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.
EXAM
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
CHEST XRAY
Read as bilateral pleural effusions
POCUS
CARDIAC
Parasternal long
LUNG
Left lower lobe
Right lower lobe