A 49-year-old man presents to the physician with fever, confusion, and abdominal pain. His wife explains that for the past few days he has had fevers, night chills, and fatigue, but suddenly developed confusion this morning. His medical history is significant for hypertension and diabetes, for which he takes losartan, amlodipine, and metformin. He denies any tobacco, ethanol, or drug use. His vitals show a temperature of 38.4°C, a blood pressure of 142/90 mmHg, a heart rate of 96 beats per minute, and a respiratory rate of 16 breaths per minute. He has poor dentition, no jugular venous distention, and a normal pulmonary examination. There is a 3/6 holosystolic murmur heard over the apex. Blood cultures are drawn, and the patient is started on empiric antibiotics. A transthoracic echocardiogram shows a normal ejection fraction with no valvular lesions.
What is the most appropriate next step in management of this patient?
Transesophageal echocardiogram. The patient in this vignette meets one major and two minor of the modified Duke criteria for infective endocarditis (new regurgitant murmur, fever, and poor dentition and diabetes as predisposing conditions). Transesophageal echocardiography (TEE) has a much higher sensitivity to detect infective endocarditis than a transthoracic echocardiogram (TTE), and thus should be performed if the TTE is negative but there is still a high clinical suspicion for the diagnosis. (B) Surgery should be performed if there is serious valvular dysfunction (e.g., cardiogenic shock), recurrent emboli despite antibiotics, infection with specific organisms that are difficult to treat with antibiotics alone, and a few other indications that are not as high yield. (C) A CT scan of the chest would not be helpful to make a diagnosis at this point. (D) These tests are nonspecific markers of inflammation and would not be very useful in confirming or ruling out infective endocarditis. Elevation in these markers is a minor criterion in the modified Jones criteria for rheumatic fever. (E) IV steroids should not be given in this condition since there is active infection.
A 62-year-old man with a history of GERD and peptic ulcer disease presents with severe upper abdominal pain. The patient reports that the pain abruptly started 6 hours ago while he was eating breakfast. He reports diffuse pain that radiates to his back. He has a blood pressure of 100/60 mmHg, pulse of 118/min, temperature of 37.9°C, and a respiratory rate of 24 breaths per minute. On physical examination, there is exquisite tenderness to superficial palpation over the entire abdomen. The patient is unable to tolerate the rest of the abdominal examination.
Which of the following is the best next step in management?
Chest x-ray. With this patient’s history of peptic ulcer disease and acute onset abdominal pain, bowel perforation should be suspected. This patient is likely suffering from a perforated peptic ulcer given his inability to tolerate an abdominal examination (guarding and other peritoneal signs may suggest gastrointestinal perforation). The best initial step in management is an upright chest x-ray to detect pneumoperitoneum (chest x-ray will show free air underneath the diaphragm, Figure below). Detecting pneumoperitoneum is diagnostic of perforation. (C) If a chest x-ray does not generate positive findings and perforation is highly suspected, proceed with abdominal CT scan. However, chest x-ray should be performed first since it can be done immediately; be cautious of sending patients that may deteriorate to the CT scanner! (A, B) Laboratory tests are too time consuming and would not help diagnose perforation; an ultrasound is not a sensitive test for detecting intestinal perforation.
A 17-year-old girl presents with 2 weeks of weight loss, intractable nausea and vomiting, and a decreased level of consciousness. She is found to have glucose of 439 mg/dL. She is started on IV fluids and insulin. Four hours later, her laboratory tests demonstrate the following.
What is the most appropriate next step in management?
Add glucose to the IV fluids. This patient has diabetic ketoacidosis (DKA), a frequent presentation of type 1 diabetes mellitus. The main goal in diabetic ketoacidosis is to bring down the blood sugar, hydrate with IV fluids, and closely monitor potassium. Once serum glucose approaches 200 to 250 mg/dL, patients should be given dextrose to help metabolize the serum ketones (note that the patient still has an anion gap). (A) A switch to subcutaneous regular or fast-acting insulin is also reasonable at this time, but long-acting insulin glargine is inappropriate. (D) Oral metformin is used for type 2 diabetes mellitus and is not effective in type 1 diabetes. Although DKA can occur in type 2 diabetes, it is less common. In addition, oral therapy is not appropriate at this time. (E) An ECG would be a good choice in patients with abnormal serum potassium levels.
A middle-aged man comes to the Emergency Department complaining of 2 days of shaking chills, as well as a cough with foul-smelling sputum and small amounts of blood. He admits to drinking a pint of vodka and smoking 3 packs of cigarettes each day. He has been to prison twice in the last year. A chest x-ray shows right upper lobe infiltrates. His laboratory tests are shown below.
An HIV and tuberculin skin test are both negative. What is the best next step in management?
Begin ceftriaxone and clindamycin. This patient’s history of alcohol abuse combined with his chest x-ray findings and foulsmelling sputum support a diagnosis of aspiration pneumonia, which should be treated with clindamycin and ceftriaxone to cover both gram-negative and anaerobic pathogens. (B) CT scan of the chest would not change the management. (C) Vancomycin and ceftriaxone is the treatment for health care associated pneumonia; however, the patient has not been hospitalized recently. (D) The patient is HIV negative, making PCP an unlikely diagnosis. (E) Although the patient has risk factors for tuberculosis (TB), the tuberculin skin test was negative.
A 33-year-old African American woman complains of fevers, night sweats, and shortness of breath over the past few weeks. Her vital signs are normal, and her lungs are clear to auscultation. She has some waxy skin plaques on her face and erythematous nodules on the anterior portion of her legs. A chest x-ray is performed, which is shown in Figure below.
Which of the following is the likely diagnosis?
Sarcoidosis. The skin findings and bilateral hilar adenopathy on chest x-ray suggest the diagnosis of sarcoidosis, and African Americans are at an increased risk. Common findings with this disease include hilar lymphadenopathy (biopsy would show noncaseating granulomas) that can produce pulmonary hypertension, erythema nodosum, waxy skin plaques, uveitis, cranial nerve palsies and other neurologic deficits, and many other findings. (A) If the patient had shortness of breath from TB, the chest x-ray would show consolidation (primary TB) or upper lobe infiltrates with or without cavitation (reactivation TB). (B) Thoracic lymphadenopathy could represent lymphoma; however, the association with skin findings makes sarcoidosis more likely. (C) Pulmonary hypertension is a complication of sarcoidosis, and is not the underlying diagnosis. Pulmonary hypertension alone would not produce hilar adenopathy or skin findings.
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