Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Endocarditis, Bacterial


Related Terms

  • Endocarditis
  • Infectious Endocarditis
  • SBE
  • Subacute Bacterial Endocarditis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Infectious Disease Internist
  • Internal Medicine Physician
  • Thoracic Surgeon

Comorbid Conditions

  • Complex congenital heart disease (e.g., transposition of the great vessels, tetralogy of fallot)
  • Hypertrophic cardiomyopathy
  • Mitral valve prolapse
  • Previous bacterial endocarditis
  • Prosthetic valve replacement
  • Substance abuse
  • Valvular heart disease

Factors Influencing Duration

Length of disability may be influenced by the site of infection, previous structural heart disease, prior valve replacement, method of treatment, presence of significant underlying medical conditions, the particular organism causing the infection, the individual's response to treatment, presence of complications, and the individual's job requirements.

Duration depends on cause. Infections caused by the organisms viridans streptococci, enterococci, or coagulase-negative staphylococci usually resolve with an average of 3 to 5 days of treatment. However, those infected by Staphylococcus aureus or Pseudomonas aeruginosa may have fevers and signs of infection that persist for 9 to 12 days. Fevers that persist beyond these ranges may be indicative of other superimposed infectious processes such as myocardial abscess or infections acquired while hospitalized (nosocomial). Relapses of bacterial endocarditis may occur within 1 to 2 months after completion of medical treatment.

Medical Codes

ICD-9-CM:
421.0 - Endocarditis, Bacterial, Acute and Subacute
424.90 - Endocarditis, Valve Unspecified, Unspecified Cause; Nonbacterial Thrombotic; Incompetence of Unspecified Valve, Unspecified Cause; Insufficiency of Unspecified Valve, Unspecified Cause; Regurgitation of Unspecified Valve, Unspecified Cause; Stenosis of Unspecified Valve, Unspecified Cause; Valvulitis (Chronic)
424.91 - Endocarditis in Diseases Classified Elsewhere
424.99 - Endocarditis, Valve Unspecified, Other

Overview

Bacterial endocarditis is an inflammation of the inner lining of the heart (endocardium), particularly of the heart valves, due to infection. Endocarditis may occur at the site of a birth defect known as a septal defect, where a hole exists between the left and right sides of the heart; on the small tendons attached to the heart valves (chordae tendineae); on the heart valves; or in the endocardium itself. Endocarditis may occur alone or as a complication of another disease. The infection can be caused by any number of microorganisms and is classified as acute or sub-acute.

Bacterial endocarditis is seen most often when the endocardium has already been damaged by rheumatic heart disease, congenital heart disease, mitral valve prolapse, mitral valve insufficiency, narrowing of the aorta by calcium (calcific aortic stenosis), or in individuals with prosthetic heart valves. Intravenous drug users are also at increased risk for bacterial endocarditis because of the possibility of introducing bacteria from a dirty syringe or unclean injection site directly into the bloodstream. Bacteria may enter the bloodstream during surgery or major dental treatment (especially tooth extraction). Infections can occur with placement of devices designed to shock the heart into a normal rhythm (implantable cardioverter defibrillators) or devices designed to pace the heart rhythm (pacemakers). Infections can also occur with placement of various tubes for diagnosis (endoscopes, colonoscopes) or intravenous tubes (catheters, Swan-Ganz catheters or Hickman catheters) for treatment.

Clots forming on the injured surfaces of the endocardium or valves trap microorganisms entering the bloodstream. These microorganisms multiply rapidly causing inflammation and further damage.

Acute bacterial endocarditis refers to an inflammation with an abrupt onset. The infection progresses quickly and may destroy the heart valves leading to rapidly progressive heart failure. In addition, clots or tissue growths (vegetations) attached to the damaged valves tend to break apart. These fragments of infected tissue are carried through the blood where they may block an artery (embolism) or spread infection to other parts of the body. Damage to valves and spread of the infection to other areas of the body occurs in a few days to several weeks. The staphylococci organism most often causes acute bacterial endocarditis. Sub-acute bacterial endocarditis refers to an inflammation that smolders undetected over several weeks to many months. Although it can cause serious damage to the heart valves, there is minimal spread to other areas of the body. The sub-acute form of bacterial endocarditis is most often caused by viridans streptococci, enterococci, and coagulase negative staphylococci organisms.

