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)