HISTORY. A common finding of patients with preexisting cardiac abnormalities is a recent history (3 to 6 months) of dental procedures. Question the patient about the type of procedure performed and if bleeding of the gums occurred.

Patients with IE may have complaints of continuous fever (103°F to 104°F) in acute IE, whereas in the subacute form, temperatures are generally in the range of 99°F to 102°F. Other

516 Infective Endocarditis symptoms include chills (limited to acute IE), fatigue, malaise, joint pain, weight loss, anorexia, and night sweats.

PHYSICAL EXAMINATION. The patient appears acutely ill. Observe for signs of temperature elevation, such as warm skin, dry mucous membranes, and alternating chills and diaphoresis. Inspect the conjunctivae, upper extremities, and mucous membranes of the mouth for the presence of petechiae, splinter hemorrhages in nail beds, Osler nodes (painful red nodes on pads of fingers and toes), and joint tenderness. Palpate the abdomen for splenomegaly, which is present in approximately 30% of patients with IE. Auscultate the heart for the presence of tachycardia and murmurs. Approximately 95% of those with subacute infective endocarditis have a heart murmur (most commonly mitral and aortic regurgitation murmurs), which is typically absent in patients with acute IE.

PSYCHOSOCIAL. Lengthy interventions such as prophylactic antibiotic treatment are generally required. Therefore, determine the patient's ability to understand the disease, as well as to comply with prescribed long-term treatments.

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