Summative Cases

Summative Case #8

Colleen Burgoyne, DNP, RN, FNP-BC

Case Study

Chief Complaint

“I feel terrible. I can’t stop shivering and it feels like I can’t catch my breath.”

Patient Profile

Name: Erin Monroe

Age: 28 years old

Gender: female

History of Present Illness

E.M. is a 28-year-old woman with a history of substance use disorder with intravenous (IV) heroin, who presents today for an urgent visit with malaise, chills, and shortness of breath. She was in her usual state of health until about one week ago, when she started feeling fatigued and experienced generalized myalgias. She then developed chills with rigors starting three days ago. She has not measured her temperature at home. Over the past two days, she has been experiencing a cough, which is sometimes productive of whitish sputum and is associated with shortness of breath with minimal activity and pain with deep inspiration. She has also developed new mid-back pain over the past four to five days. She denies any bowel or bladder incontinence and weakness or numbness of the lower extremities. She rates the back pain as a severity of seven on a scale of one to ten. This pain radiates to the left hip and groin. The pain in the left hip is worse with activity. She reports some dull, diffuse abdominal pain as well as poor appetite, nausea, and a couple of episodes of vomiting bilious material. She reports lightheadedness over the past three to four days.

She denies any preceding injury or trauma, though she does recall that she was seen at an urgent care two weeks ago for a skin abscess on the right forearm. The abscess was drained in urgent care and cultures grew methicillin-susceptible staphylococcus aureus. She was treated with a five-day course of sulfamethoxazole-trimethoprim, which she tolerated well and completed. The lesion on the arm improved and is now scabbed over and is no longer painful.

Medical History

  • Substance use disorder.
  • Recurrent skin abscesses with methicillin-resistant staphylococcus aureus.
  • Depression
  • Anxiety
  • Pregnancy complicated by opioid-use disorder.

Surgical History

Cesarean section 4 years ago

Medications

  • Escitalopram 10 mg every 24 hours by mouth
  • Hydroxyzine 25 mg, take 1 tablet up to 4 times/day as needed for anxiety
  • Prenatal multivitamin, 1 tablet daily by mouth

Social History

  • Employment: Currently unemployed. She had been working as a clerk in a gas station up until about one month ago, when she was fired. She held this job for about five months.
  • Living situation: Currently staying at her new boyfriend’s apartment. He shares the apartment with two other roommates. She has been living here for about three weeks. Prior to this, she was living with her mother. Erin and her mother had an argument three weeks ago, which prompted Erin to leave and stay with her boyfriend for the time being.
  • Family: Her mother has custody of her 4-year-old son. Erin usually gets to see him often, though not since she left her mom’s house three weeks ago.

Substance Use

  • Tobacco: Current smoker. She smokes about half a pack every two days.
  • Alcohol: Drinks two to three beers most nights of the week.
  • Illicit substances: Occasional marijuana use. Estimated to be two to three times per week via smoking or vaping route.
  • Currently uses heroin via injection route, usually four to six times per day.
  • Last use: this morning
  • Treatment history: She completed an inpatient rehabilitation program about six months ago and was engaged in outpatient treatment with buprenorphine afterwards until four to six weeks ago, when she was dismissed from the outpatient program due to violation of contract and multiple missed appointments.

Family History

  • Mother: Diabetes mellitus, hypertension, anxiety, post-traumatic stress disorder.
  • Father: Alcohol use disorder. Patient is estranged from her father since he left the family when she was 10. She does not know anything about his current health status.
  • Brother: Opioid-use disorder, currently in remission.
  • Sister: healthy
  • Child (4-year-old son): Neonatal abstinence syndrome at birth which required a stay in the neonatal intensive care unit (NICU). Currently, he is undergoing evaluation for developmental delays.

