Pyrexia – IE

You are asked to review a 40 year old lady who has presented with a history of fever and back pain. She reports severe anxiety and reports that she is unable to sleep as this makes her anxiety worse. The nurse reports that her oxygen saturations have been dropping over the past couple of hours. How would you approach this case?

I would start by taking a focused history from the patient with appropriate input from the nursing team, if the patient is unable to present a coherent history.

I would review the medical notes, blood investigations, medical imaging and drug chart to identify any obvious precipitating cause of the desaturation.

I would then perform an A to E examination:

• A – Airway: I would ensure that the airway is patent and take corrective measures if necessary.
• B – Breathing: I would assess the breathing, specifically the respiratory rate, oxygen saturations and calculate the FiO2. If there are signs of respiratory distress, such as tachypnoea, low saturations, use of accessory muscles, orthopnoea etc, I would arrange for an urgent arterial blood gas to assess PO2, PCO2, lactates and pH. I would initiate supplemental oxygen to maintain O2 saturations above 96% and ask for an urgent portable X ray chest. I would auscultate the chest to look for wheeze/crepts or conducted sounds.
• C: I would check the blood pressure, heart rate and CRT and initiate appropriate measures. If the patient is hypotensive, a fluid bolus should be given unless there is clinical evidence of pulmonary oedema. I would ensure a patent cannula and send blood for septic screen, including blood cultures. I would ask for a 12 lead ECG. I would auscultate heart sounds and look for murmurs.
• D and E: I would check temperature, blood glucose and look for other causes of acute shortness of breath such as features of acute blood loss.

You are informed that the patient has admitted to smoking and use of intravenous recreational drugs and a previous heart valve surgery. She has a childhood history of asthma, but has not been on any long term medications.

On clinical examination, there are widespread crepitations and the respiratory rate is 40 per min with an oxygen saturation of 85% on high flow oxygen. Which investigations would you like to review next?

• ABG: hypoxia, raised lactates and hypocapnia: would be consistent with acute respiratory distress or pulmonary oedema.
• ECG: sinus tachycardia, or non-specific ST-T changes.
• XRC: florid pulmonary oedema.
• Difficult to assess murmurs due to florid crepts.
• I would also look for peripheral features of infective endocarditis and document any injection marks/scars.

What would your next steps be?

This patient appears to be quite unwell and I would ask for the medical emergency team and the ICU team to help.

While you are trying to talk to the ICU team, the nurse informs you that the patient has developed frothy hemoptysis and her saturations have dropped to 70s.

I would give her a bolus of furosemide (0.5 mg/kg) and fast bleep the ICU team. I would also ask for a bedside echo to be performed on an urgent basis. If the blood pressure permits, additional measures such as GTN infusion may be considered.

I would convey to the patient/her next of kin (with her consent) the diagnosis and the plan of management and would keep them updated about the clinical situation as it evolves.