LB is a 51 year‐old man who presented for fever and shortness of breath for one week. Associated symptoms included fatigue, weakness, chills, and night sweats. There is no weight loss or hemoptysis. Symptoms worsened with exertion and improved with supplemental oxygen.
Past medical history was significant for a remote history of IV drug use, ischemic cardiomyopathy with dual chamber ICD placement, and a recent hip replacement.
On exam he was tachypneic, oxygen saturation was 92% on 4L nasal canula, tachycardic at 114 beats per minute, and he was normotensive. There were no cardiac murmurs, there were crackles heard bilaterally, no track marks could be found, and there were no rashes or lesions on his skin. The AICD pocket was clean, and his hip surgery site was non‐erythematous and healing well.
Labs revealed a leukocytosis with left shift. Chest x‐ray revealed bilateral lobar consolidations. Treatment for hospital acquired pneumonia was started. Blood cultures with Methicillin Sensitive Staph Aureus failed to clear despite tailored antibiotics. Well’s score was 6. The patient was started on anticoagulation and CT scan of the chest with PE protocol revealed pulmonary embolism. Transesophageal echocardiogram revealed vegetations on the AICD lead. The AICD was removed and he was placed on an external automated defibrillator. Cultures cleared once AICD was removed.
It is important for the hospitalist to understand that multiple treatment thresholds can be reached for a single presenting complaint. Our patient had two different life‐threatening diseases. The common idiom of “Occam’s Razor” did not apply. Initially, there was no indication that an infective endocarditis was present. It is an uncommon disease, occurring approximately 10,000 times per year. The diagnosis of infectious endocarditis was brought to light only from the persistently positive blood cultures, which prompted the transesophageal echocardiogram. The presence of pneumonia was likely an embolic phenomenon.
Infectious endocarditis alone did not reliably explain the dyspnea and low oxygen saturations. His recent orthopedic surgery placed him at risk for pulmonary embolism and his Well’s Criteria placed his pretest probability high enough to be evaluated further by computed tomography of the chest.
It is crucial to recognize that both the infectious endocarditis and pulmonary embolism were evaluated simultaneously. Both were treated simultaneously. The pretest suspicion was high enough for both conditions to be further evaluated. The treatment threshold was reached for both conditions, even before definitive testing could be done. Only by taking all of the findings together, only by tracking the clinical course, and only by reevaluating a differential on a regular basis could all the diagnoses be teased out, and an appropriate intervention made. It is essential for the hospitalist to understand that the treatment threshold can be reached for multiple illnesses simultaneously.
The hospitalist must understand and utilize probability, diagnostic, and treatment thresholds in order to appropriately, and cost‐effectively, care for hospitalized patients.
To cite this abstract:Williams D, Miller C. When You Hear Hooves, Count the Horses. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 676. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/when-you-hear-hooves-count-the-horses/. Accessed May 23, 2019.