Mrs. RK reports sudden onset of fever reaching 39.2°C

(102.6°F), accompanied by chills, malaise, and generalized weakness. She also

noticed linear dark streaks under multiple fingernails. No recent

hospitalizations or procedures apart from her known cardiac history. She denies

shortness of breath, chest pain, or cough. She denies a prosthetic valve.

Past Medical History:

• Type 2

  Diabetes Mellitus, controlled on oral hypoglycemics.

Social History:

• Denies

  intravenous drug use.

• No

  recent travel or sick contacts.

Allergies:

• No

  known drug allergies.

Physical Examination:

• Vital

  Signs: Temp: 39.2°C (Normal: 36.1–37.2°C), HR: 105 bpm (Normal: 60-100

  bpm), BP: 115/75 mmHg (Normal: 90–120/60–80 mmHg), RR: 18/min (Normal: 12-20/min),

  SpO₂: 98% on room air (Normal: 98-100%).

• Cardiovascular:

  New systolic murmur at the apex, not present in prior exams. Peripheral

  pulses palpable and symmetric.

• Skin/Extremities:

  Multiple small, non-tender erythematous macules on palms consistent with

  Janeway lesions. Linear reddish-brown streaks visible under fingernails (splinter

  hemorrhages). No petechiae elsewhere.

• Other

  Systems: Lungs clear, abdomen soft, non-tender, no hepatosplenomegaly,

  neurological exam non-focal.

Diagnostic Tests and Labs:

• Blood

  Cultures: Two separate sets grew Enterococci spp. (pan-susceptible)

• Transesophageal

  Echocardiogram (TEE): Revealed a 1.1 cm mobile vegetation

• Renal

  Function: Creatinine clearance 45 mL/min

• Other

  Labs: CBC notable for leukocytosis with neutrophilic predominance;

  inflammatory markers elevated (CRP, ESR).

Questions:

1. 

What are the subjective and objective

evidence that leads to infective endocarditis in this case? (4 marks)

2. 

Using Duke's criteria, determine the

diagnosis of infective endocarditis. (3 marks)

3. Mention the risk factors for endocarditis

in your patient. (1 mark)

4. 

Which antibiotics would you recommend for

this patient and state your reasoning. Kindly mention the name of the drug(s)

with dose, route, frequency, and duration. (7 marks)

Mr. Ahmed is a 72-year-old retired accountant who lives with

his daughter. Over the past 6–8 months, she has noticed a gradual but

progressive decline in his energy level and daily functioning. Previously

independent, he now spends most of the day seated, naps frequently, and has

reduced interest in social activities he once enjoyed. He denies chest pain or

dyspnea but reports persistent fatigue and a ‘heavy’ feeling in his limbs.

He frequently complains of feeling cold, even when other

family members are comfortable. He has begun wearing layered clothing indoors

and uses extra blankets at night. His daughter also reports that his speech has

become slower and somewhat slurred, with longer pauses between words. He

appears less expressive facially and occasionally seems forgetful, though he

denies confusion.

Past Medical History

• Myocardial

  infarction 8 months ago, treated with percutaneous coronary intervention

• Type 2

  Diabetes Mellitus (15-year history)

• Epilepsy

  (well-controlled, no seizures in 5 years)

• Hypertension
• Hyperlipidemia

Medications

• Aspirin

  81 mg daily

• Atorvastatin

  40 mg nightly

• Metoprolol

  succinate 50 mg daily

• Lisinopril

  10 mg daily

• Metformin

  1000 mg twice daily

• Phenytoin

  300 mg daily

No recent medication changes have been reported. Adherence

is described as consistent.

 Physical Examination

• General:

  Appears fatigued, slow to respond but oriented. Speech is slowed with mild

  dysarthria.

• Vital

  Signs:

• Blood

  Pressure: 128/74 mmHg

• Heart

  Rate: 54 bpm

• Respiratory

  Rate: 14/min

• Temperature:

  36.1°C

• Skin:

  Dry, coarse, cool to touch; mild non-pitting edema of hands.

• Face:

  Periorbital puffiness; thinning of the lateral eyebrows.

• Neck:

  Thyroid gland not visibly enlarged; no nodules palpated.

• Cardiovascular:

  Bradycardic but regular rhythm; no murmurs.

• Neurologic:

  Delayed relaxation phase of deep tendon reflexes; mild proximal muscle

  weakness; slowed mentation but intact cognition.

• Extremities:

  No tremor; mild non-pitting edema.

Laboratory Findings

• TSH:

  12 mIU/L (0.45–4.5 mIU/L)

• Free

  T4:

  0.3 ng/dL (0.8–1.7 ng/dL)

Questions

1. 

Provide a definitive diagnosis for Mr.

Ahmed’s thyroid status, classifying the specific type of disorder based on the

laboratory findings. (2 marks)

2.  

Identify three signs or symptoms from his

presentation that support your finding. (3 marks)

3. Formulate a specific initial therapy and dosing

regimen for Mr. Ahmed (medication name, dose and frequency). Justify your dose

selection. (5 marks)

4. Analyze the potential pharmacological

interactions between Mr. Ahmed's existing medications and the initiated therapy.

What adjustments might be necessary? (2 marks)