I Human Case - Edited

Running head: I HUMAN CASE 1
I Human Case: Left Facial Paralysis
Student’s Name
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I HUMAN CASE 2
I Human Case: Left Facial Paralysis
Facial paralysis is a common presentation that could be an implication in a wide variety
of pathological conditions. As such, making a diagnosis of such a presentation could be difficult.
However, it imperative that a clinician makes an accurate diagnosis to inform the management of
the underlying condition for better outcomes (Kestler et al., 2017). Achieving such an objective
would call for the collection of a detailed history, a thorough physical examination, objective
diagnostic testing, and informed management. As such, this management takes note of the case
of a 41-year-old patient to discuss how a detailed history, physical examination, and diagnostic
testing could inform the diagnosis of infective endocarditis for proper management.
History of Presenting Illness
A 41-year-old male patient presents with a 2-week history of complaints of left facial
paralysis, acute on the onset. The patient also reports a history of persistent cough, fever, chills,
and different new lesions on the skin that also started about a fortnight ago. The fever was high
grade, intermittent, and not associated with rigors (Papadakis, McPhee, & Rabow, 2014).
However, the patient reports no history of seizure; bladder or bowel incontinence; food
regurgitation; burning sensation on urination; increased urinary frequency; abdominal pain,
nausea, and vomiting; or cough with expectoration and breathlessness. The patient denies any
history of similar episodes but reports to have had been managed for a cardiovascular lesion
about a year ago for which prescription drugs were administered. However, the patient denies
any history of alcohol consumption nor cigarette smoking with no family history of
cardiovascular pathology.
Physical Examination
I HUMAN CASE 3
On examination, the vitals reveal that the patient is febrile with an oral temperature of
101oF, a pulse rate of 136 beats per minute revealing tachycardia, a blood pressure of 168/78
showing systolic hypertension, and a respiratory rate of 22 breaths per minute revealing
tachypnea. Cardiovascular examination reveals a new onset of 4/6 systolic ejection murmur in all
the valve areas, but loudest at the apex, which locates at the midclavicular line fifth intercostal
space. Of note on dermatological assessment is the presence of multiple macular lesions on the
skin evident bilaterally on the distal extremities (Papadakis, McPhee, & Rabow, 2014). On the
right arm, as well as on the back, plaques of psoriasis are evident with plaques on healing stages
visible not only on the arms but also on the hands. There is also the presence of splinter
hemorrhages bilaterally on the extremities. On the central nervous system examination, the
patient is conscious and oriented both in time and space. However, despite having intact
memory, the patient is dysarthria with anomic aphasia (Jameson et al., 2017). Cranial nerve
assessment reveals upper motor neuronal lesions on the facial nerve on the left side.
Differential Diagnoses and Laboratory Tests
From the assessment, the differential diagnoses include tuberculosis, Bell’s palsy, mitral
valve regurgitation, endocarditis, and transient ischemic attack. To rule out the differential
diagnoses and come up with the definitive diagnosis, the tests ordered included echocardiogram,
two sets of blood culture, complete blood count, BMP, both PA and lateral chest X-ray, and
brain MRI. Of the two samples of blood taken for culture, one was negative, whereas the other
depicted coagulase-negative staphylococci. A repeat of blood culture after five days also
revealed coagulase-negative staphylococci (Ross et al., 2017). An echocardiogram reveals
moderate mitral regurgitation, positive valvar vegetation, and ruptured chordae tendinae. As
such, brain MRI revealed small infarcts on the caudal aspect of the right paracentral gyrus with
I HUMAN CASE 4
an elevation of WBC to 20 x 109/L. From the history, assessment findings, and test results, the
definitive diagnosis as bacterial endocarditis.
Management Plan
As such, the management plan for this patient would aim at fulfilling such goals as
eradicating the underlying infectious agent from the vegetation besides addressing the
complications that would come in association with infective endocarditis, including both cardiac
and extracardiac consequences. As such, the management of this patient would employ
vancomycin 1 g IV BID for 4 weeks and gentamycin 80 mg BID for five days (Jameson et al.,
2017). However, it would be viable to continue weekly echocardiogram to assess the reduction in
the size of the vegetation with a follow-up with blood culture after three weeks to monitor the
progress of treatment.
Conclusion
In conclusion, this management takes note of the case of a 41-year-old patient to discuss
how a detailed history, physical examination, and diagnostic testing could inform the diagnosis
of infective endocarditis for proper management. The 41-year-old male patient presents with a 2-
week history of complaints of complaints of left facial paralysis, acute on onset. On examination,
the vitals reveal that the patient is febrile with an oral temperature of 101oF, a pulse rate of 136
beats per minute revealing tachycardia, a blood pressure of 168/78 revealing systolic
hypertension, and a respiratory rate of 22 breaths per minute revealing tachypnea. The
management plan for this patient would aim at fulfilling such goals as eradicating the underlying
infectious agent from the vegetation besides addressing the complications that would come in
association with infective endocarditis.

I HUMAN CASE 5
References
Jameson, J. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Loscalzo, J. (2017).
Harrison's Principles of Internal Medicine 19th Edition and Harrison's Manual of
Medicine 19th Edition (EBook) VAL PAK. McGraw Hill Professional.
Kestler, M., Munoz, P., Marin, M., Goenaga, M. A., Viedma, P. I., de Alarcón, A., ... & Costas,
C. (2017). Endocarditis caused by anaerobic bacteria. Anaerobe, 47, 33-38.
Liesenborghs, L., Meyers, S., Lox, M., Criel, M., Claes, J., Peetermans, M., ... & Missiakas, D.
(2019). Staphylococcus aureus endocarditis: distinct mechanisms of bacterial adhesion to
damaged and inflamed heart valves. European heart journal, 40(39), 3248-3259.
Papadakis, M.A., McPhee, S.J., & Rabow, M.W. (2014). Current medical diagnosis &
treatment: Geriatric (2nd ed.). New York, NY: Routledge.
Ross, K. M., Mehr, J. S., Greeley, R. D., Montoya, L. A., Kulkarni, P. A., Frontin, S., ... &
Montana, B. E. (2018). Outbreak of bacterial endocarditis associated with an oral surgery
practice: New Jersey public health surveillance, 2013 to 2014. The Journal of the
American Dental Association, 149(3), 191-201.

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Running head: I HUMAN CASE 1

I Human Case: Left Facial Paralysis

I Human Case: Left Facial Paralysis

Facial paralysis is a common presentation that could be an implication in a wide variety

of pathological conditions. As such, making a diagnosis of such a presentation could be difficult.

History of Presenting Illness

regurgitation; burning sensation on urination; increased urinary frequency; abdominal pain,

Differential Diagnoses and Laboratory Tests

revealed coagulase-negative staphylococci (Ross et al., 2017). An echocardiogram reveals

definitive diagnosis as bacterial endocarditis.

association with infective endocarditis.

Harrison's Principles of Internal Medicine 19th Edition and Harrison's Manual of

Medicine 19th Edition (EBook) VAL PAK. McGraw Hill Professional.

C. (2017). Endocarditis caused by anaerobic bacteria. Anaerobe, 47, 33-38.

(2019). Staphylococcus aureus endocarditis: distinct mechanisms of bacterial adhesion to

treatment: Geriatric (2nd ed.). New York, NY: Routledge.

Montana, B. E. (2018). Outbreak of bacterial endocarditis associated with an oral surgery

American Dental Association, 149(3), 191-201.

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