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Difficulty: EasyPhysical Examination Findings

A 34-year-old man with a history of intravenous drug use presents to the emergency department with a 2-week history of high fever, chills, and progressive fatigue. He reports no recent travel or sick contacts. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 112/min. Auscultation reveals a new, harsh holosystolic murmur at the left lower sternal border. Which of the following physical examination findings are highly characteristic of the most likely diagnosis? (Select all that apply)

  1. Painful, erythematous nodules on the pads of the fingers and toesAnswer
  2. Painless, erythematous macules on the palms and solesAnswer
  3. Non-blanching, linear reddish-brown lesions under the nail bedsAnswer
  4. D
    Bluish discoloration of the periumbilical skin
  5. E
    Involuntary flexion of the hips and knees during passive neck flexion

Answer

The correct findings are painful, erythematous nodules on the finger pads (Osler nodes); painless, erythematous macules on the palms and soles (Janeway lesions); and linear reddish-brown lesions under the nail beds (splinter hemorrhages).
The patient's presentation of high fever, intravenous drug use, and a new murmur is highly suspicious for right-sided infective endocarditis. The classic peripheral physical examination findings for this condition include painful nodules on the finger pads (Osler nodes, representing immune complex deposition), painless macules on the palms and soles (Janeway lesions, representing septic microemboli), and linear hemorrhages under the nails (splinter hemorrhages). Recognizing these classic signs is fundamental for diagnosis.

Step-by-Step Solution

1
Identify the most likely diagnosis based on the clinical vignette.
The patient has a history of intravenous drug use, high fever, and a new heart murmur, which strongly points to infective endocarditis (likely involving the tricuspid valve).
Recognizing the classic triad of fever, new murmur, and risk factors is essential for establishing the diagnosis of endocarditis.
2
Recall the classic peripheral physical examination findings associated with this diagnosis.
Infective endocarditis is classically associated with Osler nodes, Janeway lesions, splinter hemorrhages, and Roth spots.
These dermatologic and ocular manifestations are critical components of the Duke criteria used to clinically diagnose the condition.
3
Evaluate each option to determine if it describes one of these classic findings.
The options describing Osler nodes, Janeway lesions, and splinter hemorrhages correctly match the expected peripheral findings.
Accurate identification of these distinct physical signs confirms the clinical suspicion of infective endocarditis.

Key Concept

The classic peripheral stigmata of infective endocarditis include Osler nodes (painful immunologic phenomena), Janeway lesions (painless septic microemboli), and splinter hemorrhages.
Estimated Time:1m 0s
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Physical Examination Findings

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