La Consolacion University Philippines

College of Medicine
Internal Medicine Preceptorial

Medical History
Date: __August 25, 2022___
Time: _____10:00 am______

General Data:
This is a case of A.G a 47-years-old Male, Married, Filipino, Roman Catholic. He
is currently residing at City of Las Pinas. Consulted for the first time in Bulacan Medical
Center on Sept 08, 2022

Informant: Patient
Reliability: 90%

Chief Complaint: Fever of 4 weeks duration

History of Present Illness:

4 weeks prior to consultation, patient’s illness started with fever of 39.0-degree
celsius accompanied with cough and night sweat. To relieve the high fever, he
started to take Paracetamol 500mg taken as need. It is noted that the fever
subsides after taking medication. He stopped coming to work due to symptoms.
No other symptom added to the patient’s condition up until 2 weeks PTC.

2 weeks prior to consultation, he had a checkup at Perpetual Help Medical Center

and was diagnosed with UTI. It was treated with Co-amoxiclav 625mg tab BID for
7 days, there was no follow up but was compliant to the medications. CBC and
CXR was taken. Patient noticed to have decrease appetite and antipyretic
medication does not relieve high fever.

Few days prior to consultation, patient started to experience chills, and was noticed
by relatives to be pale looking and has yellowish skin. Even when he was taking
Paracetamol every 4 hours and antibiotics. Weakness is also complained due to
continuous high fever. this prompted the consult and was subsequently admitted.

Past Medical History:

Childhood:
▪ Unrecalled
Allergy:
▪ None
Medical:
▪ 2022 – Hypertension
▪ Uncontrolled due to non-compliance to medication
▪ Unrecalled highest bp record
▪ No HTN monitoring
Immunization:
▪ Unrecalled
▪ No COVID vaccine
Screening Test
▪ Complete Blood Count
▪ Chest X-ray
▪ Urinalysis
Surgical:
▪ None
Psychological:
▪ None
Family History:
Maternal:
Mother:
▪ Hypertension
Paternal:
Father:
▪ None
Siblings:
▪ None

Personal and Social History:

Patient A.G. is currently working as a Compression Diver for 5 years, he receives
a good amount of pay with the job. He is married and currently reside in a simple house
with adequate space. It is located at a subdivision. It has good ventilation, well-organized,
and twice a week garbage disposal. They have good source of water.

On her daily living, He lives an active lifestyle and usually stretches every day
before diving. He usually spends her free time with his friends. He is not a picky eater.
The patient smokes 10 sticks per day with smoking exposure of 9 pack-years, alcoholic
drinker of 1 bottle a day and he never tried drugs.

Obstetric-Gynecologic History:
▪ None

Sexual History:
The patient’s coitarche was 20 years old. Her last intimate physical contact was
last month with her husband. He had 2 partners which was her 1 st girlfriend and wife.
They do not use of any contraceptives such as condoms and pills.

Review of Systems: (change font color to red if present if your patient)

General:
□ Weight loss (%) □ Fatigue □ Fever
□ Weight gain (%) □ Weakness □ Chills
□ Trouble sleeping

Skin:
□ Rashes □ Lumps □ Itching
□ Dryness □ Color changes □ Moles
□ Hair and nail changes

Head:
□ Headache □ Head injury □ Dizziness
□ Light headedness

Eyes:
□ Vision □ Glasses or contact lenses □ Pain
□ Redness □ Blurred or double vision □ Flashing lights
□ Specks □ Glaucoma □ Cataracts
□ Last eye exam □ Excessive tearing

Ears:
□ Decrease hearing □ Ringing in ears (Tinnitus) □ Vertigo
□ Use of hearing aids □ Earaches □ Discharge

Nose and Sinuses:

□ Nasal Stuffiness □ Discharge □ Itching
□ Hay fever □ Nosebleeds □ Sinus pain
□ Frequent colds
Throat (Mouth and Pharynx):
□ Teeth with dental caries □ Gums □ Bleeding gums
□ Dentures □ Sore tongue □ Dry mouth
□ Sore throat □ Hoarseness □ Oral Thrush
□ Non-healing sores □ Last dental exam

Neck:
□ Lumps □ Swollen glands □ Pain
□ Goiter □ Stiffness of the neck

Breasts:
□ Lumps □ Pain or Discomfort □ Nipple discharge
□ Breast-feeding □ Self-examination practices

