Examination of the heart reveals a Grade III holosystolic murmur at the apex. It is noted to be louder than previously recorded. The remainder of the physical examination is normal.
Which of the following essentially confirm a diagnosis of bacterial endocarditis in this febrile patient?
Answers:
The correct answer is #1.
Why This Question Is Often Missed
– Learners focus on “classic” findings (Osler nodes, Janeway lesions) and overlook that a new or changed murmur is a major Duke criterion, whereas Osler nodes are only minor.
– Conjunctival petechiae are subtle and often mistaken for nonspecific irritation, yet they count as a vascular (minor) criterion.
What the Distractors Indicate
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| Osler nodes and fever | Immunologic phenomena + general sign | Both are Duke minor criteria – two minors alone don’t confirm definite IE. |
| Osler nodes and vascular emboli | Immunologic + vascular phenomena | Two minor criteria; still insufficient for “definite” endocarditis. |
| Fever and vascular emboli | Fever + vascular phenomena | Again, two minor criteria without any major criterion. |
| Worsening of a pre-existing murmur and conjunctival petechiae | New regurgitation (major) + vascular phenomenon (minor) | Only combination here with ≥1 major criterion → confirms definite IE. |
High-Yield Pearl
A changing or new regurgitant murmur is a major Duke criterion—pair it with any vascular or immunologic sign, and you’ve clinched the diagnosis.
Core Learning Objectives
The “Test Trick” at Play
This item hinges on knowing that only new valve regurgitation (a major criterion) combined with a single minor criterion is enough for a definite IE diagnosis—many distractors use two minors (Osler, fever, emboli) which are tempting but insufficient.
Additional Practice Questions and Remediation
Question 1
A 58-year-old IV drug user has had 2 weeks of fever, blood cultures positive for S. aureus, and a newly detected holosystolic murmur at the apex. Which combination meets definite IE by Duke criteria?
A. Positive blood cultures + new regurgitant murmur
B. Positive blood cultures + splinter hemorrhages
C. Fever + Janeway lesions
D. Osler nodes + Janeway lesions
Question 2
A 62-year-old with suspected endocarditis has tender nodules on fingertips and painless, flat erythematous macules on palms and soles. Which pairing correctly classifies them?
A. Janeway lesions = immunologic; Osler nodes = vascular
B. Osler nodes = immunologic; Janeway lesions = vascular
C. Janeway lesions = immunologic; splinter hemorrhages = vascular
D. Splinter hemorrhages = immunologic; Janeway lesions = vascular
Question 3
Which of the following combinations represents one major and one minor Duke criterion?
A. New regurgitant murmur + Osler nodes
B. New regurgitant murmur + conjunctival petechiae
C. Fever + Janeway lesions
D. Positive echo showing vegetation + Osler nodes
Mini Case Discussion Prompt
Discuss how immunologic phenomena (Osler nodes, Roth spots) versus vascular phenomena (Janeway lesions, petechiae) reflect different pathophysiologic mechanisms in infective endocarditis, and how recognizing each influences both diagnosis and management.
This question appears in Med-Challenger Internal Medicine Review with CME
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