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  #1  
Old 07-24-2011
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Stethoscope Guess which murmur in this patient?

A 34-yr-old female presented with back and heel ache and stiffness present early morning and resolve with exercise. She participated in some genetic research studies and was positive for ARTS1 and IL23R and also had h/o diarrhea in the past. ECG shows PR interval > 2 seconds. What is the most likely murmur in this patient?

1. Frictional rub
2. Midsystolic click with late systolic murmur
3. Holosystolic murmur at lower left sternal border
4. Diastolic rumble
5. Fixed split S2
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  #2  
Old 07-24-2011
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i think, 4. Diastolic rumble
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as the pt has RA so it's friction rub
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Quote:
Originally Posted by dr_lizard View Post
as the pt has RA so it's friction rub
Why you think its RA ??
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Old 07-24-2011
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maybe wrong. maybe it is ankylosing spondilytis!!!! .
The Heart
A small number of people with spondylitis will display signs of chronic inflammation in the base of the heart - around the aortic valve and origin of the aorta (i.e. that vessel which takes all blood from the heart to be distributed throughout the body). Years of chronic and silent inflammation at these sites can eventually lead to heart block and valve leakage, sometimes requiring surgical treatment. Although recognized, these cardiac lesions probably are seen in fewer than two percent of all patients with spondylitis, and nearly always in males. The lesions are readily detectable by the physician's examination and when necessary, cardiac testing.
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Ankylosng Spondilytis and crohn's could be together sometimes! that's for diarrhea, and genes i hadn't heard about but they are with A.S when i searched.
but the aortic valve presentation is almost always in men how come patient is female!?
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Quote:
Originally Posted by dr_lizard View Post
Ankylosng.Spondilytis and crown could be together sometimes!that's for diarrhea, and genes i hadn't heard about but they are with A.S when i searched.
but the aortic valve presention is almost always in men how come pt is female!?
I think variable clinical presentation can be seen....
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That's a good question ,thanks for posting


I'd go with diastolic rumble .
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Quote:
Originally Posted by confident View Post
I think variable clinical presentation can be seen....
yea, just 2% of ankylosings males get aortic involvement, now imagine variation! it would be 0.00001 % chance of this clinical vignette to be seen in real practice! this is not fair ! can i ask about source of question?
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Quote:
Originally Posted by dr_lizard View Post
yea,just 2% of ankylosings males get aortic involvement,now imagine variation! it would be 0.00001 % chance of this clinical vignette to be seen in real practice! this is not fair ! can i ask about source of question?
yes ..source is i have some printed notes from friend i dont know the ultimate source...and yes purpose of exam is not to miss that 0.00001% chance if patient comes to clinic...i dont know the percentage of in practice but i dont want to miss this concept in exam...purpose of questions is to get concept and learn...there is no where written that it is 100% sure ...thats why they say may be or may not....
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4. Diastolic rumble

ankylosing spondlitis causing aortic regurg.
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confident,thnx for sharing such a good question....answer u may delay
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That is a question!

The clinical setting points to Ankylosing Spondylitis: Back pain which improves with exercise, less than 40 years, diarrhea could be a manifestation of the disease too. (IBD as some of you guys said, is related to AS)
The genes: No idea... it is the first time I read about them.

The answer would be 4. Ruling out options.

1. Frictional rub is most seen in LES
2. Midsystolic click is seen in MVP
3. Holosystolic murmur is seen in VSD
5. Fixed split in S2, i am not very sure about it, but I think is seen in pulmonary hypertension, right?
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Quote:
Originally Posted by Sadalssud View Post
That is a question!

The clinical setting points to Ankylosing Spondylitis: Back pain which improves with exercise, less than 40 years, diarrhea could be a manifestation of the disease too. (IBD as some of you guys said, is related to AS)
The genes: No idea... it is the first time I read about them.

The answer would be 4. Ruling out options.

1. Frictional rub is most seen in LES
2. Midsystolic click is seen in MVP
3. Holosystolic murmur is seen in VSD
5. Fixed split in S2, i am not very sure about it, but I think is seen in pulmonary hypertension, right?

Fixed split s2 seen in ASD and i think RHF. Pulmonary hypertention will occur primary or secondary to any condition and i think it will be systolic in nature.

Holosystolic murmur seen in VSD, Regurgitation murmur like TR, MR.

What is LES?
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Quote:
Originally Posted by confident View Post
A 34-yr-old female presented with back and heel ache and stiffness present early morning and resolve with exercise. She participated in some genetic research studies and was positive for ARTS1 and IL23R and also had h/o diarrhea in the past. ECG shows PR interval > 2 seconds. What is the most likely murmur in this patient?

