08-15-2009, 10:39 AM
A 30-year old Asian woman has complaints of fatigue, body aches, and a fever for the last 2 weeks. Upon physical examination her temperature is 101.3 F, pulse is 76/min, respirations are 20/min, and blood pressure is 130/72 mm Hg. A systolic murmur is heard at the apical area radiating to the axilla. The first heart sound is diminished, and a third heart sound is heard. The chest x-ray shows no signs of cardiomegaly or congestive heart failure. The echocardiogram shows vegetations. Blood cultures are sent, and the patient is started on antibiotic therapy with vancomycin and gentamicin. One set of blood culture is positive for Streptococcus viridans.
After 8 days of hospitalization on the same antibiotics, the patient has the sudden onset of shortness of breath, orthopnea, and an episode of hemoptysis.
Physical examination currently shows a temperature of 99.6 F, pulse of 108/min, respirations of 28-30/min, and a blood pressure of 90/50 mm Hg. Bilateral crackles are heard. A holosystolic murmur is heard in the apical area. A repeat chest x-ray shows signs of pulmonary congestion. The echocardiogram shows flail leaflets with premature closure of the mitral valve. The left ventricular end systolic diameter is more than 50 mm, and the ejection fraction is 60%.
Which of the following is the most effective management for this patient?
(A) Send for repeat blood cultures and change antibiotics based on culture and sensitivity results
(B) Start the patient on digoxin and captopril immediately
© Continue antibiotics for 6 weeks and repeat a transthoracic echocardiogram
(D) Arrange for immediate mitral valve reconstruction
(E) Start coumadin
After 8 days of hospitalization on the same antibiotics, the patient has the sudden onset of shortness of breath, orthopnea, and an episode of hemoptysis.
Physical examination currently shows a temperature of 99.6 F, pulse of 108/min, respirations of 28-30/min, and a blood pressure of 90/50 mm Hg. Bilateral crackles are heard. A holosystolic murmur is heard in the apical area. A repeat chest x-ray shows signs of pulmonary congestion. The echocardiogram shows flail leaflets with premature closure of the mitral valve. The left ventricular end systolic diameter is more than 50 mm, and the ejection fraction is 60%.
Which of the following is the most effective management for this patient?
(A) Send for repeat blood cultures and change antibiotics based on culture and sensitivity results
(B) Start the patient on digoxin and captopril immediately
© Continue antibiotics for 6 weeks and repeat a transthoracic echocardiogram
(D) Arrange for immediate mitral valve reconstruction
(E) Start coumadin