Review of Systems

  • General: Reports 15-pound weight loss over past four to six months. Reports fevers, chills, fatigue, and generalized weakness.
  • Skin: Reports some new red lesions on the palms of her hands. Reports a few new, small areas of linear, purple discoloration under her fingernails.
  • Head, Eyes, Ears, Nose, Throat (HEENT)
    • Head: Denies headache and recent trauma.
    • Eyes: Denies pain, double vision, blurred vision, excessive tearing drainage, and changes in visual acuity.
    • Ears: Denies changes in hearing acuity, tinnitus, vertigo, pain, and drainage.
    • Nose: Reports some increase in nasal drainage. Denies epistaxis and sinus pain.
    • Mouth and throat: Denies throat pain, difficulty swallowing, and hoarse voice. Denies any active tooth pain but reports that she has several broken teeth.
  • Neck: Denies pain, stiffness, and swollen lymph nodes.
  • Breasts: Denies pain, lumps, nipple discharge, and change in size.
  • Respiratory: Reports cough which is sometimes productive of white sputum and shortness of breath with minimal activity. Reports pleuritic chest pain. Denies hemoptysis.
  • Cardiovascular: Reports chest pain with deep breathing, denies palpitations. Reports new shortness of breath with minimal activity. Denies swelling in the extremities.
  • Gastrointestinal: Reports poor appetite and nausea with two to three episodes of vomiting bilious material. Reports some mild abdominal pain. Denies constipation, diarrhea, and bloody or black tarry stools.
  • Peripheral Vascular: Denies leg pain, varicose veins, swelling in the extremities, and changes in temperature or color of the extremities.
  • Urinary: Denies dysuria, hematuria, frequency of urination, urgency of urination, incontinence, and suprapubic pain.
  • Genital: Menstrual periods are irregular, usually lasting three to four days. Denies vaginal bleeding with intercourse or between periods. Denies increased vaginal discharge, vulvovaginal itching, genital lesions, and dyspareunia.
  • Musculoskeletal: Reports pain in the left hip but no associated redness or swelling. Denies redness, pain, and swelling in any other joint. Reports mid-back pain.
  • Psychiatric: Reports feeling anxious and depressed. Denies memory changes or hallucinations. Denies suicidal and homicidal ideation.
  • Neurological: Denies confusion, headache, syncope, numbness in any extremity, weakness in any extremity, tremors, or seizures. Reports dizziness.
  • Hematologic: Denies easy bruising or bleeding.
  • Endocrine: Denies heat or cold intolerance, excessive sweating, excessive thirst, excessive hunger, or increased urine output.

Physical Exam

Vital Signs

  • Heart rate: 116 bpm
  • Respiratory rate: 22 bpm
  • Blood pressure: 105/62 mm Hg
  • Oxygen saturation: 96% on room air
  • Temperature: 101.7°F
  • Height: 5 ft 6 in (167.6 cm)
  • Weight: 112 lbs
  • BMI: 18.1

General Survey

Thin woman who is distressed and tearful. Her appearance is disheveled and her grooming is poor. She is wearing a heavy sweatshirt and sweatpants despite the warm weather. Her clothes appear unwashed and too big for her size.