1. Frictional rub
2. Midsystolic click with late systolic murmur
3. Holosystolic murmur at lower left sternal border
4. Diastolic rumble
5. Fixed split S2

Characteristic murmurs of acute carditis include the high-pitched, blowing, holosystolic, apical murmur of mitral regurgitation; the low-pitched, apical, mid-diastolic, flow murmur (Carey-Coombs murmur); and a high-pitched, decrescendo, diastolic murmur of aortic regurgitation heard at the aortic area. Murmurs of mitral and aortic stenosis are observed in chronic valvular heart disease. Isolated aortic disease is distinctly unusual.
The features of CHF include tachycardia, a third heart sound, rales, and edema.
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ankylosing spondylitis associated with ulcerative colitis thats why diarrhea occurs........
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Quote:
Originally Posted by confident View Post
Fixed split s2 seen in ASD and i think RHF. Pulmonary hypertention will occur primary or secondary to any condition and i think it will be systolic in nature.

Holosystolic murmur seen in VSD, Regurgitation murmur like TR, MR.

What is LES?


I meant SLE, I typed it wrong , thanks for the feedback
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I would go for Diastolic rumble ,
Patient with Ankylosing spond. have AV block and Aortic insufficiency as a cardiac problems..
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Old 07-26-2011
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Quote:
Originally Posted by confident View Post
A 34-yr-old female presented with back and heel ache and stiffness present early morning and resolve with exercise. She participated in some genetic research studies and was positive for ARTS1 and IL23R and also had h/o diarrhea in the past. ECG shows PR interval > 2 seconds. What is the most likely murmur in this patient?

1. Frictional rub
2. Midsystolic click with late systolic murmur
3. Holosystolic murmur at lower left sternal border
4. Diastolic rumble
5. Fixed split S2
Answer is 4. Diastolic rumble.

Low back and heel pain are mostly seen in Ankylosing spondylitis. Mostly sacroiliac and achillies joint are involved. Large joints are involved in seronegative arthritis.

Small symmetrical and multiple joints are involved in (RA, SLE) seropositive conditions. So it can be ruled out.

HLAB27,ARTS1 and IL23R are seen Ankylosing spondylitis.

ARTS1 and IL23R are seen in Ankylosing spondylitis, Breast cancer, Autoimmune thyroiditis, Multiple sclerosis.

IL23R seen in IBD(crohns), Psoriasis as well.

Ankylosing spondylitis mainly cause spondylitis i,e vertebral column (spinal) disease, enthesitis, uveitis, aortitis and AR.

Due to sharing common genes as mentioned above IBD and ankylosing spondylitis togeather form part of spondyloarthropathies.

5% chance of Heart involvement seen in long standing AS. It cause aortitis, fibrosis of av node and interventricular system and may cause 2nd degree and complete heart block, heart failure etc so the murmur...

10% chance of heart involvement seen in Reiter syndrome.

Fixed split s2 seen in ASD and i think RHF. Pulmonary hypertention will occur primary or secondary to any condition and i think it will be systolic in nature.

Holosystolic murmur seen in VSD, Regurgitation murmur like TR, MR.

Friction rub seen in pericarditis.

Answer was just limited to saying aortits and heart block are seen in AS on long standing. I just added remaining thing, source from First aid, google books for complition sake...so let me know if any correction.
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  #20  
Old 08-31-2011
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Quote:
Originally Posted by confident View Post
Answer is 4. Diastolic rumble.

Low back and heel pain are mostly seen in Ankylosing spondylitis. Mostly sacroiliac and achillies joint are involved. Large joints are involved in seronegative arthritis.

Small symmetrical and multiple joints are involved in (RA, SLE) seropositive conditions. So it can be ruled out.

HLAB27,ARTS1 and IL23R are seen Ankylosing spondylitis.

ARTS1 and IL23R are seen in Ankylosing spondylitis, Breast cancer, Autoimmune thyroiditis, Multiple sclerosis.

IL23R seen in IBD(crohns), Psoriasis as well.

Ankylosing spondylitis mainly cause spondylitis i,e vertebral column (spinal) disease, enthesitis, uveitis, aortitis and AR.

Due to sharing common genes as mentioned above IBD and ankylosing spondylitis togeather form part of spondyloarthropathies.

5% chance of Heart involvement seen in long standing AS. It cause aortitis, fibrosis of av node and interventricular system and may cause 2nd degree and complete heart block, heart failure etc so the murmur...

10% chance of heart involvement seen in Reiter syndrome.

Fixed split s2 seen in ASD and i think RHF. Pulmonary hypertention will occur primary or secondary to any condition and i think it will be systolic in nature.

Holosystolic murmur seen in VSD, Regurgitation murmur like TR, MR.

Friction rub seen in pericarditis.

Answer was just limited to saying aortits and heart block are seen in AS on long standing. I just added remaining thing, source from First aid, google books for complition sake...so let me know if any correction.
agree with everything u said, but i didnt know that fixed split of s2 was associated with any condition other than ASD...as u guyz mentioned RHF??

would u mention the surce of this info??
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Old 08-31-2011
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Quote:
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agree with everything u said, but i didnt know that fixed split of s2 was associated with any condition other than ASD...as u guyz mentioned RHF??

would u mention the surce of this info??

I meant that time that in CONGENITAL HEART DISEASE RHF chances are more. so dd have fixed split above so that mean similar case scenario with RHF with ASD C/F murmur can be fixed split in that case.

http://en.wikipedia.org/wiki/Split_S2: here it says fixed split both in asd and vsd.
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