3rd Quarter 2015-16 Volume 1:2

Author:  Islam Badawy, DO

A 42-year-old man presents with subjective fever, night sweats, malaise, headaches, abdominal pain, chest discomfort, and LE edema. Several months ago he had similar symptoms.  He notes that these symptoms last a week or two, and then appear to resolve, but then recur after a few weeks. He tried taking antibiotics given by an urgent care clinic for a week for one of the episodes, but noted no major difference/improvement. He has no prior medical problems though he thinks he was told that he had a heart murmur noted during childhood (he doesn’t remember any definitive diagnosis), grew up on a cattle ranch, and reveals no family history. He recently returned from Iraq, where he was doing work as a defense contractor. Examination is notable for a temperature of 38.3°C (100.9°F), pulse rate of 114 beats per minute, and question of a soft, difficult to characterize murmur at the base of the heart. The laboratory studies are notable for moderate serum transaminases. Blood cultures are negative at 48 hours.

 

What would be the next most reasonable step?

a.       Transthoracic Echocardiogram

b.      Start Antibiotic therapy without additional testing

c.       Cardiac CT

d.      Transesophageal Echocardiogram

e.       Start Lasix IV

Hepatitis serologies are negative. Abdominal ultrasonography reveals mild hepatomegaly, but is otherwise unremarkable. A tuberculin skin test is negative. The patient continues to be febrile. Computed tomography scanning of the chest, abdomen, and pelvis are unremarkable. The original blood cultures remain negative at 96 hours, as are repeat blood cultures. A TEE is performed, demonstrating two small, 1.5-2.0 mm vegetations on the aortic valve.

What would be the most likely organism causing this patients constitution of symptoms?

a.       Staphylococcus aureus

b.      Streptococcus Viridans

c.       Coxiella Burnetti

d.      Pseudamonas Aeruginosa

e.       Enterococcus faecalis

To confirm the diagnosis suspected in this patient what would be the indicated test of choice?

a.       Repeat Blood Culture now

b.      Follow up previously drawn Blood Culture in 2-3 months

c.       Electron Microscopy

d.      Immunofluorescence with polyclonal or monoclonal antibodies

e.       Culture from cardiac valves

What would be the best treatment for the suspected diagnosis?

a.       Vancomycin and Invanz for 6 weeks

b.      Doxycycline and hydroxychloroquine for 18 months

c.       Ampicillin and Gentamycin for 4 weeks

d.      Bactrim for 12 weeks

e.       Surgical Valve Replacement 

Chief Resident Update

  • Review ICU protocol carefully at the start of each month.
  • Plan ahead to make sure interviews/ activities do not conflict with Blue team/ ICU.
  • Patients’ pain management and overall satisfaction must be kept in mind while on the floors, including consult services.  Avoid giving missed messages, esp in terms of discharge.

Committee Updates

  • Code airway for ER help should be called for difficult airway.  ACLS review coming with with Dr. Lamonto.
  • Pain control and Infection control must be paid keen attention.

Upcoming Reminders

  • Inservice Exam: results to be discussed at quarterly meetings
  • Clinic 360 evals.
  • Committee meetings.
  • Apr 29 Grand Round
  • M&M (Dr. Scott)4/15

Scholarly Activity/Questions (N. Dsilva, DO)

A 40 yo AA woman with no pmhx presented with headaches, stating they have been increasing in frequency and intensity over the past few days. Reports taking OTC tylenol with minimal to no relief. On ROS, she denies everything except for intermittent joint pain, decreased urination with darker urine, and does mention that her fingers have been turning pale when she is outside in the coldor shopping in the frozen food section. Denies FamHx, stating she is adopted. No surgeries. NKDA. She was prescribed prednisone 20mg by her PCP for her joint pain and swelling 2 weeks ago. She does not take any other medications/ supplements. She works at a bank. Denies tob, ETOH or illicits.

T 98.6F, HR 82, BP 200/105, RR 14, SpO2 99% onRA; pain in head 9/10. On exam, she is AAOx3, mild distress due to headache, PERRLA, ophthalmic exam reveals cotton wool exudates, heart RRR, lungs clear, abdomen benign, trace ble edema. On exam of her nail fold beds, you note capillary cutoff. Plain CT head was unremarkable.

Na 135, K 4.7, Cl 110, CO2 22, BUN 45, Cr 2.5 (normal 0.9), WBC: 15.0, Hgb: 9.8, Plts: 110

ANA & anti-RNA polymerase III-positive

RF, CCP, Anti-SSA/SSB & dsDNA -negative

Given this patient’s clinical scenario, what is the first step in your treatment?

A. Start high dose IV corticosteroids

B. Continue oral prednisone, start labetalol drip

C. Plasmapheresis

D. Discontinue prednisone, give IV captopril

E. Emergent dialysis