  • HEENT
    • Head: Hair is dry appearing. Head is normocephalic/atraumatic. Scalp is without lesions.
    • Eyes: Pupils 4 mm constricting to 2 mm with exposure to light, round, regular bilaterally. Conjunctival injection in the right eye. Roth spot visible on ophthalmic exam of the right eye. Left optic disc has sharp margins and is without hemorrhage or exudate. No arteriolar narrowing or AV nicking bilaterally.
A fundoscopic view of the retina of the right eye. A Roth spot is seen near the center of the picture. It presents as a hemorrhagic ring with a pale center.
A fundoscopic view of the retina, or the back of the right eye.
    • Ears: Small amount of amber cerumen in the ear canals bilaterally. Tympanic membranes are intact with visible cone of light bilaterally. Hearing acuity is good with whispered voice test. No tenderness with palpation of the external ear structures.
    • Nose: Mucosa are pink and septum is midline. No sinus tenderness.
    • Oral: Mucus membranes appear dry overall with some cracking of the lips observed. There are scattered petechiae on the hard palate. Dentition is poor with several broken or decayed teeth. Tongue is midline. Pharynx is without exudate.
The pharynx and oral cavity of a patient with scattered, small red spots, or petechiae visible on the posterior soft palate.
Intraoral view
    • Neck: Supple, trachea is midline. No enlarged cervical lymph nodes. Full active range of motion with flexion, extension, tilt bilaterally, and rotation bilaterally.
  • Respiratory: Respiratory rate is fast. No use of accessory muscles. Thorax expansion is symmetrical. Lung sounds are clear to auscultation in three lobes on the right and two lobes on the left.
  • Cardiovascular: Grade 2 out of 6 holosystolic murmur with medium pitch and increasing intensity during inspiration, heard best at the lower left sternal border.
  • Abdomen: Flat, well-healed scar in suprapubic region, bowel sounds active in all quadrants. No masses. No pain with palpation.
  • Liver span is 7 cm at the right midclavicular line and 4 cm at the midsternal line. Liver edge is soft, smooth, and palpable 1 cm below the right costal margin.
  • There is dullness with percussion along Traube’s space. There is dullness with percussion in the lowest intercostal space in the left axillary line during deep inspiration.
  • The spleen tip is palpable 2 cm below the left costal margin on inspiration. Positive costovertebral angle tenderness on left side.
  • Musculoskeletal: No erythematous, edematous, or deformed joints on inspection. The left hip is tender with palpation; passive extension of the left hip causes pain, which is relieved when the hip is returned to a flexed position. She has tenderness with palpation along the thoracic spine.
  • Neurological: Alert and cooperative. Oriented to person, place, time, and situation. Cranial nerves II-XII intact. 5/5 strength in bilateral upper and lower extremities.
  • Skin: There are non-blanching, linear reddish-brown lesions under the nail bed of the right thumb and fourth finger. Several nontender erythematous macules on the plantar surface of the left foot. There are numerous scabbed lesions in various stages of healing on the bilateral forearms.
2nd, 3rd and 4th fingers of a patient’s hand. Reddish, longitudinal lines are visible on the distal aspect of the nail on the 2nd and 3rd finger.
The reddish, longitudinal lines visible on the distal aspect of the nail on the 2nd and 3rd finger are splinter hemorrhages which can be caused by trauma to the nail or by systemic illness like infective endocarditis.
Janeway lesions (arrows) on the toes and sole, seen in a patient with massive aortic valve vegetation.
The patient’s left foot shows several small, flat red lesions on the sole of the foot consistent with Janeway lesions.

Checkpoint

  1. Based on the presentation, history, and physical exam findings, which heart valve do you suspect is infected?
    1. Mitral valve
    2. Aortic valve
    3. Tricuspid valve
    4. Pulmonic valve
  1. Endocarditis can lead to a myriad of serious sequelae and complications. Based on the history and physical exam findings for this patient, what sequelae or complications are you most concerned about? Select the three most relevant complications.
    1. Psoas muscle abscess
    2. Vertebral osteomyelitis
    3. Septic arthritis of the hip
    4. Septic pulmonary emboli
    5. Heart failure
    6. Embolic stroke
    7. Meningitis
    8. Mycotic aortic aneurysm
  1. The patient has all of the following clinical manifestations of infective endocarditis except:
    1. Janeway lesions
    2. Roth’s spots
    3. Splinter hemorrhages
    4. Osler’s nodes
  1. This patient very likely has infective endocarditis. However, confirming the diagnosis requires further testing. All of the following tests are needed. Select the choice that is the highest priority to complete first.
    1. Echocardiogram
    2. Blood cultures
    3. CT abdomen and pelvis with contrast
    4. Chest x-ray
  1. Based on the likely diagnosis and the patient’s history, which of the following is the most likely pathogen causing endocarditis in this case?
    1. Enterococcus faecalis 
    2. Staphylococcus aureus
    3. Streptococcus species 
    4. Escherichia coli 
  1. Review the findings of the physical exam of the abdomen in the case study. Which condition is most likely based on this abdominal exam and the patient’s presentation?
    1. Acute hepatitis
    2. Mesenteric ischemia
    3. Splenic abscess
    4. Pyelonephritis

