A 32 yr old man present to ER with history of high-grade fever, dyspnea and fatigue. On physical examination reveals a new holosystolic murmur that is best heard over cardiac apex. Skin examination shows following skin lesion. What is most likely diagnosis?
First, the new holosystolic murmur at the apex suggests mitral regurgitation. That's a red flag for something causing valvular damage. High-grade fever and fatigue make me think of an infectious process. The skin lesion is another clue. Osler nodes and Janeway lesions are classic for infective endocarditis. Osler nodes are tender, red lesions on fingers/toes, while Janeway lesions are non-tender on palms/soles. The combination of fever, murmur (valve issue), and skin lesions points to endocarditis.
Now, the options. Let's assume the choices are something like: A. RHD, B. MI, C. Endocarditis, D. Pneumonia.
A. Rheumatic heart disease usually presents with a history of rheumatic fever, which is more common in younger individuals. But the acute presentation with fever doesn't fit. Plus, RHD is more subacute or chronic.
B. Myocardial infarction can cause chest pain and murmur, but the fever is a red flag. MI doesn't typically present with fever unless there's a complication like Dressler's syndrome, which is post-MI. But the skin lesions and holosystolic murmur are more indicative of valvular infection.
C. Endocarditis is the most likely. The acute presentation with fever, new murmur (valve damage), and Osler/Janeway lesions are classic. The patient's age and the presence of a skin lesion support this.
D. Pneumonia can cause fever and dyspnea, but the murmur is a key differentiator. Pneumonia doesn't cause valvular issues unless there's a complication, which is less likely.
Clinical pearl: Remember the triad of fever, new murmur, and skin lesions (Osler, Janeway) as a hallmark of infective endocarditis. Always consider endocarditis in patients with unexplained fevers and valvular heart disease signs.
**Core Concept**
The clinical scenario combines systemic infection (fever), valvular heart disease (holosystolic murmur at apex), and skin lesions (likely Osler nodes or Janeway lesions). These findings are classic for **infective endocarditis (IE)**, a life-threatening infection of heart valves or endocardium.
**Why the Correct Answer is Right**
Infective endocarditis presents with **Fever**, **New or changing heart murmur** (due to valve damage), and **Skin lesions** (Osler nodes: tender, red nodules on fingers/toes; Janeway lesions: painless macules on palms/soles). The holosystolic murmur at the apex suggests **mitral valve involvement**, common in IE. Systemic symptoms like dyspnea and fatigue arise from embolic events or heart failure.
**Why Each Wrong Option is Incorrect**
**Option A:** *Rheumatic heart disease* causes chronic valvular damage but does not present with acute fever or skin lesions.
**Option B:**