Ms. Collins, a 25-year old female, presents to the Emergency Department (ED) complaining of chest pain and tooth pain. You notice her eyes are bloodshot and she has what appear to be recent track marks from IV drug use on her arms. She is breathing rapidly and seems very uncomfortable. She has very poor dentition and appears to have multiple cavities and broken teeth. She denies any medical history.

Upon further assessment, Ms. Collins’ lungs are clear, pulses are 2+ bilaterally in radial and pedal pulses, S1 and S2 are present with a loud systolic murmur over the mitral and tricuspid valves. She has small bruises on her hands and arms and says her fingers are always cold. She admits to the use of IV heroin and cries that she wants to stop using. Per the provider, you insert a 20g peripheral IV in her left forearm and send a CBC and BMP. Her vital signs are as follows: BP 98/62 mmHg Ht 170 cm HR 92 bpm and regular Wt 55 kg RR 32 bpm SpO2 92% on Room Air Temp 37.9°C Pain 4/10, “comes and goes”

The ED provider orders the following: Blood – Blood Cultures x 2, Lactate level Diagnostics – CXR, Cardiac Echo. Interventions – 12-Lead ECG. Nasal Cannula to keep SpO2> 92%. Meds – Vancomycin 1,000mg IVPB one time, now. Morphine 2 mg PRN q4h for pain.

The 12-lead ECG shows normal sinus rhythm at 96 bpm with no ST abnormalities. After drawing blood cultures, you initiate the Vancomycin IVPB. The echocardiogram is completed which shows vegetation on valves and moderate to severe endocarditis with an EF of 50%. She is still complaining of chest pain so you also administer 2 mg Morphine IV push and place her on a bedside monitor. Ms. Collins’s lab results have resulted, the following abnormal values were reported: WBC 23,000/mcL BUN 38 mg/dL Creatinine 2.4 mg/dL Lactate 2.7 mmol/L You return 30 minutes later to take another set of vital signs and find Ms. Collins’ left eye and mouth drooping, she reports a new headache. You notify the provider who orders a STAT Head CT. The scan shows multiple small embolic strokes.

Ms. Collins is admitted to the cardiac telemetry unit for monitoring and continuous heparin infusion. She is also initiated on three different IV antibiotics to be administered around the clock. After 24 hours, her facial drooping and headache have resolved. Her vital signs are as follows: BP 90/56 mmHg SpO2 94% on 2L nc HR 102 bpm Pain 5/10 chest, comes and goes 3/10 left jaw pain, continuous RR 26 bpm
Doctors determine that Ms. Collins needs to have her mitral valve repaired, but that multiple teeth will need to be pulled first to prevent further infection or complications.

After 3 weeks of IV antibiotics, Ms. Collins is taken to the OR to remove 6 infected molars. She recovers well and is tolerating all antibiotics and medications. Her most recent echocardiogram showed less vegetation and inflammation and an EF of 65%. Three weeks later she has completed a 6-week course of antibiotics and is able to receive a balloon valvuloplasty. She is now ready to be discharged home on clopidogrel (Plavix) and Aspirin.