GP is suspended for failing to properly treat patient through telephone consultationsBMJ 2023; 382 doi: https://doi.org/10.1136/bmj.p1918 (Published 18 August 2023) Cite this as: BMJ 2023;382:p1918
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A sad story for the patient.
A sad story for the doctor.
This is a cautionary tale that evokes the triusm that , even "high-tech" investigations such as computed tomography can be no substitute for clinical inspection(with the naked eye) in a patient with occult infective endocarditis.
Inspection involves a search for mucocutaneous stigmata of infective endocarditis such as petechial haemorrhages in the soft palate and buccal mucosa, subconjunctival haemorrhages, purpura, finger clubbing, splinter haemorrhages, Janeway lesions, and Osler's nodes.
Inspection also includes a search for stigmata of risk factors for infective endocarditis such as needle marks signifying illicit intravenous drug usage, evidence of body piercing and tattoing,, and dental caries.
The caveat is that mucocutaneous stigmata may occur even in the total absence of cardiac murmurs. In some of the patients with mucocutaneous stigmata but no murmurs the "red flag" for infective endocarditis(IE) is the presence of risk factors for IE such as dental caries or intravenous drug usage or body piercing. In others the red flag is the occurrence of catastrophic complications such as intracranial embolism, meningitis, and congestive heart failure.
The final caveat is that the occasional patient with IE may have an afebrile presentation and absence of murmurs notwithstanding the coexistence of mucocutaneous stigmata and IE-related intracranial embolism.. In the latter patient the interval between the initial presentation with mucocutaneous stigmata of IE and echocardiographic documentation of vegetations was as long as 7 months..
I have no conflict of interest.
GP is suspended for failing to properly treat patient through telephone consultations
Petechial hemorrhages on the soft palate in other infective endocarditis contexts
American Journal, of Medicine 2023;136:E125
 Jolobe, OMP
Silent infective endocarditis with mucocutaneous stigmata and delay in initiating echocardiography
British Journal of Cardiology 2023;30:77-78
 Nichols L., Hernandes M., Henderson JM
Infective endocarditis masked by narrow focus thinking, inadequate physical examination, and analgesic medication
Competing interests: No competing interests