A 40-year-old female was referred by her new PCP to the local Emergency Department with complaints of fever, severe headache for six days, myalgias, and joint pain. In the ED, she also reported that she had had recent episodes of fainting in the shower and nausea. Her initial evaluation revealed a temperature of 103, blood pressure of 135/77, heart rate of 128, and respiratory rate of 20. A CT scan of her head was normal; a lumbar puncture was negative; and she was not pregnant. The patient had two blood cultures drawn, and was treated with a single dose of IV antibiotics.
Because her providers believed her that her symptoms were improving, she was discharged with instructions to follow-up with her PCP within a week.
Two days later, a Thursday, her blood cultures came back positive for Group B streptococcus. The results were received by the ED physician on duty, who had not been her treating physician during her visit. Per hospital policy, a dedicated LPN in the ED followed up on abnormal test results. The LPN tried to reach the patient that afternoon, and left a message to call the hospital.
The following morning (Friday), the ED tried again, and was also unsuccessful at reaching the patient. (The phone number the patient gave during triage was for her husband’s workplace). The staff nurse told the ED physician that she was still unable to reach the patient. No other attempts were made over the weekend, as the doctor felt the patient should be fine with the one dose of IV antibiotics she received during her first ED visit. Additionally, the patient’s chart included no documentation of the identity of the PCP, who had initially called the ED to let them know that she was coming in.
On Monday, the patient returned to the ED with chills and a fever of 103. Her white blood cell count was 12.1, and a chest x-ray was negative, as was an initial echocardiogram at the bedside. Her positive blood culture results were obtained, and the patient was admitted for IV antibiotics. The patient was diagnosed with bacterial endocarditis, which was confirmed by a transesophageal echocardiogram with vegetation noted on the aortic valve. The patient experienced some complications of supraventricular tachycardia during her stay. She was discharged 15 days later, and remained on IV antibiotics for five weeks.
A month and a half later, the patient was admitted with a left thalamic stroke, which resolved with no residual side effects. The patient is currently healthy, but will most likely require an aortic valve replacement in the future.