9.A 32-year-old woman presents to the ED with a persistent fever of
101 °F over the last 3 days. The patient states that she used to work as a
convenience store clerk but was fired 2 weeks ago. Since then, she has been
using drugs intravenously daily. Cardiac examination reveals a heart murmur.
Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph
reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal
white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%,
and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart
block. Which of the following is the most appropriate next step in management?
a. Obtain four sets of blood cultures, order a transthoracic echocardiogram (TTE),
and start antibiotic treatment.
b. Order a monospot test and recommend that the patient refrain from vigorous
activities for 1 month.
c. Administer a nonsteroidal anti-inflammatory drug (NSAID) and inform the
patient she has pericarditis.
d. Administer isoniazid (INH) and report the patient to the Department of Health.
e. Order a Lyme antibody and begin antibiotic therapy.
6 Emergency Medicine