A 38-Year-Old Man Comes to the Emergency Department Due to a Day

question 301

Multiple Choice

A 38-year-old man comes to the emergency department due to a day of progressive shortness of breath.  Over the past week, he has also had fever and malaise.  The patient uses intravenous heroin daily.  Temperature is 39.6 C (103.3 F) , blood pressure is 100/56 mm Hg, pulse is 102/min and regular, and respirations are 20/min.  Oxygen saturation is 93% on room air.  The patient is in moderate respiratory distress.  Bibasilar crackles are heard on lung auscultation.  Cardiac examination reveals a 3/6 holosystolic murmur that radiates to the left axilla.  There is 1+ bilateral pedal edema.  Laboratory evaluation shows a hematocrit of 33% and a leukocyte count of 19,000/mm³ with a left shift.  ECG reveals sinus tachycardia.  Chest x-ray reveals pulmonary edema and no cardiomegaly.  Echocardiography demonstrates a 1-cm vegetation on the mitral valve and severe mitral regurgitation.  Blood cultures are drawn, and empiric broad-spectrum antibiotics are initiated.  Oxygen is also administered via nasal canula.  What is the most appropriate next step in management?

• A)Intravenous heparin infusion
• B)Intravenous metoprolol
• C)No additional intervention
• D)Radionucleotide bone scan
• E)Surgical consultation

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Definitions:

Suicide

The act of deliberately taking one's own life through various means.

Personality Disorder

A type of mental disorder characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, shown across many contexts.

Maladaptive Pattern

Behaviors or thoughts that inhibit one's ability to adjust healthily to particular situations.

Behavior

The actions or reactions of an individual or group in response to external or internal stimuli.