Case Study, Continued

Diagnosis

You discuss the likely diagnosis of infective endocarditis with Erin. She is tearful and expresses fear and uncertainty about going to the hospital for admission. You engage in a shared decision-making discussion with Erin and she agrees to go to the hospital as long as she can be directly admitted and avoid going to the ED, where she has had several negative and traumatic experiences. You contact the attending physician of the medicine service at the hospital associated with your organization and request a direct admission. The attending physician agrees to accept the patient and you are contacted by the admission coordinator nurse, who informs you that a bed will be ready for Erin in about one hour. To expedite her care, you collect three sets of blood cultures while waiting for her to be transferred to the ED.

Hospital Course

She was admitted to the hospital and started on intravenous antibiotics and underwent additional diagnostic testing and consultation from cardiovascular surgery. Ultimately, the diagnosis of tricuspid valve endocarditis with methicillin-susceptible staphylococcus aureus was confirmed, with a small vegetation on the tricuspid valve observed on echocardiography. She was also diagnosed with vertebral osteomyelitis of L2-L3 with no epidural abscess. An orthopedic surgery consult determined that no surgical intervention was needed for the vertebral osteomyelitis. She also had evidence of a left psoas muscle abscess on CT imaging. This was drained percutaneously in interventional radiology with staphylococcus aureus identified on cultures of the aspirated fluid. Her antibiotic regimen was able to be narrowed to pathogen-directed therapy with IV oxacillin.

She remained in the hospital receiving IV oxacillin for about 10 days, at which point she informed her team that she was not able to remain inpatient any longer. The team engages in shared decision-making with her and they ultimately decide that she will be discharged and complete the remainder of her antibiotic course with oral antibiotics.

Erin’s mom came to visit her often when she was in the hospital. They were able to reconcile their previous disagreement and Erin returned to live with her mom and her son after discharge.

You are now seeing Erin for a follow-up appointment one week after discharge from the hospital.

Erin started substance use treatment while in the hospital but has struggled to find a provider to continue this outpatient and is unsure how she wants to address this issue. She is feeling overwhelmed with taking care of her son, helping her mom run the household, and trying to find a new job. She and her mom have been busy with taking her son to numerous appointments as he undergoes evaluation of developmental delays. She does not have transportation, so she anticipates that it is going to be challenging to attend the frequent appointments required to establish care with a new outpatient substance use provider. Recall that she was dismissed from the previous outpatient treatment center for violation of contract and missed appointments.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. What is the best response to Erin’s request for your input on how to move forward with treatment for substance use disorder?
    1. This is not a priority at this time. She is recovering from a serious illness and there are many complications that will require additional follow-up and monitoring. It would be best to prioritize these medical issues and address the substance use disorder when she is done with treatment and medically stable.
    2. Arranging follow-up care with an outpatient substance use treatment provider was the responsibility of the inpatient team, who should have ensured that this was done prior to discharge. Advise her to try contacting the inpatient team by calling the main number of the hospital.
    3. If she had not been dismissed from the outpatient treatment center earlier this year, this would not be a problem. You have a frank conversation with her, highlighting how her current situation is a direct consequence of her actions and it is unreasonable of her to expect a solution to this.
    4. Recognize that treatment for her substance use disorder is integral to successfully treating the endocarditis. Engage in shared decision-making with Erin to understand her needs and values related to substance use treatment. Develop a plan with her input and provide the necessary care, including medication-assisted treatment, until a referral to a more specialized setting can be arranged if necessary.
Answer:

D. Recognize that treatment for her substance use disorder is integral to successfully treating the endocarditis. Engage in shared decision-making with Erin to understand her needs and values related to substance use treatment. Develop a plan with her input and provide the necessary care, including medication-assisted treatment, until a referral to a more specialized setting can be arranged if necessary.

