View source for WBR1065

 {{WBRQuestion
|QuestionAuthor= {{MM}}
|ExamType=USMLE Step 3
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|MainCategory=Primary Care Office
|MainCategory=Primary Care Office
|SubCategory=Cardiovascular
|Prompt=A 45 year-old male comes to your office complaining of fever, along with chills, anorexia, malaise, and chest pain.  These symptoms started gradually over the last 2 weeks.  The patient has a past medical history of rheumatic fever when she was 7 years old.  He doesn’t smoke, but drink alcohol occasionally.  She is sexually active.  On examination, His temperature is 102.9°F (39.4° C), blood pressure 140/90 mmgH, heart rate 100/min, and respiratory rate of 21/min.  Heart examination shows ejection systolic murmur on the apex that propagates to axilla.  There is a painful, red, raised lesion on the finger pulps, and inflamed swollen right knee. His echocardiography shows mitral valve vegetation.   His blood culture results shows streptococcus bovis  that is penicillin-susceptible, and a treatment plan is started accordingly.  What is the best next test that should be done for this patient? 
|Explanation=This is subacute case of Infective endocarditis; it is diagnosed according to the Duke clinical criteria.  Streptococcus bovis  is associated with colonic pathology, and a colonoscopy should be done to eliminate the source of infection.
|AnswerA=Repeat echocardiography
|AnswerAExp=Repeating the echocardiography will not add any new information to the case.  On the other hand, colonoscopy is important to exclude any source of infection in the colon, that usually accompany streptococcus bovis endocarditis.
|AnswerB=Colonoscopy
|AnswerBExp=Correct
Streptococcus bovis  is associated with colonic pathology, and a colonoscopy should be done to eliminate the source of infection.


|AnswerC=Liver function test
|AnswerCExp=Incorrect
There is not any signs of liver functions abnormality in this case, and it is not a diagnostic test for infective endocarditis. 
|AnswerD=Rheumatoid factor analysis
|AnswerDExp=Incorrect
Although rheumatoid factor may be elevated, the patient is already have the diagnostic criteria needed to establish infective endocarditis diagnosis. 
|AnswerE=Biopsy from finger lesions
|AnswerEExp=Incorrect
Biopsy from finger lesions will not add any thing to the diagnosis.
|EducationalObjectives=Infective endocarditis caused by streptococcus bovis is usually associated with colonic pathology, and a colonoscopy should be done to eliminate the source of infection.
|RightAnswer=B
|WBRKeyword=[[Infective endocarditis]]
|Approved=No
}}