What's the Take Home?

A 66-Year-Old Man With Severe Fatigue

Ronald N. Rubin, MD1,2 Series Editor

1Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
2Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania

Rubin RN. A 66-year-old man with severe fatigueConsultant. 2023;63(2):e12. doi:10.25270/con.2023.02.000003

The author reports no relevant financial relationships.

Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (


  • Introduction. A 66-year-old man presented to our clinic with new fatigue and several weeks of exhaustion.

    Patient history. The patient had been in his usual state of health until about 1 month prior, when he noted easy fatigue and tiredness involving all activities including golf and family visits, which were not problematic before now. The patient has mild type II diabetes mellitus, which was controlled by oral agents. The only other medical history of significance was a long-term known diagnosis of mild aortic stenosis due to a congenitally bicuspid valve (valvular gradient 25 mm as of 1 year ago). He denied any history of chronic heart failure symptoms, syncope, or angina related to the aortic stenosis. He had remote surgery for an appendix removal as a teenager. He has undergone dental work in preparation for implants in recent months. He intermittently took antibiotics as part of this but none for the last 3 months.

    Diagnostic testing. The patient had a mildly pale appearance. Regarding the patient’s vitals, his blood pressure was 105/70 mm Hg, his temperature reached 100.8˚F, he had a pulse of 104 beats/min, and a respiration of 14 breaths/min. A Head, Eyes, Ears, Nose, and Throat examination revealed a degree of pallor in the conjunctivae with a single petechial lesion in the right lower region. There were no enlarged nodes, and his chest was clear from posterior to anterior. His heart was in regular rhythm without gallops. A Gr II/VI soft systolic murmur typical of AS was heard, but there were no diastolic murmurs. The patient’s abdominal examination was negative and there was no peripheral edema.

    Initial labs showed hemoglobin of 10.2 g/dl, a mean corpuscular volume of 84 fl, white blood cell count of 12,300/ uL with predominance of PMN forms and platelet count of 240,000/ uL. His blood glucose was unusually elevated for him at 180 mg/dL.  Creatinine and electrolyte levels were within normal limits. Urine analysis showed a small amount of red blood cells but was otherwise negative. Plain chest film was negative for infiltrates and cardiomegaly of chronic heart failure. The patient’s electrocardiogram showed sinus tachycardia and possibly minimal criteria for left ventricular hypertrophy but was otherwise within normal limits. A blood culture was sent and transthoracic and transesopheal echocardiograms were ordered. He was admitted to floor care.

    Which of the following statements relating to the presented patient is correct?

    A. Molecular testing by polymerase chain reaction should be used to confirm the diagnosis and infectious organism.
    B. Positron emission tomography-computed tomography (PET-CT) scanning should be used to confirm the presence and size of vegetations.
    C. The clinical data already in hand make early surgery the appropriate option.
    D. Two more separate sets of blood cultures drawn 30 minutes apart should be obtained prior to initiation of antibiotics.

    (Answer and discussion on next page)

  1. Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016;387:882-893. doi:10.1016/S0140-6736(15)00067-7.
  2. Chambers HF, Bayer AS. Native valve endocarditis. N Eng J Med. 2020;383:567-576. doi:10.1056/NEJMcp2000400.
  3. Gomes A, Glaudemans AWJM, Touw DJ, et al. Diagnostic value of imaging in infective endocarditis: a systemic review. Lancet Inf Dis. 2017;17:1-14. doi:10.1016/S1473-3099(16)30141-4.
  4. Wong D, Rubinstein R, Keynan Y. Alternative cardiac imaging modalities to echocardiography for the diagnosis of infective endocarditis. Am J Cardiol. 2016;118:1410-1418 doi:10.1016/j.amjcard.2016.07.053.
  5. Kang DH, Kim Y-J, Kim S-H, et al. Early surgery versus conventional treatment for infective endocarditis. N Eng J Med. 2012;366:2466-2473 doi:10.1056/NEJMoa1112843.