The mitral valve is the valve most frequently damaged by bacterial endocarditis, followed by the aortic valve, mitral and aortic valve, tricuspid valve, and rarely, the pulmonic valve.

Incidence and Prevalence: In the US, the incidence remains 2 to 4 cases per 100,000 individuals per year, which has not changed over 50 years (Pelletier). Fifty-five percent to seventy-five percent of infections occur in native valves, 7% to 25% in prosthetic valves. No predisposing factor could be identified in 25% to 45% of individuals (Karchmer).

Bacteria in the bloodstream (bacteremia) increase the risk for developing bacterial endocarditis. Rates for bacteremia following specific procedures is as follows: inserting a diagnostic scope into the stomach (endoscopy) 0% to 20%, inserting a diagnostic scope in to the colon (colonoscopy) 0% to 20%, dental extractions 40% to 100%, and inserting a transducer in the esophagus during an echocardiogram (transesophageal echocardiogram) 0% to 20% (Pelletier).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Increasing age is a risk factor for bacterial endocarditis. Of 100,000 cases, 15 to 30 occur in individuals aged 60 to 90 (Karchmer). Bacterial endocarditis occurs 3 times more often in males than females (Pelletier).

Source: Medical Disability Advisor



Diagnosis

History: Acute bacterial endocarditis comes on suddenly. Symptoms include high fever, severe chills, cough, and shortness of breath. In subacute bacterial endocarditis, the symptoms are general and nonspecific, such as fatigue, weight loss, loss of appetite, weakness, night sweats, or vague aches and pains. Fever may be low-grade or absent in elderly and debilitated persons.

Physical exam: Fever, rapid or irregular heartbeat, and numerous small, flat, red to blue spots (petechiae) on the lining of the eye (conjunctiva), the arms and legs, and the mucous membranes of the mouth and throat may be evident upon exam. Dark, red, linear streaks (splinter hemorrhages) may be present in the nail beds, accompanied by small, raised, and tender blue or red areas in the pads of the fingers or toes (Osler's nodes). Exam may also reveal joint tenderness or swelling, muscle tenderness, an enlarged spleen (splenomegaly), and a heart murmur (new or changed). Individuals may exhibit signs of a stroke, such as weakness on one side, difficulty speaking, or walking.

Tests: Blood cultures are used both for diagnosis, sensitivity to antibiotics, and for following the response to therapy. Examination of vegetations on the valves may also be done. Additional diagnostic laboratory tests include complete blood count (CBC), erythrocyte sedimentation rate, blood studies (serology), and urinalysis. Evaluation of the heart may include detecting abnormal valve function or heart disease with a procedure that uses sound waves to produce an image of the heart (echocardiogram). Doppler echocardiograms can determine abnormal blood flow patterns. Additional tests include examining the electrical patterns of the heart through electrocardiogram (ECG), and via x-ray of blood vessels after injection with contrast medium (angiography). Individuals with symptoms suggesting a stroke should have a CT scan of the head done to evaluate for an abscess.

Source: Medical Disability Advisor



Treatment

Treatment involves high doses of antibiotics given intravenously over a 4 to 6 week period. If infection has extensively damaged a heart valve, the valve may need to be surgically replaced with an artificial one (valve replacement). Fifteen percent to twenty-five percent of patients with bacterial endocarditis ultimately require surgery (Pelletier). When an artificial heart valve that is already in place becomes infected, it must be replaced. Heart valve replacement often becomes an emergency procedure.

Infected pacemakers and implantable defibrillators usually require removal and replacement. The electrodes implanted in the heart muscle may be treated with laser technology to remove any vegetations.

Source: Medical Disability Advisor



Prognosis

Most individuals recover completely. There is a mortality rate of 16% to 27% (Karchmer). The mortality rate increases with age, presence of underlying disease, development of congestive heart failure, kidney failure, or central nervous system complications. Mortality rate for those individuals with prosthetic valves is 33% to 45% (Karchmer). Relapses occur in 2% to 20% of individuals depending on the causative organism, and usually occur within 2 months after treatment.

