Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main presenting concerns related to infective endocarditis (IE). This may include:
Fever (common)
Night sweats
Fatigue and malaise
New or worsening shortness of breath
Chest pain (pleuritic – sharp pain worse with breathing)
Joint pain or swelling
Skin lesions (e.g., petechiae, splinter hemorrhages)
Neurological symptoms (e.g., confusion, stroke) in severe cases
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Progression of symptoms (worsening, stable, or improving).
Any recent dental procedures, intravenous drug use, or healthcare procedures that could have introduced bacteria into the bloodstream.
Underlying medical conditions that predispose to IE (e.g., congenital heart defects, prosthetic heart valves).
既往史 (jì wàng shǐ) Past Medical History:
Prior history of endocarditis or other heart valve abnormalities.
Underlying medical conditions (e.g., diabetes, chronic kidney disease) that can worsen the prognosis of IE.
Prior surgeries or procedures (especially cardiac).
家族史 (jiā zú shǐ) Family History:
Family history of heart disease (uncommon for IE specifically).
社会史 (shè huì shǐ) Social History:
Intravenous drug use (high risk factor).
Recent dental procedures (potential source of bacteremia).
Occupation (certain professions have higher risk of exposure to bacteria).
查体 (chá tǐ) Physical Examination:
Vital signs (often elevated temperature, tachycardia).
General examination: assess for signs of systemic inflammation (e.g., weight loss, fatigue).
Cardiovascular examination:
Listen for heart murmurs (new or worsening) suggestive of valvular dysfunction.
Assess for signs of heart failure (e.g., jugular venous distention, peripheral edema) if present.
Skin examination:
Look for petechiae (small red spots), splinter hemorrhages (red lines under fingernails), Osler nodes (painful red nodules on fingertips), Janeway lesions (red papules on palms and soles).
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC):
May show elevated white blood cells (leukocytosis) indicating infection.
Blood cultures: Multiple blood cultures over several days are essential to identify the causative organism.
Serologic tests:
May be helpful for specific organisms (e.g., Q fever serology).
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR):
Elevated levels suggest inflammation, but not specific for IE.
Electrocardiogram (ECG):
May show abnormalities suggestive of underlying heart disease.
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Echocardiography (transthoracic or transesophageal):
The cornerstone of diagnosis, visualizing valvular vegetations (abnormal growths) and assessing valve function.
Chest X-ray: May show signs of heart failure (e.g., cardiomegaly, pulmonary edema).
诊断 (zhěn duàn) Diagnosis:
Infective endocarditis (IE).
Specify the suspected valve involved (e.g., aortic valve endocarditis, mitral valve endocarditis).
If possible, identify the causative organism based on blood culture results.
分期 (fēn qī) Staging (optional):
Some classification systems categorize IE based on severity or complications.
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Infective endocarditis is a serious medical emergency requiring hospitalization and prompt intravenous antibiotic therapy based on culture results or empiric broad-spectrum antibiotics.
The duration of antibiotic therapy can vary depending on the organism and response to treatment.
Surgery may be necessary in some cases, such as:
Heart valve replacement if the valve is severely damaged or failing.
Drainage of abscesses if present.
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of infection, valve involvement, and underlying health conditions.
Early diagnosis and treatment are crucial for a better prognosis.