Case Presentation MARK D. WINTON, MD FACP

Case Presentation

57 yo woman with several days of lightheadedness and some right

arm dysfunction.

Chief complaint – Dizziness

2 days of right arm numbness and clumsiness of arm

2 days of “floaters”

2 days of global headache

Known diabetic with HTN.

BP usually 130/70’s

No hypoglycemic episodes

Emergency Dept. Arrival

VS: BP 194/90 P 88 R 13 SpO2 94% RA T 36.9C

Medications:

Atenolol 50 mg daily

Glipizide 5 mg daily

Atorvastatin 20 mg daily

HCTZ 25 mg daily

Losartan 50 mg daily

Metformin 1000 mg BID

Allergies: Sulfas, unknown reaction

PSHX: Appendectomy

Cholecystectomy

C Section

Knee surgery

PMHX: DM2

HTN

Hyperlipidemia

Obesity

Family Hx:

Father and siblings all with HTN

Mother with CVA age 42, had DM, ESRD, fatal MI at age 68

Social Hx:

Works at grocery store, mainly as a checker

No tobacco for 18 years, 10-15 pack year Hx.

ETOH – rare

IDU - none

Physical Exam

General: Awake, alert, NAD.

Skin: No rashes

HEENT: unremarkable

Neck: supple

Lungs: Clear

Cor: RRR

Abdomen: Obese, nontender.

Ext: No cyanosis, clubbing, or edema.

Neuro: Fluent speech, no right arm weakness remained. No facial

droop. RAM normal. Motor 5/5. DTR symmetrical

Lab data

WBC 9.7, Hgb 14.2, plts 140K

Sodium 133, potassium 3.8, chloride 98, bicarbonate 25, BUN 14,

creatinine 0.77, glucose 170.

AST, ALT, Alk Phos, T. bilirubin all normal.

INR 1.21. Troponin 1.6

Troponin range: 0.000 – 0.045 ng/ml

Radiology data

CT head – noncontrast CT. Read as unremarkable.

CT Head images

Initial Hospital Course

Admit to ICU

IV Heparin for NSTEMI

IV NTG for blood pressure control

ECHO planned

A diagnostic procedure was performed, followed by Infectious

Disease consult.

Diagnostic procedure

What diagnostic procedure led to the ID consult?

ID Consult

History as before, but with the addition of recent dental work.

Extraction of tooth on left maxillary surface, filling of caries right side

maxillary tooth 3 weeks prior to admission.

No antibiotics were indicated, or given in this time frame.

Exam as before, but with the findings as noted.

3/6 SEM at LUSB and RUSB.

She recalled having a murmur for years.

MRI reviewed.

MRI images

MRI images

Differential Diagnosis

Clinical Course

After ECHO, she was transferred to a higher level of care for her

cardiac lesions.

Blood cultures remained no growth.

Hospitalist decided to add antibiotics despite negative cultures, and no signs of clinical deterioration.

What empiric antibiotics would be considered?

Antibiotic considerations

Ampicillin

Vancomycin

Ampicillin/Sulbactam

Ceftriaxone

Cefepime

Meropenem

Other diagnostic testing?

Subsequent History

Transferred to outside hospital for aortic valve lesion.

CT angiogram of the chest found a tortuous circumflex artery that

had been felt to represent an aortic valve ring abscess.

CT abdomen showed multiple lesions in liver, and renal and splenic infarcts.

EUS confirmed a 3.4 X 2.9 cm mass with irregular margins in the head

of the pancreas.

EUS biopsy confirmed adenocarcinoma.

CME Question

What is the most common cause of splinter hemorrhages?

A: Infective endocarditis

B: Systemic Lupus erythematosus

C: Trauma

D: Onychomycosis

E: Progressive Systemic Sclerosis (scleroderma)

CME Question

What is the most common cause of splinter hemorrhages?

A: Infective endocarditis

B: Systemic Lupus erythematosus

C: Trauma

D: Onychomycosis

E: Progressive Systemic Sclerosis (scleroderma)

Reference: Saladi, R. Persaud, A. et al. “Idiopathic Splinter

Hemorrhages”.JAAD Volume 50, Issue 2 (2/004), Pages 289-292.