Feedback: Substance use disorder is the underlying pathology which put Erin at risk for infective endocarditis. Therefore, providing ongoing care and treatment of this condition is integral to successful treatment of endocarditis and to prevent recurrences. Patient-centered care and shared decision-making are essential attributes of a collaborative relationship between clinicians and the patient and their family. Both patient-centered care and shared decision-making recognize the importance of developing a plan of care with input from the patient, which incorporates the patient’s values, experience, and comfort, and accounts for the unique strengths and weaknesses of the patient’s situation. Providing patient-centered care and using shared decision-making has a positive impact on patient satisfaction, quality of life, and health outcomes. Therefore, it is recommended that care during a particularly challenging period, like after discharge from a hospitalization for endocarditis, be aligned with these principles (Delgado et al., 2023).

Choice “D” is the only option that addresses the underlying substance use disorder in a manner which is aligned with patient-centered care and shared decision-making. Choice “A” disregards the importance and integral nature of treating the substance use disorder. Choice “B” demonstrates an attempt to avoid taking responsibility for an important aspect of the patient’s care and shifts the burden of addressing a gap in care to the patient during an already difficult period for her. Choice “C” does nothing to effectively address the substance use disorder and is likely to increase the patient’s emotional distress. It may even discourage her from continuing to engage with the healthcare system.

  1. Select the three most important education points to discuss with a patient after an episode of infective endocarditis.
    1. Improving and maintaining oral hygiene by meticulous brushing with a fluoridated toothpaste, flossing, avoiding refined sugars in the diet, and maintaining regular care with a dentist for routine cleanings and monitoring.
    2. The need for antimicrobial prophylaxis prior to high-risk dental procedures.
    3. Staphylococcus aureus infections are highly contagious. Her 4-year-old son is particularly at risk, due to his young age. She should wear a mask and avoid any direct contact with him until complete eradication has been confirmed.
    4. There is a risk of recurrence with endocarditis. Therefore, she should seek prompt medical attention for any febrile illness so that a physical exam to determine the cause of the fever can be performed and blood cultures collected prior to starting antibiotics if these are needed.
    5. She must wear an N95 mask whenever she is in public.
    6. To avoid recurrence of endocarditis from the gastrointestinal tract, she should no longer eat any foods that contain live bacteria, such as yogurt or kimchi.
Answer:

A. Improving and maintaining oral hygiene by meticulous brushing with a fluoridated toothpaste, flossing, avoiding refined sugars in the diet, and maintaining regular care with a dentist for routine cleanings and monitoring; B. The need for antimicrobial prophylaxis prior to high-risk dental procedures; D. There is a risk of recurrence with endocarditis. Therefore, she should seek prompt medical attention for any febrile illness so that a physical exam to determine the cause of the fever can be performed and blood cultures collected prior to starting antibiotics if these are needed.

Feedback: Poor oral health can result in gingivitis and periodontitis, both of which are associated with community-acquired infective endocarditis. All of the interventions listed in choice “A” are aimed at preventing bacterial plaque formation on the teeth. The amount of refined sugars and other carbohydrates in the diet impacts the growth of pathogenic bacterial species, which can form plaques and contribute to gingivitis and periodontitis. Maintaining regular dental care allows for close monitoring of oral health and early identification and treatment of oral disease. The use of a fluoridated toothpaste for daily brushing reduces the decalcification of tooth surfaces by plaque bacteria, which can result in dental caries (Baddour et al., 2015). Patients with a history of infective endocarditis are considered high-risk for developing infective endocarditis as a result of the transient bacteremia, which can occur during the trauma and manipulation of the gingival tissue that accompanies invasive dental procedures.

