A 24-year-old woman comes to the physician with a 3-week history of progressive fatigue. Physical examination shows lesions involving the nail beds, as seen in the photograph below. Further evaluation would most likely reveal additional abnormalities during which part of the physical examination?

Question

A 24-year-old woman comes to the physician with a 3-week history of progressive fatigue.  Physical examination shows lesions involving the nail beds, as seen in the photograph below.  Further evaluation would most likely reveal additional abnormalities during which part of the physical examination?

Quizplus · Accepted Answer

11ec160b_38cc_f435_9249_596720190c0e_MD0001_00 These lesions are subungual splinter hemorrhages, splinter- or flame-shaped hemorrhagic streaks in the nail bed that appear as a consequence of microemboli. Janeway lesions (small, macular, erythematous or hemorrhagic, nontender lesions on the palms and soles) are also a sign of microembolism. Infectious endocarditis (IE) is the usual cause of such microemboli, and progressive fatigue may be the presenting symptom of subacute bacterial endocarditis. Chronically destructive, infected vegetations involving the cardiac valves are the source of the microemboli in bacterial endocarditis. Patients with suspected IE should therefore be evaluated for a regurgitant murmur during cardiac auscultation. (Choices A, B, and D) Unless the primary source of the bacteremia initiating the IE is a focal neck, pulmonary, or abdominal infection, one would not expect to find any abnormalities in these systems. (Choice E) Unless the primary source of the original bacteremia was a peri-rectal infection or necrotic, infected rectal neoplasm, one would not expect to find any abnormalities on rectal examination. Educational objective: Microemboli from the valvular vegetations of bacterial endocarditis are the most common cause of subungual splinter hemorrhages. The presence of these lesions necessitates careful cardiac auscultation to detect a possible new-onset regurgitant murmur.

A 24-Year-Old Woman Comes to the Physician with a 3-Week