A 43-year-old man with past history of nonintravenous drug abuse and hepatitis C was hospitalized in the internal medicine department because of fatigue and dizziness. On admission he was alert, his heart rate was 90 beats per minute, blood pressure was 91/53 mm Hg, oxygen saturation was 98%, and body temperature was 37.1°C. Physical examination was unremarkable except for cachexia and poor sanitation.
The morning after admission, the patient was somnolent, non-febrile with new onset left hemiplegia. A consult neurologist diagnosed an ischemic stroke.
Computed tomography showed hypodense lesions in the right frontal and parietal lobes consistent with acute ischemic stroke in the right middle cerebral artery territory.
Immediate thrombolysis was planned for the patient. However, on physical examination a new diastolic murmur was noticed. Bedside ultrasound, using a pocket-sized device (Figure A ) performed by a cardiology fellow, demonstrated a lesion consistent with vegetation on the aortic valve and aortic insufficiency. The image was sent to an expert echocardiographer that confirmed the diagnosis. Peripheral signs consistent with emboli were later observed as well (Figure B).
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-Dan Haberman, MDa,c, Meital Zikry, MDb,c, Natasha Kozak, MDb,c, Jacob George, MDa,c, Sara Shimoni, MDa,c
