WBR1061

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	USMLE Step 3
Main Category	Primary Care Office
Sub Category	Cardiovascular
Prompt	A 27 year-old female comes to your office complaining of fever, along with chills, anorexia, malaise, and chest pain. These symptoms started gradually over the last 2 weeks after she had been treated from serious urinary tract infections. The patient has a past medical history of rheumatic fever when she was 7 years old. She doesn’t smoke, but drink alcohol occasionally. She is sexually active. On examination, her temperature is 102.9°F (39.4° C), blood pressure 140/90 mmgH, heart rate 100/min, and respiratory rate of 21/min. Heart examination shows ejection systolic murmur on the apex that propagates to axilla. There is a painful, red, raised lesion on the finger pulps. Her chest x-ray shows patchy infiltrations, and her echocardiography shows mitral valve vegetations. What is the best next step in managing this patient?
Answer A	Blood culture and wait for the results to start antibiotic therapy
Answer A Explanation	Correct Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting for the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of empiric treatment.
Answer B	Blood culture and start antibiotics before the results
Answer B Explanation	Incorrect The rapid progression of acute cases necessitates the start of empirical treatment antibiotic therapy once the blood cultures have been collected
Answer C	Start empiric antibiotics immediately
Answer C Explanation	Incorrect Blood cultures have to be drawn first
Answer D	Start with thrombolytic therapy to prevent more emboli
Answer D Explanation	Incorrect Anticoagulants can cause or worsen hemorrhage in patients with endocarditis but may be carefully administered when needed.
Answer E	Order EKG
Answer E Explanation	Incorrect Blood cultures have to be drawn first
Right Answer	A
Explanation	[[Explanation::This is subacute case of infective endocarditis, it is diagnosed according to the Duke clinical criteria, which include: Two major criteria, or One major and three minor criteria, or Five minor criteria Major Criteria 1.Positive blood culture for infective endocarditis 2.Evidence of endocardial involvement: which include positive echocardiogram for infective endocarditis Minor criteria: Predisposition: predisposing heart condition or intravenous drug use Fever: temperature > 38.0° c (100.4° f) Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and janeway lesions Immunologic phenomena: glomerulonephritis, osler's nodes, roth spots, and rheumatoid factor Microbiological evidence: positive blood culture but does not meet a major criterion as noted above or serological evidence of active infection with organism consistent with infectious endocarditis Echocardiographic findings: consistent with infectious endocarditis but do not meet a major criterion as noted above Antibiotic therapy for subacute hemodynamically stable disease, and in those who have received antibiotics recently can be delayed waiting for the results of blood cultures, as this delay allows an additional blood cultures without the confounding effect of empiric treatment. On the other hand, the rapid progression of acute cases necessitates the start of empirical treatment antibiotic therapy once the blood cultures have been collected. Educational Objective: References: ]]
Approved	No
Keyword	[[WBRKeyword::Infective endocarditis]]
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