Examkin

Question

Difficulty: HardPhysical Examination Findings

A 47-year-old man with a history of intravenous drug use is admitted to the inpatient medical ward with a 2-week history of spiking fevers, generalized myalgias, and progressive fatigue. His temperature is 39.2°C (102.6°F), blood pressure is 110/65 mm Hg, and pulse is 112/min. Cardiac auscultation reveals a new high-pitched holosystolic murmur at the apex radiating to the axilla. Transesophageal echocardiography visualizes a large, mobile vegetation on the mitral valve leaflets. The physician conducts a thorough physical examination to identify peripheral stigmata of infective endocarditis. Among the classic peripheral manifestations of this disease, which of the following physical examination findings are pathophysiologically mediated by immune complex deposition rather than direct septic microembolization? (Select all that apply)

  1. Tender, violaceous nodules on the volar pads of the fingers and toesAnswer
  2. Retinal hemorrhages with pale, white centers on funduscopic examinationAnswer
  3. C
    Nontender, erythematous, and macular lesions on the palms and soles
  4. D
    Linear, dark red streaks beneath the proximal portion of the fingernails
  5. E
    A focal, pulsatile, and expansile mass with a systolic bruit in a peripheral artery

Answer

The correct physical examination findings are tender, violaceous nodules on the volar pads of the digits (Osler nodes) and retinal hemorrhages with pale centers (Roth spots).
Both tender, violaceous nodules on the digits (Osler nodes) and pale-centered retinal hemorrhages (Roth spots) are classic immunologic manifestations of infective endocarditis caused by circulating immune complexes depositing in small vessels and causing vasculitis.

Step-by-Step Solution

1
Identify the patient's primary diagnosis based on the clinical vignette.
The patient has a history of intravenous drug use, fever, a new mitral valve murmur, and an echocardiogram showing a vegetation, confirming the diagnosis of left-sided infective endocarditis.
Establishing the primary diagnosis is necessary to understand the context of the physical examination findings.
2
Categorize the requested physical examination findings by their underlying pathophysiological mechanisms.
The question asks specifically for peripheral stigmata mediated by immune complex deposition, contrasting them with those caused by septic microembolization.
Infective endocarditis produces distinct peripheral signs through two major mechanisms: embolic events and immunologic phenomena.
3
Evaluate each answer choice to determine its specific pathophysiology.
Osler nodes (tender digital nodules) and Roth spots (pale-centered retinal hemorrhages) are immunologic phenomena. Janeway lesions (nontender palmar/plantar macules), splinter hemorrhages, and mycotic aneurysms are embolic or microthrombotic phenomena.
Accurate correlation of each physical sign with its mechanism is required to select all correct options.

Key Concept

Infective endocarditis presents with peripheral stigmata that can be divided into embolic phenomena (e.g., Janeway lesions, mycotic aneurysms, splinter hemorrhages) and immunologic phenomena (e.g., Osler nodes, Roth spots, glomerulonephritis).
Rate this question

Topics

Physical Examination Findings

More questions from this topic