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Case Presentation MARK D. WINTON, MD FACP
Case Presentation
57 yo woman with several days of lightheadedness and some right
arm dysfunction.
Chief complaint – Dizziness
2 days of right arm numbness and clumsiness of arm
2 days of “floaters”
2 days of global headache
Known diabetic with HTN.
BP usually 130/70’s
No hypoglycemic episodes
Emergency Dept. Arrival
VS: BP 194/90 P 88 R 13 SpO2 94% RA T 36.9C
Medications:
Atenolol 50 mg daily
Glipizide 5 mg daily
Atorvastatin 20 mg daily
HCTZ 25 mg daily
Losartan 50 mg daily
Metformin 1000 mg BID
Allergies: Sulfas, unknown reaction
PSHX: Appendectomy
Cholecystectomy
C Section
Knee surgery
PMHX: DM2
HTN
Hyperlipidemia
Obesity
Family Hx:
Father and siblings all with HTN
Mother with CVA age 42, had DM, ESRD, fatal MI at age 68
Social Hx:
Works at grocery store, mainly as a checker
No tobacco for 18 years, 10-15 pack year Hx.
ETOH – rare
IDU - none
Physical Exam
General: Awake, alert, NAD.
Skin: No rashes
HEENT: unremarkable
Neck: supple
Lungs: Clear
Cor: RRR
Abdomen: Obese, nontender.
Ext: No cyanosis, clubbing, or edema.
Neuro: Fluent speech, no right arm weakness remained. No facial
droop. RAM normal. Motor 5/5. DTR symmetrical
Lab data
WBC 9.7, Hgb 14.2, plts 140K
Sodium 133, potassium 3.8, chloride 98, bicarbonate 25, BUN 14,
creatinine 0.77, glucose 170.
AST, ALT, Alk Phos, T. bilirubin all normal.
INR 1.21. Troponin 1.6
Troponin range: 0.000 – 0.045 ng/ml
Radiology data
CT head – noncontrast CT. Read as unremarkable.
CT Head images
Initial Hospital Course
Admit to ICU
IV Heparin for NSTEMI
IV NTG for blood pressure control
ECHO planned
A diagnostic procedure was performed, followed by Infectious
Disease consult.
Diagnostic procedure
What diagnostic procedure led to the ID consult?
ID Consult
History as before, but with the addition of recent dental work.
Extraction of tooth on left maxillary surface, filling of caries right side
maxillary tooth 3 weeks prior to admission.
No antibiotics were indicated, or given in this time frame.
Exam as before, but with the findings as noted.
3/6 SEM at LUSB and RUSB.
She recalled having a murmur for years.
MRI reviewed.
MRI images
MRI images
Differential Diagnosis
Clinical Course
After ECHO, she was transferred to a higher level of care for her
cardiac lesions.
Blood cultures remained no growth.
Hospitalist decided to add antibiotics despite negative cultures, and no signs of clinical deterioration.
What empiric antibiotics would be considered?
Antibiotic considerations
Ampicillin
Vancomycin
Ampicillin/Sulbactam
Ceftriaxone
Cefepime
Meropenem
Other diagnostic testing?
Subsequent History
Transferred to outside hospital for aortic valve lesion.
CT angiogram of the chest found a tortuous circumflex artery that
had been felt to represent an aortic valve ring abscess.
CT abdomen showed multiple lesions in liver, and renal and splenic infarcts.
EUS confirmed a 3.4 X 2.9 cm mass with irregular margins in the head
of the pancreas.
EUS biopsy confirmed adenocarcinoma.
CME Question
What is the most common cause of splinter hemorrhages?
A: Infective endocarditis
B: Systemic Lupus erythematosus
C: Trauma
D: Onychomycosis
E: Progressive Systemic Sclerosis (scleroderma)
CME Question
What is the most common cause of splinter hemorrhages?
A: Infective endocarditis
B: Systemic Lupus erythematosus
C: Trauma
D: Onychomycosis
E: Progressive Systemic Sclerosis (scleroderma)
Reference: Saladi, R. Persaud, A. et al. “Idiopathic Splinter
Hemorrhages”.JAAD Volume 50, Issue 2 (2/004), Pages 289-292.