Bedside Diagnostic Challenge – 54-year-old man with fever and lumps on his hands

Paul Griner, MD, MACPBedside Diagnostic Challenge, Internal Medicine, Medical News

bedside diagnostic challenge bacterial endocarditis

Today’s Bedside Diagnostic Challenge question comes from the desk of Med-Challenger Internal Medicine Editor-in-Chief, Paul F. Griner, MD, MACP.

Test your bedside diagnostic skills with this review question.


A 54-year-old man presents to his physician’s office with the complaint of fever of 2 weeks duration. His temperature has varied between 101° F and 103° F. He has had no chills, cough, or urinary symptoms. Over the past few days, he has had painful “lumps” on his fingers

Two months ago, the patient underwent a diagnostic left heart catheterization without acute intervention. The patient’s past history was otherwise uneventful. He exercises regularly, does not smoke and drinks 5-6 glasses of wine a week.

Physical examination reveals a patient who appears mildly ill. Temperature is 102° F, Blood Pressure is 132/80 in the right arm, Pulse is 96 and regular, and Respirations 16/minute.

Examination of the skin reveals a very tender nodule on the flexor surface of distal interphalangeal (DIP) joint of the 3rd finger and cyanotic changes at the tips of three fingers (Fig 1). The lesion is papular and is very tender. There are a moderate number of petechiae along the inner surface of the conjunctiva of the lower lid of the right eye (Fig 2).

Med-Challenger, Bedside Diagnostic Challenge, Diagnostic Skills, Bedside Diagnostic Skills, Internal Medicine, Bacterial Endocarditis

Figure 1. Osler Node

Med-Challenger, Bedside Diagnostic Challenge, Diagnostic Skills, Bedside Diagnostic Skills, Internal Medicine, Bacterial Endocarditis

Figure 2. Conjunctival Petechiae

Examination of the heart reveals a Grade III holosystolic murmur at the apex. It is noted to be louder than previously recorded. The remainder of the physical examination is normal.


Based on the diagnostic value of careful listening and looking …

Which of the following essentially confirm a diagnosis of bacterial endocarditis in this febrile patient?

Answer Options:

Worsening of a pre-existing heart murmur and conjunctival petechiae

Osler nodes and fever

Osler nodes and vascular emboli

Fever and vascular emboli

Answer Explanation & References:

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About Bedside Diagnostic Challenge:

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most internists will spend the bulk of their professional time with patients in an office setting.

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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He returned to Rochester as Chief Resident in Medicine and Hematology Fellow and remained in their Department of Medicine, rising to Professor. He served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine.

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