Case No 1

35-year old female i.v. drug user admitted to the hospital firstly for pain in right elbow and for two week-persisting fever with chills and shivering and no prominent respiratory symptoms

Medical History

Present Illness: 14 days before pain in right elbow. In a surgery out-patient department, synovialitis cubiti on the right side was diagnosed, diclofenac was prescribed. She was not treated with antibiotics. After 3 days pains in the whole body, weakness, to fainting, fever rised up to 40 °C with chills, antibiotics were not taken till admission to hospital. No dysuria, normal stool, pain in elbow subseded, cough irritation from time to time

FHx: No information about parents, no contact with mother, father died, her children are healthy
EHx: Antibiotics denied, does not travel anywhere
WSHx: Previously worked as a waitress, now unemployed, registered at the Employment Bureau, divorced, caring for 2 children (aged 8 and 10), parents-in law helps her with them
PMHx: viral hepatitis, probably type C, 20 years ago
PSHx: appendectomy at 11 years
GA: surgery of ovarial cyst during her gravidity, 2 deliveries of healthy children
Allergies: none, NKDA
Medications: Not using anything
Abuse: She started to use drugs 20 years ago, and maybe next 8 years did not take them, started again half a year ago due to family problems, pervitin i.v., she would like to stop using it again

Physical Examination

T 39.8 °C, asthenic body habitus, oriented, pale face, small scars after ulcerous affections on the skin, no other rash, no apparent fresh peripheral emboli. Head: eyes: no scleral icterus, conjunctiva pale. Ears without discharge, oral cavity is clear, throat and tonsils without erythema or exudate, neck supple with no LAD or masses. Breathing: slightly pursy when speaking, D 24/min., dry irritating cough during examination, brath sounds weakened on left basis what corresponds with dullness on percussion, fine crakle and friction rub on right lung basis, SpO2 95 % in air. Cardiovascular: RRR 108/min. Heart sounds, S1 and S2 with short systolic murmur (probable anemic), BP 109/51/72. Pulses 2+ equal on both sides. Abdomen below niveau with scars of older time (lower midline incision, appendectomy scar), soft by palpation, painless, the liver is a little enlarged by +3 cm below costal margin, spleen not palpable. No rebound or guarding. Normoactive bowel sounds. Extremities: numerous scars on the left forearm after cut wounds. Right elbow without any finding, flection is free. No bilateral cyanosis, clubbing or edema. No petechiae. Capillary refill <3 sec. Meningeal signs negative, Lasègue manoeuvre provokes pain in hips, gross neurologic examination not reveal lateralizing signs .

Laboratory Examination

Hematologic laboratory:

Biochemical laboratory:

Immunologic tests:


Microbiology laboratory examinations:

Imaging and Other Examinations

Imaging studies:


Chest X-ray   Fig 1 Chest X-ray


Chest CT scan   Fig 2 Chest CT scan


Electrophysiological and functional examinations:

Echocardiogram Echocardiography
Fig 3 Echocardiogram Fig 4 Echocardiography



Diagnostic Conclusion

Tell the principal diagnosis and write all diagnoses, even secondary ones.

Make a diagnosis


Suggest the antimicrobial therapy.


You will know it after answering the questions.


  1. What examination do you recommend to add to give the diagnosis and propose a therapy?
Home page

© Mar-07-2021