Exhibit: fever, a new murmur, and three sets of blood cultures
A simulated electronic record frame with four tabs across the top, monospaced tabular clinical content, light row striping, and pointer chips standing in for three laboratory value fields.
`[VITAL SIGNS]` `NURSES' NOTES` `LABORATORY` `ORDERS`
| TIME | TEMP | HR | RR | BP | PULSE PRESSURE | SpO2 |
|---|---|---|---|---|---|---|
| Day 1 · 0600 | 100.8 F oral | 96 | 18 | 122/76 | 46 | 97 percent room air |
| Day 1 · 1800 | 101.6 F oral | 104 | 20 | 126/70 | 56 | 96 percent room air |
| Day 2 · 0600 | 101.2 F oral | 112 | 20 | 130/62 | 68 | 95 percent room air |
| Day 2 · 1400 | 102.4 F oral | 120 | 22 | 138/54 | 84 | 94 percent room air |
`VITAL SIGNS` `[NURSES' NOTES]` `LABORATORY` `ORDERS`
- Day 1 · 0615 42-year-old admitted from the clinic for fever of unknown source. Reports three weeks of fatigue, poor appetite, and night sweats that soak the bedding. Dental extraction sixteen days ago. No prior cardiac history documented.
- Day 1 · 0630 Receiving nurse documents a blowing murmur at the apex, described as new; no murmur recorded on the clinic note from six weeks ago.
- Day 1 · 1810 Small dark linear marks under the nail beds of two fingers on the right hand. One tender raised lesion on the pad of the left index finger. Client reports it hurts to press.
- Day 2 · 0610 Fever persists overnight despite antipyretic. Client reports feeling "more tired than yesterday."
- Day 2 · 1410 Client oriented to person, place, and time. No new weakness. Neurologic checks continued each shift per order.
`VITAL SIGNS` `NURSES' NOTES` `[LABORATORY]` `ORDERS`
| TEST | STATUS | RESULT |
|---|---|---|
| Blood culture set 1, right antecubital | Day 1 · 0700, collected | Pending |
| Blood culture set 2, left antecubital, separate site | Day 1 · 0725, collected | Pending |
| Blood culture set 3 | Day 1 · 0755, collected | Pending |
| Erythrocyte sedimentation rate | Resulted | Flagged high → BOOK 07 · P4 |
| C-reactive protein | Resulted | Flagged high → BOOK 07 · P4 |
| Complete blood count, white cell count | Resulted | Flagged high → BOOK 07 · P4 |
| Urinalysis | Resulted | Microscopic blood present |
`VITAL SIGNS` `NURSES' NOTES` `LABORATORY` `[ORDERS]`
- Transthoracic echocardiogram today; transesophageal study if the transthoracic is not diagnostic.
- Intravenous antibiotics to begin after all three culture sets are drawn.
- Peripherally inserted central catheter for a multi-week intravenous course.
- Neurologic assessment every shift and with any change.
- Notify provider for new focal weakness, new visual change, sudden abdominal or flank pain, or a new or changed murmur.
Valve side card
- Aortic stenosis: harsh systolic murmur at the right second intercostal space radiating to the carotids, with exertional angina, syncope, and dyspnea.
- Mitral regurgitation: blowing holosystolic murmur at the apex radiating toward the axilla.
- Mitral stenosis: low-pitched diastolic rumble at the apex with an opening snap, commonly with atrial fibrillation.
- Aortic regurgitation: early diastolic murmur at the left sternal border with a widening pulse pressure and bounding pulses.
The four cues. Fever that will not settle. A murmur documented as new. A recent invasive procedure with a mucosal breach. Peripheral embolic and immune findings: splinter hemorrhages, a tender fingertip lesion, and microscopic blood in the urine.
Margin notecultures before antibiotics, every time.
Watch outa sudden neurologic change in this patient is an embolus until proven otherwise. Report it immediately.
Takeawaya new murmur with a fever and a recent invasive procedure is endocarditis until cultures say otherwise.