Endocarditis or Not? A Saturday Triage Decision

Saturday clinic. No lab. Just me and a medical assistant.

A fifty year old woman comes in with a fever a couple of days after a dental cleaning. Her gums are sore and she has some bodyaches. I’ve never seen her before. She used to see Dr. Wilford Brown and transferred to Dr. Kim.

The inflammation in her mouth is mild. She has a Grade 1 holosystolic murmur. Nobody has documented that before, but a Grade 1 is usually insignificant and barely worth documenting.

The only other thing I notice on her exam is that she has two thin brown lines under one of her fingernails. Like splinter hemorrhages. But there are only two.

“I banged that finger by accident a month ago, I’m pretty sure those lines have been there since way before my dental cleaning”, she said.

“Hmm, how bad are your bodyaches?”

“I’m not a complainer, I guess you could call them pretty bad.”

Time to make a decision. A judgement call: Hospital for blood cultures, possibly IV antibiotics, or blame the whole thing on a sore mouth and a virus and an incidental fingertip injury. One explanation or three?

Logic seemed to dictate one explanation for three clinical signs: mouth, fever, fingernail. But then there are bodyaches, bad bodyaches.

I made my decision, explained it carefully, and she concurred.

“So, stop in first thing Monday morning for some bloodwork, pick up the prescription I’m sending to the pharmacy, and call us if you don’t hear back from me by 10 am”, I said.

I slept well for two nights and did my Sunday farm chores without thinking much about it.

Monday, 9 am:

Lowish white blood cell count, close to 50% each of lymphocytes and neutrophils.

“I got your bloodwork. How are you feeling?”

“Fine, my mouth feels great and the fever is gone.”

“The blood count looks very typical for a virus.”

Minor mouth infection, viral illness and a banged fingertip. Bingo.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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