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Bacteria in the blood.

74 year old female with history of atrial fibrilation on xarelto, coronary artery disease with history of CABG, ischemic cardiomyopathy with ejection fraction of 30% presented to the hospital with shortness of breath and volume overload. She was diagnosed with a CHF exacerbation and started on intravenous diuretics. She initially showed some improvement, however her breathing started to deteriorate again, requiring bipap. That evening her blood cultures grew gram positive cocci and she was started on vancomycin.

You are seeing the patient for the first time the following morning and trying to find a source for her bacteremia.


T 99.6 HR 95 BP 117/67 SPO2 100% on Bipap

Gen: Appears comfortable on bipap, conversant, nods head to questions appropriately

CVD: tachycardic, 2/6 systolic murmur over right upper sternal border

Lungs: bilateral crackles, difficult to auscultate with bipap

Abd: soft, nontender, no RUQ tenderness; no distention

Extremities: 1+ pitting edema bilaterally

Skin: no apparent erythema consistent with cellulitis or abscess


Read as bilateral pleural effusions



Parasternal long


Left lower lobe

Right lower lobe

What is a possible source based on the above exam and what should be done next?

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