A 43-year-old man comes to the emergency department with a 3-day history of fever, malaise, and chills. He was hospitalized a year ago for alcohol withdrawal symptoms but otherwise no medical history is available. He admits to using intravenous drugs.
The patient's temperature is 38.4 C (101.1 F), blood pressure is 144/90 mm Hg, and pulse is 102/min. He has poor oral dentition. A small white plaque is seen on the buccal mucosa. Cervical lymph nodes are palpable bilaterally but are small and nontender. Lungs are clear on auscultation. There is a short 2/6 early diastolic murmur heard at the right upper sternal border. The abdomen is soft and nontender. Extremity pulses are full and symmetric, and there is no edema.
Laboratory results are as follows:

Blood cultures are sent.
Which of the following tests is most important for making treatment decisions at this point?

Question

A 43-year-old man comes to the emergency department with a 3-day history of fever, malaise, and chills.  He was hospitalized a year ago for alcohol withdrawal symptoms but otherwise no medical history is available.  He admits to using intravenous drugs.
The patient's temperature is 38.4 C (101.1 F), blood pressure is 144/90 mm Hg, and pulse is 102/min.  He has poor oral dentition.  A small white plaque is seen on the buccal mucosa.  Cervical lymph nodes are palpable bilaterally but are small and nontender.  Lungs are clear on auscultation.  There is a short 2/6 early diastolic murmur heard at the right upper sternal border.  The abdomen is soft and nontender.  Extremity pulses are full and symmetric, and there is no edema.
Laboratory results are as follows:

Blood cultures are sent.
Which of the following tests is most important for making treatment decisions at this point?

Quizplus · Accepted Answer

11ec193a_95e7_3e39_853d_69de666557ee_MD0002_00 This patient's clinical presentation (fever, malaise, and heart murmur [aortic regurgitation]) and history of intravenous drug use are highly suggestive of infective endocarditis (IE). The diagnosis of IE is based on a combination of clinical, laboratory and imaging characteristics (modified Duke criteria). A transthoracic or transesophageal echocardiogram is essential for the diagnosis and appropriate management of patients with suspected IE. Early echocardiography helps to characterize the size and location of valvular vegetations, severity of valvular regurgitation, and associated complications (perivalvular abscess, leaflet perforation, and/or fistula formation). It can also identify the subset of patients who may benefit from early surgical intervention to reduce the frequency of embolic events, recurrent IE, and risk of cardiovascular morbidity and mortality. surgical intervention (Choices A and B) This patient's leukocytosis and thrombocytopenia are appropriate inflammatory responses to the infection, and are unlikely to represent hematologic malignancy. A peripheral blood smear or bone marrow biopsy is not indicated at this time. (Choice C) A CT scan has no role in the initial diagnostic evaluation of endocarditis, though it may be helpful for further assessment if echocardiography is inconclusive. (Choice E) Fever, cervical lymphadenopathy, and oral mucosal lesions in an intravenous drug user are suggestive of HIV infection. However, an echocardiogram should be obtained first to screen for IE and identify associated complications that might require early surgical intervention. Educational objective: An echocardiogram should be obtained early in patients with suspected infective endocarditis to identify the size and location of valvular vegetations, the degree of valvular regurgitation, and associated complications (perivalvular abscess, leaflet perforation, and/or fistula formation). __________ References: Infectious endocarditis: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22612050)

A 43-Year-Old Man Comes to the Emergency Department with a 3-Day