Download gabe cPathlet_1

(Play audio file of murmur continuously) Courtesy of Eric Strong MD
A 31 year old male comes into the emergency room complaining of shortness of breath. He is
disoriented and his history is unreliable.
General impression is poor. He presents with pallor, dyspnea, and diaphoresis. Temperature is 101.9 F,
pulse 110, respirations 25. Pulse pressure is remarkably wide. Respiratory crackles are heard bilaterally.
Upon auscultation, a 3/6 diastolic decrescendo murmur is detected (turn on audio to hear the murmur).
A bobbing of his head occurs when he is in systole, indicating a positive de Musset sign.
What is causing the shortness of breath?
-
Chronic bronchitis
Asthma attack
Congestive heart failure
Recent excessive exercise
Emphysema
………………………………………………………….
This patient is in congestive heart failure, and is starting to go into compensated shock. What murmur is
the congestive heart failure due to?
-
Tricuspid stenosis
Tricuspid regurgitation
Pulmonic stenosis
Pulmonic regurgitation
Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
…………………………………………………..
The murmur you are hearing, and the clinical signs above, are indicative of aortic regurgitation.
The patient is stabilized and admitted. What are some test would you like to order?
-
None, the patient just needs some rest (You had better think again)
Chest x-ray (Yes)
CT of the head (You might want to focus on the chest first)
MRI of the head (You might want to focus on the chest first)
CT of the thorax (Yes)
MRI of the thorax (Maybe)
Electrocardiogram (Yes)
-
Ultrasound of the heart (Yes)
Complete Blood Count (Yes)
Chemical profile (Yes)
Urinalysis (Yes)
Culture blood (Yes)
Stool culture (Maybe)
…………………………………………………………………….
Ultrasound confirms the aortic regurgitation. Blood lab results reveal elevated neutrophils, low
hemoglobin, and low serum iron.
Upon examination, you note a slender man, with many tattoos. Track marks from illicit drug use are
noted. You observe the following lesions:
Pictures of: janeway lesions, roth spots, osler nodes, proximal splinter hemorrhages.
What is your diagnosis?
-
Acute Rheumatic Fever
Bacterial endocarditis
Libman-Sacks endocarditis
Kaposi Sarcoma
Ehlers-Danlos Syndrome type IV
............................................................................
The goes back into congestive heart failure. He dies shortly thereafter. Autopsy confirms the diagnosis
of bacterial endocarditis.
*Although bacterial endocarditis most commonly affects the tricuspid valve, any valve can be
affected. In this case, the aortic valve was affected.
Picture of aortic valve with vegetations, courtesy of Steven Gustafson.
Blood culture results come back, identifying the infectious agent.
Picutures of catalase and coagulase tests, courtesy of Tracey Taylor.
Had this patient survived, what would have been the drug of choice for this infectious agent?
-
Penicillin G
Ceftriaxone
-
Vancomycin
Gentamicin
Ampicillin
Cefazolin
Daptomycin
Clyndamycin
Azithromycin
Nafcillin
Linezolid
Tobramycin
……………………………………………………………………..
The positive catalase and coagulase tests indicate that the infectious agent is Staphylococcus Aureus, the
most common agent of bacterial endocarditis in IV drug users. As of the time of update to this Pathlet,
drug of choice is as follows:
MSSA: First line is Nafcillin.
*If the patient has a mild allergy to Nafcillin, use Cefazolin. If the patient experiences
anaphylaxis to Nafcillin, use Vancomycin.
MRSA: First line is Vancomycin.
*If the patient has a prosthetic valve, rifampin and gentamicin should be added to the
treatment.
The IV drug abuser injected Staphylococcus Aureus directly into his bloodstream. The bacteria colonized
on the aortic valve. The colonization impeded closure of the valve, causing the regurgitation. Bacterial
emboli caused the proximal splinter hemorrhages, Osler nodes, Roth spots, and Janeway lesions.
Remember that Janeway lesions indicate bacterial endocarditis, and the clinical signs of endocarditis are
“FROM JANE”:
Fever
Roth Spots
Osler Nodes
Murmur
Janeway Lesions
Anemia
Nail bed hemorrhages
Emboli