In 1881, Sir William Osler, MD, CM, 1st Baronet, described this clinical triad: An African American patient looking about 60 years old is brought in from the streets with altered mental status. He looks sick. In his pockets, he has a couple packs of cigarettes, a bottle of Vodka, insulin syringes, and crack cocaine (he has really large pockets). He is febrile, tachycardic, hypotensive. On exam, he is altered, not answering appropriately; pupils are sluggish, he has no focal neurologic deficits, but he does have nuchal rigidity.
On pulmonary exam, you hear decreased breath sounds at the right base. A chest X-ray is shown below:
On cardiac exam, you note a systolic murmur at the right upper sternal border. The echo tech is rolling the machine by so you grab it and take a look:
The abdominal exam is remarkable only for a LUQ scar. The extremities are normal. A rectal exam is normal. Here are the blood cultures:
Challenge: Name three disease processes occurring here. Name the organism. There's your triad.
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