A 64-year-old man with a history of congenital bicuspid aortic valve and bioprosthetic valve replacement presented with fever, chills, and dysuria. He was treated with ciprofloxacin as an outpatient for presumed urinary tract infection by his primary care physician. In the emergency center, his urinalysis result was positive. He was given intravenous ceftriaxone sodium and admitted for observation.
The patient was alert and oriented to person, place, and time. He was in no acute distress. His blood pressure was 116/72 mm Hg, his heart rate was 82 beats/min, and his axillary temperature was 39.1°C. His pupils were equal, round, and reactive, and his neck was supple without jugular venous distension. Cardiovascular examination revealed a regular rate and rhythm. A harsh grade III/VI systolic murmur, best heard in the left second intercostal space, was detected. A grade II/VI protodiastolic murmur was also noted. The point of maximal impulse was diffuse and minimally displaced toward the axilla. No rubs or gallops were noted. His lungs were clear to auscultation, and his abdomen was soft, nontender, and without hepatosplenomegaly. Cranial nerves II to XII were grossly intact. Extremities were free of any clubbing, cyanosis, or edema. Skin examination revealed no ecchymoses, purpura, or petechiae.