Respiratory:
□ Cough (dry or wet, productive) □ Sputum (color and amount)
□ Coughing up blood (hemoptysis) □ Shortness of breath (dyspnea)
□ Wheezing □ Pain with deep breath (Pleuritic pain)
□ Last Chest X-ray

Cardiovascular:
□ Chest pain or discomfort/Tightness □ High blood pressure
□ Palpitations □ Shortness of breath with activity
□ Need to use pillows at night to ease breathing (Orthopnea
□ Sudden awakening from sleep with shortness of breath (Paroxysmal Nocturnal
Dyspnea)
□ Swelling in the hands, ankles or feet (Edema)
□ Results of past Electrocardiogram (ECG) or other cardiovascular tests.

Gastrointestinal:
□ Swallowing difficulties □ Heartburn □ Change in appetite.
□ Nausea □ Rectal bleeding □ Change in bowel habits
□ Stools color and size □ Pain with defecation □ Constipation
□ Diarrhea □ Abdominal Pain □ Food intolerance
□ Hemorrhoids □ Excessive belching or passing of gas
□ Yellow eyes or skin (Jaundice) □ Liver or gallbladder problems

Urinary:
□ Frequency of urination □ Urgency □ Polyuria
□ Nocturia □ Incontinence □ Flank pain
□ Blood in urine (hematuria) □ Reduced caliber or force of the urinary stream
□ Hesitancy □ Burning or pain during urination
□ Dribbling □ Urine color (Amber)

Genital: Male
□ Pain with sex □ Hernias □ Penile discharge
□ Sores □ Masses or pain □ Erectile dysfunction
□ STD’s □ Testicular pain □ scrotal pain or swelling

Genital: Female
□ Pain with sex □ Vaginal dryness □ Hot flashes
□ Vaginal discharge □ Itching or rash □ STD’s

Peripheral Vascular:
□ Leg cramps □ Intermittent leg pain with exertion (Claudication)
□ Varicose veins □ Swelling in calves, legs or feet
□ Swelling with redness or tenderness
□ Color change in fingertips or toes during cold weather

Musculoskeletal:
□ Muscle or joint pain □ Stiffness □ Back pain
□ Redness of joint □ Swelling of joints □ Trauma
□ Limitation of motion or activity □ Generalized body pain

Neurologic:
□ Dizziness □ Vertigo □ Seizure
□ Changes in mood, attention, or speech □ Weakness
□ Changes in orientation, memory, insight or judgment □ Headache
□ Numbness □ Fainting □ Tremors
□ Weakness □ Paralysis □ Tingling

Hematologic:
□ Ease of bruising □ Ease of bleeding □ Anemia
□ Past transfusions □ Transfusion reactions

Endocrine:
□ Head or cold intolerance □ Excessive Thirst (Polydipsia)
□ Excessive Sweating □ Frequent urination (polyuria)
□ Change in appetite (polyphagia)

Psychiatric:
□ Nervousness □ Depression □ Memory loss
□ Tension □ Suicidal ideations □ Mood
□ Past counseling, psychotherapy or psychiatric admissions

Physical Examination:
GENERAL SURVEY
The patient arrived ambulatory to the ER. He is conscious, coherent, oriented, in
respiratory distress.

VITAL SIGNS
Blood pressure: 90/60 mmHg Heart Rate: 118 bpm Respiratory Rate: 40 rpm
Temperature: 38.8 O2 Saturation: 95% at room air
Height: N/A Weight: N/A BMI: N/A

SKIN
Skin is yellowish in color, dry, warm to touch, smooth, with good turgor. Pallor, no edema,
no jaundice, no lesions.

HEAD AND NECK

Normocephalic, no deformities, lesions or masses. Hair is generally normal in texture.
No scalp tenderness. Facial features are symmetrical. Skull and face are symmetrical.
No cervical lymphadenopathy noted.

EYES
Slightly icteric sclerae, lids are symmetrical, pale palpebral conjunctiva, no hyperemic
PPW. No noted discharge, redness, swelling, no lens opacity.

EARS
Normoset external ear. No skin tags and deformities. No discharge and lesions noted.
Cone of light is present.

NOSE
Nose is symmetrical, no lesions, masses, deformities. No discharge. No alar flaring.
Nasal septum midline.

