Woman with a Fever for the Last 15 Days - Patient Case of the Week
Try this free febrile patient case Q&A courtesy of Med-Challenger.
A 39-year-old woman presents with a fever that has been present for the last 15 days. She has been seen at 2 different walk-in clinics, where she received a diagnosis of a viral illness.
She completed a course of azithromycin 4 days ago, but she now has generalized weakness with mild nausea. She has a significant past medical history of mitral valve prolapse.
On today's visit, she is tachycardic and febrile. She has a high-pitched, 3/6 holosystolic murmur that starts at the left sternal border and is heard into the axilla.
The patient also has foci of tenderness and discoloration on the palmar surface of his hand and fingers (see Figure 1).
Initial evaluation of this patient should include which of the following?
- transesophageal echocardiography, heparin, electrocardiography (ECG)
- transthoracic echocardiography (TTE), 2 sets of blood cultures, electrocardiography (ECG), chest x-ray
- chest x-ray, 2 sets of blood cultures, prescription for amoxicillin/clavulanic acid
- helical computed tomography (CT) of the chest, 2 blood cultures
See Full Answer
The correct answer is:
transthoracic echocardiography (TTE), 2 sets of blood cultures, electrocardiography (ECG), chest x-ray
Identify the preferred initial evaluation when infective endocarditis is suspected.
Echocardiography provides a rapid diagnosis of infective endocarditis and should be performed promptly. Antibiotics should not be administered to patients with clinical signs of endocarditis until 2 sets of blood cultures are obtained and sent to microbiology.
This patient’s clinical findings of fever, a cardiac predisposition with Osler nodes (see Figure 1), and heart murmur are collectively strongly suggestive of infective endocarditis (IE). In such patients, antibiotic therapy should be held until first obtaining blood cultures from 2 separate sites. ECG should be performed to identify conduction abnormalities. Chest x-ray should be obtained to identify heart failure or pulmonary infiltrates. TTE should be performed in all patients suspected of having IE to rapidly confirm the diagnosis, and it should be repeated on a weekly basis. It is noninvasive and has a high specificity for valvular vegetations.
Echocardiographic evidence of regurgitation or a valvular mass is a major Duke criterion for the diagnosis of IE. The role of helical CT of the chest is currently used more often in the evaluation of coronary artery disease; however, in cases in which there are small vegetations or leaflet perforations, which are missed with echocardiography, multislice CT may provide additional diagnostic information.
January CT, Wann LS, Alpert JS, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society [Erratum appears in: J Am Coll Cardiol. 2014;64(21):2305-2307]. J Am Coll Cardiol. 2014;64(21):e1-e76.
Kosowsky JM, Takhar SS. Infective endocarditis, rheumatic fever, and valvular heart disease. In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1000-1006.e1.
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