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* nbme form 4
 #470386  
  benu - 12/15/09 11:57
 
 
33.  
A 17-year-old boy with mental retardation is brought to the physician because of low-grade fever and abdominal pain for 6 days. His temperature is 37.8°C (100.1°F), pulse is 110/min, respirations are 22/min, and blood pressure is 120/70 mm Hg. Examination shows splinter hemorrhages under the nails. A grade 2/6 systolic murmur is heard best at the upper left sternal border. There is a systolic ejection click. S1 and S2 are normal. Abdominal examination shows splenomegaly. Laboratory studies show:
 
Hemoglobin
9.1 g/dL
Leukocyte count
30,000/mm3
Platelet count
928,000/mm3
Erythrocyte sedimentation rate
110 mm/h
Urine
 
   Blood
2+
   Protein
1+
 
Which of the following is the most appropriate next step in management?

A 24-Hour urine collection for measurement of protein and creatinine concentrations

B Blood cultures

C Ultrasonography of the abdomen

D CT scan of the abdomen

E Broad-spectrum antibiotic therapy

 
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* Re:nbme form 4
#1974819
  dr_bubbles - 12/15/09 12:36
 
  B. blood cultures but it has to be before giving him Antibiotics???  
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* Re:nbme form 4
#1975478
  benu - 12/16/09 00:44
 
  thanks for the reply.
blood cultures seems a safe choice, but what the heck is wrong with this patient? whay splenic and renal involvement? very dissatisfying - trying this one!
 
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* Re:nbme form 4
#1975538
  agnosia - 12/16/09 05:13
 
  IE , with septic emboli , splenic abscess, renal infarction  
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* Re:nbme form 4
#1975544
  leowafner - 12/16/09 05:50
 
  Why this plateletis so high?  
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* Re:nbme form 4
#1975715
  benu - 12/16/09 11:27
 
  Thanks agnosia, that does clear up some confusion!  
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* Re:nbme form 4
#2000359
  drsaphire84 - 01/19/10 20:18
 
  y not e ... wen its straightforward case of IE..some body plyz clarify
 
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* Re:nbme form 4
#2007948
  guadsquad - 01/27/10 21:36
 
  I would say the answer is B.

This is a Duke's criteria question and the patient doesn't quite meet the criteria yet. He has no major criteria (the murmur is probably associated endocardial cushing defect secondary to his probable trisomy 21). He certainly doesn't have 5 minor criteria to slap him with a dx of IE. So ur best test is blood culture first to see if he meets the major criteria of positive blood cultures plus 3 minors (Predisposing heart condition, emboli, splinter hemorrrhages).
 
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