MOUTH AND PHARYNX

Lips and mucosa are pinkish, palates are intact, tongue is symmetrical, uvula is at
midline and not inflamed. The oropharynx is pink with no tonsillar erythema or exudate.
There was no evidence of abnormal masses or leukoplakia. No bleeding. No oral
lesions. No cleft lip or cleft palate. Non-hyperemic pharyngeal walls
CHEST AND LUNGS
Symmetric Chest expansion. No nipple discharges. in respiratory distress. No
Retraction. No lesions or masses present. No abnormality on thoracic wall. No palpable
masses or tenderness on anterior and posterior chest. Equal Fremitus. Resonant in
percussion. Clear breath sound, negative crackles or any other abnormal lung sounds.

CARDIOVACULAR
Dynamic precordium, PMI 5th left ICS midclavicular line, no lifts, no thrills, no heaves, S1
heard best at apex, S2 heard best at base, Tachycardic, regular rhythm, grade 4/6
holosystolic murmurs at 5th mid LICS

ABDOMEN
Flat or Globular. No ascites noted. No skin discoloration. Normal bowel sound noted,
Negative abdominal bruits. Soft and no tenderness in all quadrant. Normal Liver size.
No palpable mass. Not distended bladder. No tenderness upon palpation of both
Kidneys. Negative kidney punch test.

RECTAL EXAMINATION
No rashes, lesions, sores. No palpable mass and tenderness noted.

GENITALS
No CVA tenderness, No rashes, normal color, no lesions, no discharges.

EXTREMITIES
Full and equal pulses, No edema. No lesion or ulceration. Capillary Refill Time less than
2 seconds.

NEUROLOGICAL EXAMINATION: Essentially normal

Cerebrum: Conscious, coherent, oriented to time, place and person; and able to follow
simple commands

Cerebellum: Patient able to do:

1. Finger to Nose test
2. Heel to Shin test
3. Rapid alternating movements of arms
4. Walk across the room or down the hill

CN I: able to identify odor of different substances e.g. coffee

CN II: 2-3mm, equally reactive to light and accommodation
CN III, IV, VI: intact EOMs, (-) nystagmus
CN V: (+) corneal reflex
CN VII: no facial asymmetry
CN VIII: intact gross hearing
CN IX, X: (+) Gag reflex
CN XI: can weakly shrug and elevate shoulders
CN XII: tongue in midline
O O O

Motor Sensory DTRs

(-) Babinski
(-) Nuchal rigidity
(-) Kernig’s, (-) Brudzinski
Fundoscopy: (+) Red-Orange Reflex, (-) Papilledema
Primary Impression and basis: to consider Subacute Bacterial Endocarditis
secondary to Pseudomonas infection, Septicemia, Hemolytic anemia, Mixed
aortic valve disease and mitral valve disease.

According to the 2015 ESC Guidelines on Infective Endocarditis, Patient A.G.’s case
shows clinical feature of IE such as fever, often associated with systemic symptoms of
chills, poor appetite and possible weight loss. Diagnostic findings in the CBC shows signs
of infection, increase in creatinine, SGPT, SGOP and alkaline phosphate suggest that the
liver and kidney is affected, there is also increase in bilirubin which is why patient presents
with jaundice. Urinalysis findings show hematuria and low-level proteinuria commonly
present in IE. Peripheral blood smear findings suggest anisocytosis which can be caused
by anemia.

Based on the Modified Duke criteria for IE, there are 3 minor criteria that can be seen in
the patient having predisposing heart condition which is seen in the 2D echo of the patient
presenting with Mixed aortic valve disease, mitral stenosis and mitral regurgitation.
Having fever of more than 38 degree celsius which is existing to our patient. Lastly, is the
microbiological evidence of having positive culture of active infection with organism
consistent with IE that can be seen in the Blood culture showing the existence of
Pseudomonas alcaligenes. These criteria suggest that there is possible IE in our patient.

On the Physical examination of the patient, finding in the HEENT which is icteric sclerae
and pale palpebral conjunctiva suggest anemia. CVS findings shows dynamic precordium
with grade IV to VI loud heart murmurs with palpable thrills that can be signs of IE.

Salient Features:

▪ Fever of 39 degree celsius

▪ Chills
▪ Night sweat
▪ Persistent cough
▪ Poor appetite
▪ Weakness
▪ Pallor
▪ Generalized body pain
▪ Dyspnea
▪ Heart murmurs

Differential Diagnosis:

COVID-19 infection- patient’s symptoms that include fever, cough, and shortness of
breath. There is also evidence of not being vaccinated with Covid 19 vaccines. It can be
ruled out since there is no loss of taste or smell and it need PCR testing to confirm
infection.

