Endocarditis Quiz: Ace Your Exams

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A 36-year-old man presents to the emergency department with fever, chills, and cough of three days duration. The patient uses intravenous heroin regularly and reports he last used heroin earlier today. He is currently living in a homeless shelter. Temperature of 38.7 °C (101.6 °F), pulse is 105/min, respirations are 22/min, blood pressure is 100/63 mmHg, and oxygen saturation is 91% on room air. On physical examination, the patient appears disheveled. Erythematous lesions are noted on the chest and arms bilaterally. Rales are appreciated in the lungs bilaterally, and a holosystolic murmur is appreciated at the left lower sternal border. Laboratory values are demonstrated below:  
 
 Laboratory value  Result 
 Complete Blood Count, Serum 
 Hemoglobin  12.5 g/dL (reference range: 13.5-17.5 g/dL) 
 Hematocrit  40.5% (reference range: 41-53%) 
 Leukocyte count  18,100 /mm3 (reference range: 4,500-11,000/mm3) 
 Platelet count  250,000/mm3 (reference range: 150,000-400,000/mm3) 
 Inflammatory Markers, Serum 
 ESR                 44 mm/hr (reference range: 0-15 mm/hr) 
 CRP  18 mg/dL (reference range: 0.08–3.1 mg/dL) 
 Electrolytes, Serum 
                  Sodium                131 mEq/L (reference range: 136-146 mEq/L) 
               Potassium                 3.6 mEq/L (reference range:3.5-5 mEq/L) 
                 Chloride                 94 mEq/L (reference range: 95-105 mEq/L) 
              Bicarbonate                 20 mEq/L (reference range: 22-28 mEq/L) 
                 Calcium                8.4 mg/dL (reference range: 8.4-10.2 mg/dL) 
   
Blood is drawn and sent for culture, and the patient is started on empiric antibiotics. Three days later, 3 of 4 blood cultures obtained on admission grow Gram-positive, coagulase-positive bacteria. Which of the following is the most common initial site of infection in this patient? 

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