Staphylococcus aureus is a bacteria that can be carried on the skin or in the nasal passage. It is estimated that about 30% of healthy people are colonized with staphylococcus aureus in one or both of these locations. Usually, colonization causes no symptoms. However, when the body’s defense mechanisms are compromised in some way, such as with a break in skin integrity, it is possible for staphylococcus aureus to cause invasive infections such as abscesses, bacteremia, and endocarditis. Staphylococcus aureus can be spread to other people through direct contact or contact with contaminated fomites. Erin should be sure to follow careful hand hygiene, avoid sharing towels and other personal items, avoid touching any open wounds, and cover any of her own wounds. There is no evidence that wearing a mask reduces transmission of the bacteria to household contacts and avoiding direct contact with her son is not reasonable.

Recurrence of endocarditis can occur as a result of relapse or reinfection. Therefore, it is important for the patient to seek prompt attention for any illness with persistent fever so that evaluation for endocarditis can be performed, including the collection of blood cultures prior to starting empiric antibiotics (Baddour et al., 2015).

The organisms that cause infective endocarditis are generally transmitted via direct contact or are a part of the patient’s own normal flora, which has gained access to the cardiovascular system via a breach in integrity of the skin or mucus membranes. Therefore, an N95 mask or any mask would be unlikely to change the risk of infection. Similarly, there is no pathophysiological basis for the consumption of probiotic foods being a significant risk factor for infective endocarditis.

References

Baddour, L. M., Wilson, W. R., Bayer, A.S., Fowler, V.G., Tleyjeh, I.M., Rybak, M.J., Barsic, B., Lockhart, P. B., Gewitz, M. H., Levison, M.E., Bolger, A. F., Steckelberg, J. M., Baltimore, R. S., Fink, A. M., O’Gara, P., Taubert, K. A., & American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. (2015). Infective endocarditis in adults: Diagnosis, antimicrobial therapy, and management of complications: A scientific statement for healthcare professionals from the American Heart Association. Circulation, 132(15), 1435–1486. http://doi.org/10.1161/CIR.0000000000000296

Bickley, L. S. (2024). Bates’ guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Chu, V. H. (2024a). Clinical Manifestations and evaluation of adults with suspected left-sided native valve endocarditis. UpToDate. Retrieved February 23, 2025, from https://www.uptodate.com/contents/clinical-manifestations-and-evaluation-of-adults-with-suspected-left-sided-native-valve-endocarditis

Chu, V. H. (2024b). Right-sided native valve infective endocarditis. UpToDate. Retrieved February 23, 2025, from https://www.uptodate.com/contents/right-sided-native-valve-infective-endocarditis

Delgado, V., Marsan, N. A., de Waha, S., Bonaros, N., Brida, M., Burri, H., Caselli, S., Doenst, T., Ederhy, S., Erba, P. A., Foldager, D., FosbØl, E. L., Kovac, J., Mestres, C. A., Miller, O. I., Miro, J. M., Pazdernik, M., Pizzi, M. N., Quintana, E., Rasmussen, T. B., Ristić, A. D., Rodés-Cabau, J., Sionis, A., Zühlke, L. J., Borger, M. A., & The European Society of Cardiology Document Group. (2023). 2023 ESC Guidelines for the management of endocarditis. European heart journal, 44(39), 3948–4042. https://doi.org/10.1093/eurheartj/ehad193

Rich, P. (2025). Overview of nail disorders. UpToDate. Retrieved February 23, 2025, from https://www.uptodate.com/contents/overview-of-nail-disorders

Spelman, D. (2024). Complications and outcome of infective endocarditis. UpToDate. Retrieved February 24, 2025, from https://www.uptodate.com/contents/complications-and-outcome-of-infective-endocarditis

Tendler, D. A., & Lamont, J. T. (2024). Overview of intestinal ischemia in adults. UpToDate. Retrieved May 27, 2025, from https://www.uptodate.com/contents/overview-of-intestinal-ischemia-in-adults

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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