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Difficulty: MediumPhysical Examination Findings

A 34-year-old man with a history of intravenous substance use is brought to the emergency department due to a 1-week history of severe chills, intermittent high fevers, and profound fatigue. His temperature is 39.1°C (102.4°F), blood pressure is 112/64 mm Hg, and pulse is 115/min. Cardiac auscultation reveals a prominent holosystolic murmur heard best at the left lower sternal border that significantly increases in intensity during inspiration. Based on the most likely underlying diagnosis, which of the following physical examination findings may also be characteristic of this patient's condition? (Select all that apply)

  1. Tender, violaceous subcutaneous nodules on the pads of the fingers and toesAnswer
  2. Nontender, erythematous or hemorrhagic macular lesions on the palms and solesAnswer
  3. C
    Erythematous, non-pruritic, ring-like skin lesions with central clearing on the trunk
  4. D
    Firm, painless subcutaneous nodules positioned over the extensor surfaces of joints
  5. E
    A sharply demarcated, erythematous facial eruption that characteristically spares the nasolabial folds

Answer

The correct findings are tender, violaceous subcutaneous nodules on the pads of the fingers and toes (Osler nodes) and nontender, erythematous or hemorrhagic macular lesions on the palms and soles (Janeway lesions).
Infective endocarditis frequently presents with distinct peripheral microvascular phenomena. Tender, violaceous nodules on the digits describe Osler nodes (an immunologic phenomenon), and nontender macular lesions on the palms and soles describe Janeway lesions (septic microemboli). Both are classic, highly tested physical examination findings indicative of infective endocarditis.

Step-by-Step Solution

1
Analyze the clinical presentation and auscultatory findings.
The patient has a history of intravenous drug use, high fever, and a holosystolic murmur at the left lower sternal border that increases with inspiration (Carvallo's sign).
This triad is highly suspicious for right-sided (tricuspid valve) infective endocarditis, most commonly due to Staphylococcus aureus in this demographic.
2
Identify the specific physical examination signs associated with the suspected diagnosis.
Classic peripheral stigmata of infective endocarditis include Osler nodes (tender), Janeway lesions (nontender), splinter hemorrhages, and Roth spots.
Recognizing these specific vascular and immunologic phenomena is crucial for supporting the clinical diagnosis of infective endocarditis during the physical examination.

Key Concept

Recognizing the classic peripheral stigmata of infective endocarditis during a physical examination.
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Physical Examination Findings

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