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* nbme form 4
  benu - 12/15/09 11:57
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:
9.1 g/dL
Leukocyte count
Platelet count
Erythrocyte sedimentation rate
110 mm/h
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
  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
  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
  agnosia - 12/16/09 05:13
  IE , with septic emboli , splenic abscess, renal infarction  
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* Re:nbme form 4
  leowafner - 12/16/09 05:50
  Why this plateletis so high?  
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* Re:nbme form 4
  benu - 12/16/09 11:27
  Thanks agnosia, that does clear up some confusion!  
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* Re:nbme form 4
  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
  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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* Re:nbme form 4
  joseluisra3004 - 02/08/16 16:57
  This is a sub acute IE, spleen disease is greater with sub acute. also low grade fever. once they mention heart murmur and splinter hemorrhages... the presumptive diagnosis couldn't be other than IE. (more meticulous people would relate mental retardation with congenital heart defect, or blood and protein in urine with GROMERULONEPHRITIS, but otherwise no needed).

Having said that is obvious that next best step is B.- BLOOD CULTURES.

Abdominal pain and elevated platelets are definitely distractors, that may or may not have their reason to be present in this patient current clinical picture. (embolism can cause intestinal microinfarctions that produce pain or the splenomegaly can do that by itself) who cares, the above sings and symptoms should be enough to answer the question. This is a straight forward case of IE indeed. cant believe i got it wrong. My answer was E.-Broad spectrum ATB, but that is not the next best step.
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