Rheumatic Heart Disease – relating with the patient’s heart valves disease and
presenting symptoms such as heart murmur and shortness of breath. But commonly it is
caused by bacterial infections called group A streptococci and pertinent features is having
strep throat or scarlet fever.

Myocarditis – signs of fever, sweats, chills, dyspnea are present to the patient however
there is no findings of palpitations, arrhythmias or atrioventricular block which are
pertinent to myocarditis.
Plans for the patient (Diet, Diagnostics, Drugs, Disposition:)

Surgical therapy

Heart valve surgery may be needed to treat persistent endocarditis infections or to

replace a damaged valve.

The two primary objectives of surgery are total removal of infected tissues and
reconstruction of cardiac morphology, including repair or replacement of the
affected valve(s).

In aortic IE, replacement of the aortic valve using a mechanical or biological

prosthesis is the technique of choice.

Residual mitral regurgitation should be assessed using intraoperative TOE. Mitral

subannular, annular or supraannular tissue defects are preferably repaired with
autologous or bovine pericardium, a prosthetic valve then being secured to the
reconstructed/reinforced annulus, if necessary. The choice of technique depends
on the vertical extension of the lesion/tissue defect. The use of mitral valve
homografts and pulmonary autografts (Ross II procedure) has been suggested.

Diagnostics

• Blood culture test. This test helps identify germs in the bloodstream. Results
from this test help determine the antibiotic or combination of antibiotics to use
for treatment.

• Complete blood count. This test can determine if there's a lot of white blood
cells, which can be a sign of infection. A complete blood count can also help
diagnose low levels of healthy red blood cells (anemia), which can be a sign
of endocarditis. Other blood tests also may be done.

• Echocardiogram. Sound waves are used to create images of the beating

heart. This test shows how well the heart's chambers and valves pump blood.
It can also show the heart's structure. Your provider may use two different
types of echocardiograms to help diagnose endocarditis.

In a transesophageal echocardiogram, a flexible tube containing a transducer

is guided down the throat and into the tube connecting the mouth to the
stomach (esophagus). A transesophageal echocardiogram provides much
more detailed pictures of the heart than is possible with a standard
echocardiogram.

• Electrocardiogram (ECG or EKG). This quick and painless test measures

the electrical activity of the heart. During an ECG, sensors (electrodes) are
attached to the chest and sometimes to the arms or legs. It isn't specifically
used to diagnose endocarditis, but it can show if something is affecting the
heart's electrical activity.

• Chest X-ray. A chest X-ray shows the condition of the lungs and heart. It can
help determine if endocarditis has caused heart swelling or if any infection
has spread to the lungs.

• Computerized tomography (CT) scan or magnetic resonance imaging

(MRI). You may need scans of your brain, chest or other parts of your body if
your provider thinks that infection has spread to these areas.
Medications

▪ Give the prescribed antibiotics sensitive for Pseudomonas alcaligenes

o Ceftriaxone - 2 g/day i.v. or i.m. in 1 dose
o Gentamycin - 3 mg/kg/day i.v. or i.m. in 1 dose
▪ IV fluid replacement
▪ Iron supplement with folic acid and vitamin C supplement
▪ For Non-HACEK species
- Recommended treatment by ESC Guidelines for IE is early surgery plus
long-term (at least 6 weeks) therapy with bactericidal combinations of beta
lactams and aminoglycosides, sometimes with additional quinolones or
cotrimoxazole. In vitro bactericidal tests and monitoring of serum antibiotic
concentrations may be helpful.

Overall disposition:

Based on the patient’s history, he may have a poor outcome with infective endocarditis
due to the Non-HACEK Gram negative bacilli, severe left-sided valve regurgitation,
and signs of elevated diastolic pressures.

Patient should be admitted to the hospital for additional monitoring and evaluation. if
symptoms continue to worsen even with empiric antibiotic treatment, surgical therapy
may be considered. Patient may also be referred to Endocarditis team, Nephrologist,
Gastroenterologist and Cardiologist for further assessment.

Name of Medical Student: ___Jose Mari S. Ignacio___

Year level 3
Date: September 10, 2022