Bloodstream Infections and Infective Endocarditis — DCE Clinical Case

The systematic routine

End of the bed first. Look before touching: fever chart and observations at the foot, oxygen or monitoring, visible distress, cachexia from weeks of illness, and the clues to source and severity — intravenous lines, a PICC, a dialysis catheter, track marks suggesting injecting drug use [2].

Hands — the highest-yield peripheral examination. Splinter haemorrhages under the nails, Janeway lesions (non-tender macules on palms and thenar eminences), Osler nodes (tender nodules in the finger pulp), clubbing, and peripheral perfusion — a cold pulseless finger here is an embolus, and that is a vascular Duke criterion [1] [2].

Arms and access sites. Dialysis fistulae, old and new puncture sites, PICC or central line sites with any erythema — each is a potential portal of entry and changes the organism list [2].

Face, eyes and mouth. Conjunctival pallor and petechiae; then say the words — "I would examine the fundi for Roth spots" (retinal haemorrhages with pale centres). Inspect the teeth and gums: the dental state is both a source and a prevention conversation, and palatal petechiae count [1] [2].

The precordium. Inspect for a median sternotomy scar, a CIED pocket (and any erythema over it), then palpate and auscultate systematically. You are listening for regurgitant murmurs: the early diastolic murmur of aortic regurgitation at the left sternal edge in expiration, and the pansystolic murmur of mitral regurgitation at the apex radiating to the axilla — and for the mechanical clicks of a prosthetic valve. A new regurgitant murmur is itself a major Duke criterion [1].

Complete the circuit. Sacral and peripheral oedema and auscultated lung bases for heart failure (the surgical urgency), abdominal palpation for splenomegaly, a urine dipstick for haematuria (glomerulonephritis — an immunologic criterion), and a quick neurological screen for embolic deficits [1] [2].

Close the loop. "To complete my assessment I would review the temperature chart, the blood culture results and the echocardiogram" [3].