John Murtagh

·World General Practice/Family Medicine·

Case Studies of John Murtagh(45)
——Undifferentiated Illness with Fever，F(xiàn)atigue and Generalised Aches in A Young Man

John Murtagh

Infective endocarditis;Fever;Fatigue;Pain;Undifferentiated illness

1 History

Mr KC，a 36-year-old office worker，presents with a 4 week history of tiredness，fatigue on the slightest exertion and fever.At times hisbody aches allover and he has lost3 to4 kilograms of weight.This illness ismost unusual since he has always kept excellent health.

2 Further history

Further history reveals the following facts:

?The symptoms have developed rather suddenly;

?Aching joints especially shoulders，wrists and knee;

?Night sweats for the past week with saturated pyjamas in past 3 nights;

?Occasional temporary palpitations for past year especially in recent days;

?No chest pain，breathlessness，rigors or back pain;

?No overseas travel or use of intravenous drugs;

?Not on any medication;

?No recent visits to doctors but several recent visits to dentist for dental problems including root canal fillings;

?No significant pastmedical history including rheumatic fever.

3 Questions

3.1 Question 1:Would you consider a possible diagnostic hypothesiswith this limited information?

3.2 Question 2:What features of the physical examination would be particularly relevant?

4 Answers

4.1 Answer1:Possible diagnostic hypothesis This type of history with a febrile illnessmakes it difficult to pin-point a diagnosisbut the key is the recent dental work.Although various intercurrent infections are possible it would be appropriate to consider infective endocarditis.

4.2 Answer 2:Features of physical examination The physical examination findingswere:

?General appearance-looks unwell and moves slowly;

?Vital signs:pulse 88/min＆regular，BP 135/55 mm Hg(1 mm Hg=0.133 kPa)，temperature38.5℃，respirations15/min;

?Hands and skin:no evidence of infection，emboli or splinter haemorrhages;

?Mouth and teeth:normal;

?Cardiovascular:an ejection systolic murmur and a long diastolic murmurmaximal at the second LICS;

?Respiratory:normal;

?Abdomen:palpable spleen(2 cm below costalmargin);

?Urinalysis:protein and blood present.

5 Further questions

5.1 Question 3:What is your provisional diagnosis?

5.2 Question 4:What investigationswould you consider?

6 Further answers

6.1 Answer 3:Provisional diagnosis A lthough there are a number of possible causes for the febrile illness，infective endocarditis must be considered likely because of the physical signs which indicate aortic valvular incompetence.

Other possible diagnoseswould include lymphoma or othermalignancies，tuberculosis and empyema but infective endocarditis must be excluded because of its serious nature.

6.2 Answer 4:Appropriate investigations:

?Blood cultures(at least three sets);

?ECG;

?Chest X ray;

?FBE，ESR and C-reactive protein;

?Urinemicroscopy，culture and sensitivity;

?Echocardiography:usually transthoracic but often followed by a transoesophageal echocardiogram.

7 Follow up

Blood cultures in Mr KC proved infection with Streptococcal viridans.

He was treated in hospital with a combination of antibioticsbenzylpenicillin，flucloxacillin and gentamicin.

2012-12-07)

(本文編輯:閆行敏)