Source: Medical Disability Advisor



Rehabilitation

Once the acute symptoms of bacterial endocarditis have subsided, a rehabilitation program comprised of both physical and occupational therapy at a cardiac rehabilitation clinic can help to return individuals to their previous physical status and activities. Rehabilitation addresses any weakness or functional deficits caused by the illness.

A physical therapist knowledgeable in cardiac rehabilitation will design an exercise program considered safe for the individual's physical stamina. ECG monitoring is used initially but may be discontinued when the individual's physical stamina has improved. Individuals perform aerobic exercise, such as treadmill walking or stationary bicycling. Aerobic exercise helps the heart muscle improve efficiency of oxygen use reducing the need for the heart to pump as much blood. The improved fitness level reduces the total workload of the heart and increases endurance enabling individuals to return to their prior activity levels.

Occupational therapy addresses any fatigue or shortness of breath that may occur during activities of daily living. Individuals learn energy conservation techniques such as breaking tasks into smaller components and to utilize equipment as needed to decrease energy expended during activities of daily living such as bathing or meal preparation.

Modifications are made for those individuals taking various medications or experiencing other conditions resulting from endocarditis.

The goal of occupational therapy and physical rehabilitation is to increase aerobic activity and activities of daily living in a stepwise fashion to promote cardiovascular endurance and strength so the individual may return to work or resume prior activity levels.

Source: Medical Disability Advisor



Complications

Complications include blood vessels obstructed by fragments of tissue carried through the bloodstream (systemic emboli), tissue death in the spleen (splenic infarction), stroke, valvular insufficiency, congestive heart failure, kidney failure, and thrombophlebitis. The emboli may also be infected, which can lead to overwhelming systemic infection (sepsis). Additionally, infection can extend into the heart muscle resulting in heart rhythm disturbances. Death is a possibility.

If valve replacement surgery is required, complications associated with surgery include bleeding, infection, medication reaction, failure of the wound to heal and replacement valve malfunction or failure.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Extended sick leave may be required. Individuals may need temporary assignment to light or sedentary work until fully recovered.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have a history of rheumatic heart disease, congenital heart disease, mitral valve prolapse, mitral valve insufficiency, or a prosthetic heart valve?
  • Has individual recently had surgery, dental treatment, had an intravenous catheter placed or exploratory procedures where a viewing tube is inserted into the body for diagnostic examination?
  • Is individual an intravenous drug user?
  • Does individual complain of high fever, severe chills, cough, and shortness of breath? Does individual report fatigue, weakness, night sweats, vague aches and pains, low-grade or absent fever?
  • On exam did individual have fever, rapid or irregular heartbeat, and petechiae on the conjunctiva, the arms and legs, and the mucous membranes of the mouth and throat?
  • Does individual have splinter hemorrhages in the nail beds, accompanied by small, raised, and tender blue or red areas in the pads of the fingers or toes (Osler's nodes)?
  • Does exam also reveal joint pain, muscle pain, and a new or changed heart murmur?
  • Has individual had blood cultures and sensitivity, CBC, erythrocyte sedimentation rate, serology, urinalysis?
  • Does individual have sepsis?
  • Has individual had an echocardiogram, ECG, or angiography?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Is individual being treated with high dose IV antibiotics for 4 to 6 weeks?
  • Was it necessary to surgically replace a damaged or infected heart valve?
  • Was it necessary to do the surgery on an emergency basis?

Regarding prognosis:

  • Is individual active in rehabilitation?
  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that could affect ability to recover?
  • Does individual have any complications such as arrhythmias, systemic emboli, splenic infarction, stroke, brain hemorrhage, valvular insufficiency, congestive heart failure, kidney failure, or thrombophlebitis that may contribute to disability?

Source: Medical Disability Advisor



References

Cited

Karchmer, Adolf. "Infective Endocarditis." Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. Eds. Robert O. Bonow, et al. 9th ed. Philadelphia: W.B. Saunders, 2012.

Pelletier, Lawrence, and John L. Brusch. "Infective Endocarditis." eMedicine. Eds. Wesley W. Emmons, et al. 22 Jan. 2004. Medscape. 25 Oct. 2004 <http://emedicine.com/med/topic671.htm>.

Source: Medical Disability Advisor






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