abscess (TOA), a common and potentially fatal complication of pelvic
inflammatory disease (PID). While PID can usually be treated with outpa-
tient antibiotics, the Center for Disease Control (CDC) lists several guide-
lines for inpatient admission, including: (1) cases in which surgical
emergencies (eg, appendicitis) cannot be excluded; (2) pregnancy; (3) fail-
ure of outpatient therapy; (4) inability to tolerate oral intake; (5) severe ill-
ness, including nausea, vomiting, or high fever; and (6) TOA. This patient
has several of these factors and should, therefore, be admitted for further
management. IV antibiotics are curative in 60% to 80% of cases and must
be selected to cover N gonorrhoeae and Chlamydia trachomatis, the most
common pathogens responsible for PID, as well as bacteroides, the most
common cause of TOA. Surgical drainage or salpingectomy and oophorec-
tomy may be required in resistant cases.
(a and b)Both of these regimens are appropriate for outpatient treat-
ment of PID, but this patient requires IV antibiotics and an inpatient
admission for optimal management. (c)The ultrasound is consistent with
a TOA, not a ruptured ovarian cyst, and requires closer monitoring and IV
antibiotics in an inpatient setting.(e)Theβ-hCG is negative, virtually rul-
ing out an ectopic pregnancy.
185.The answer is e.(Rosen, pp 1149-1152.)Symptoms of endocarditis
are nonspecific and vary widely, but the most common include fever (85%)
and malaise (80%). In IV drug users, fever is present 98% of the time.
Other symptoms include weakness, myalgias, dyspnea, chest pain, cough,
headache, and anorexia. Neurologic signs and symptoms (eg, confusion,
personality changes, decreased level of consciousness, and focal motor
deficits) are seen in 30% to 40% of patients. Vasculitic lesions, including
petechiae, splinter hemorrhages, tender fingertip nodules (Osler nodes),
and nontender palmar plaques (Janeway lesions) are seen in 35% of
patients. Splenomegaly, new heart murmur, and retinal hemorrhages may
also be detected on physical examination. Risk factors for infective endo-
carditis include rheumatic or congenital heart disease, calcific degenerative
valve disease, prosthetic heart valve, mitral valve prolapse, a history of IV
drug use, or a history of endocarditis. Although any valve can be affected,
IV drug use is the most common cause of right-sided endocarditis. The
recurrence rate in these patients is 41%, significantly higher than the rate
of less than 20% in non-IV drug use patients.
(a)Also known as sinus node dysfunction or tachy-brady syndrome,
sick sinus syndrome results from any combination of intermittent fast and
Fever Answers 203