. When you assess her, you fi nd a grade II/VI holosystolic
(throughout systole) murmur and a grade III/VI diastolic murmur; 2+ pitting tibial edema but no peripheral
cyanosis; clear lungs; orientation \3 but drowsy; soft abdomen with slight left upper quadrant
(LUQ) tenderness;... [continues]
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