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Difficulty: MediumPhysical Examination Findings

A 42-year-old man is brought to the emergency department by his wife due to a 3-week history of recurrent fevers, profound fatigue, night sweats, and new-onset shortness of breath with exertion. One month ago, he was hospitalized for a complicated methicillin-susceptible Staphylococcus aureus (MSSA) skin infection that was treated with a short course of oral antibiotics against medical advice. He appears acutely ill and diaphoretic. His temperature is 39.2°C (102.6°F), blood pressure is 110/50 mmHg, heart rate is 112/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on ambient air. The physician suspects a severe, acute systemic intravascular infection. Which of the following physical examination findings are highly indicative of the most likely diagnosis in this patient? (Select all that apply)

  1. Painless, erythematous macules on the palms and solesAnswer
  2. Tender, raised, violaceous nodules on the pads of the fingersAnswer
  3. A blowing, holosystolic murmur heard best at the cardiac apex that radiates to the axillaAnswer
  4. D
    A low-pitched, rumbling diastolic murmur at the cardiac apex preceded by an opening snap
  5. E
    A harsh, crescendo-decrescendo systolic murmur at the left lower sternal border that increases in intensity during the Valsalva maneuver
  6. F
    Painless, non-pruritic, pink macules with central clearing on the trunk and inner surfaces of the limbs

Answer

The correct findings are painless erythematous macules on the palms and soles (Janeway lesions), tender violaceous nodules on the finger pads (Osler nodes), and a blowing holosystolic murmur at the cardiac apex (mitral regurgitation).
The patient's presentation of high fevers, toxicity, and a recent incompletely treated Staphylococcal skin infection is highly suspicious for acute infective endocarditis (IE). The classic physical examination findings for IE reflect either direct valvular destruction or systemic embolization/immune complex deposition. A new blowing, holosystolic murmur at the apex radiating to the axilla indicates acute mitral regurgitation, which can occur due to leaflet perforation or chordal rupture from a vegetation. Furthermore, septic microemboli can cause painless, erythematous macules on the palms and soles known as Janeway lesions. Deposition of circulating immune complexes can lead to the formation of Osler nodes, which are tender, violaceous nodules on the pads of the fingers and toes. Recognizing this specific constellation of findings is essential for promptly diagnosing and managing this life-threatening condition.

Step-by-Step Solution

1
Analyze the patient's history and vital signs.
The patient has high fevers, toxicity, and a recent history of inadequately treated MSSA bacteremia.
To establish the primary clinical syndrome, which strongly points towards an acute, severe infection such as infective endocarditis.
2
Identify the classic physical examination manifestations associated with the suspected diagnosis.
Infective endocarditis is classically associated with valvular destruction (causing new regurgitant murmurs) and peripheral stigmata (vascular and immunologic phenomena).
To correlate the pathophysiology of the disease with the specific physical signs being tested.
3
Evaluate each answer choice for its association with infective endocarditis.
Janeway lesions (painless palmar/plantar macules), Osler nodes (tender finger nodules), and mitral regurgitation (holosystolic apical murmur) are all strongly indicative of this condition.
To confirm the correct constellation of findings and rule out distractors belonging to other cardiac conditions like rheumatic fever or hypertrophic cardiomyopathy.

Key Concept

Physical Examination Findings of Infective Endocarditis
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Topics

Physical Examination Findings

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