A 46-Year-Old Man Comes to the Emergency Department After Awakening

question 117

Multiple Choice

A 46-year-old man comes to the emergency department after awakening with dyspnea and diaphoresis this morning.  He has had 6 weeks of fever, increased weakness, and fatigue.  The patient underwent a root canal procedure 4 months ago but reports that he has been otherwise healthy.  He has no history of cardiovascular disease, pulmonary disease, or cardiac surgery.
Temperature is 38.4 C (101.1 F) , blood pressure is 144/76 mm Hg, pulse is 106/min, and respirations are 28/min.  The patient is diaphoretic and appears uncomfortable.  There are no skin rashes.  The pupils are equal, round, and reactive without conjunctival lesions or suffusion.  There is no neck stiffness or meningeal signs.  A short, early diastolic murmur is heard at the left sternal border.  Coarse inspiratory crackles are heard bilaterally halfway up the lung fields.  The spleen is not palpable.  His speech is abnormal.
Chest x-ray reveals pulmonary congestion.  Transthoracic echocardiogram shows a 7-mm, mobile echodensity on the aortic valve with high-grade aortic regurgitation.  MRI of the brain reveals a small area of acute infarction in the left frontal lobe.
Blood cultures are obtained and empiric antibiotics are initiated.  Noninvasive positive-pressure ventilation is started with some improvement in respiratory distress.
Which of the following is an indication for cardiac valve surgery in this patient?

• A)Aortic valve involvement
• B)Embolic left frontal lobe infarct
• C)High-grade valvular regurgitation
• D)Signs of acute heart failure
• E)Size of the vegetation

---

Definitions:

Promoting Ecotourism

The practice of advocating for and implementing tourism that is environmentally responsible, supports conservation efforts, and benefits local communities.

Local Agencies

Regional or community-based organizations that provide specific services, support, or resources to the local population, often in the context of government, social services, or healthcare.

Staycation

A vacation spent at home or nearby, exploring local attractions instead of traveling far, often for budgetary or convenience reasons.

Summer Vacation

A period of time during the summer season when educational institutions are closed, allowing students and staff a break from academic activities.