26 yo F with fatigue and fevers

Original post by Brandon Fainstad, MD
Edits and graphics by Yilin Zhang, MD.


  • Conduct an interview surrounding potentially sensitive topics


A 26 year old woman with active injection drug use (IVDU) presents to the ED with persistent fevers and chills over the past two weeks. She additionally reports a non-productive cough, SOB, diffuse joint aches and weakness.  She denies chest pain, hemoptysis, orthopnea/PND, significant weight gain or leg swelling.  She has a history of injection related soft tissue infections and chronic hepatitis C.  She does not take any regular medications.  Her primary source of income is though sex work.  She has marginal housing and has been using IV heroin and cocaine since she was 19.  For the past week she has felt too ill to inject intravenously but has been muscling and skin popping heroin to help with withdrawal symptoms.

It is important to discuss a patient’s drug use habits using non-judgemental terms and open-ended questions in order to identify their specific risk factors and properly educate them on safe practices.   What are some initial questions you ask patients when starting this discussion?

Which drug use practices put patients at increased risk for specific complications

Physical exam

VS: T 37C, HR 105, BP 110/70, SpO2 95% 4L NC.
GEN: pale, cachectic and diaphoretic.
HEENT: poor dentition, but no palpable fluctuance along her gum line.
PULM: tachypneic with mildly labored breathing and occasional crackles heard thoughout the chest, most notably over R anterior chest.
CV: tachycardic with regular rhythm and 2/6 systolic murmur heard best over LLSB, non-elevated JVD.
SKIN: track marks are seen on all four extremities, no erythema or swelling at injection sites. No other notable skin or nail findings.

Na 130, Cr 1.4
WBC 14, Hct 20, Plt 65
INR 1.1


What are your top three diagnoses to explain this patient’s presentation?

What additional work up and management do you want to initiate overnight?



What are the indications for consideration of surgical intervention? 



  1. Gordon, Rachel J., and Franklin D. Lowy. “Bacterial Infections in Drug Users.” New England Journal of Medicine N Engl J Med 353.18 (2005): 1945-954.
  2. Baddour, Larry M., et al. “Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications.” Circulation 132.15 (2015): 1435-486.
  3. Angelo, Michael. “Ways Guys Do Meth.” Tweaker.org. 2012 San Francisco AIDS Foundation., n.d. Web. 31 Dec. 2015. <http://www.tweaker.org/crystal101/waysguysdo.html?referrer=https%3A%2F%2Fwww.google.com%2F>.

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