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Rheumatology Case : Mornings are a Pain in the Butt


Rheumatology Case : Mornings are a Pain in the Butt


حالة سريرية

الوصف الكامل Background
A 21-year-old male college student comes to see you because of low back pain and stiffness of six months duration. Onset of his symptoms was insidious. The pain and stiffness are worse in the morning, but the discomfort improves considerably with activity. He wakes up in the middle of the night with back pain that goes away after he walks around. His pain is located in the low back and intermittently goes down the back of one leg or the other to the knee. He has an uncle, age 50, who has “always” had a stiff back.
The patient's health has been generally good except for a painful red eye six months ago, which was treated by an ophthalmologist for two months. He has not sustained any recent trauma, but he did play football in high school and one time was tackled hard and had back pain for three weeks.
He denies drug use, is sexually active with one partner, and uses condoms. He has experienced no fever or weight loss, rashes, mouth sores, recent eye inflammation, cough, dyspnea, or palpitations. Every few months he has aching in the anterior chest for several days, which is not worsened by exertion and seems to be relieved by aspirin. He also denies nausea, vomiting, diarrhea, dysuria, hematuria, emotional problems, headaches, seizures, or weakness or numbness in his arms or legs.
The patient is muscular and walks without a limp, but he moves stiffly as he gets on the examination table.
Physical examination reveals no skin rash or lymphadenopathy. His right eye is red, with injected vessels, and a small area of clear, white space around the iris, but there is no purulent drainage present. The right pupil’s constriction to light causes pain. No mucosal lesions are present, and his ears are normal.
His lungs are clear, and chest expansion at the nipple line is 5 cm. Auscultation reveals normal sinus rhythm with no murmurs, gallops, or rubs. His abdomen is scaphoid and without hepatosplenomegaly, masses, or tenderness. He has no balanitis or testicular masses, and no prostate abnormalities are found on rectal examination.
Examination of his back reveals a slight scoliosis to the right. Spine movement is limited to 5° on extension and 20° on forward flexion. With the Schober test expansion is from 10 to 12 cm ; lateral bending to right and left is also restricted. He can touch the floor with his fingers, and while standing with his back to the wall, his head touches the wall. Both sacroiliac joints are tender, as are the posterior spinous processes at T10–T12 and L3–L5.
No abnormalities are discovered on neurologic examination. His peripheral joints are not tender or swollen. However, the insertion of the right Achilles tendon is tender to palpation.

طالب جامعة عمره 21 سنة أتى لمقابلتك بسبب ألم أسفل الظهر ويبوسة منذ نحو 6 أشهر. بدأت أعراضه بشكل مفاجئ. الألم واليبوسة تزداد في الصباح, واكنها تتحسن على الحركة. يستيقظ في منتصف الليل بسبب الألم الظهري الذي يزول بعد المشي. يتوضع هذا الألم في أسفل الظهر وبشكل متقطع ينتشر إلى الناحية الخلفية لإحدى الرجلين أو الأخرى ويصل حتر الركبة. لديه عم في الـ 50 من عمره دائماً ما يعاني من ظهره المتيبس.
كانت الحالة العامة للمريض جيدة بشكل عام ما عدا ألم واحمرار في عينه منذ 6 أشهر, والتي عولجت من قبل طبيب عينية لمدة شهرين. لم يتعرض لأي رض حديث, لكنه لعب كرة القدم في الثانوية ومرة تمت عرقلته بشدة وأصيب بألم ظهري لثلاثة اسابيع.
نفى المريض استخدامه للعقارات, لكنه ممارس للجنس مع شريك واحد,ويستخدم الواقيات. لم يعاني المريض من أي حمى, نقص وزن, طفح جلدي, تقرحات فموية, التهاب عيني حديث, سعال, زلة, أو خفقان. وكان يعاني كل بضعة أشهر من ألم في الناحية الأمامية من صدره لعدة أيام, هذا الألم لا يزداد بالجهد وعادة ما يزول بالأسبرين. نفى المريض أيضاً وجود الغثيان, الإقياء, عسر التبول, البيلة الدموية, المشاكل العاطفية, الصداع, النوبات, أو الضعف والتنميل في يديه أورجليه.
كان المريض مفتول العضلات ولا يعاني من عرج في مشيته, ولكن حركاته كانت متيبسة أثناء صعوده لسرير الفحص.
في الفحص السريري, لم يلاحظ وجود أي طفح جلدي أو ضخامة عقد لمفية.كانت عينه اليمنى حمراء مع أوعية محتقنة, ومنطقة صغيرة بيضاءحول القزحية, لكن لا يوجد أي نز قيحي. استجابة الحدقة اليمنى للضوء كانت مؤلمة.لا وجود لآفات مخاطية, وكانت أذناه سليمتان.

كانت رئتاه واضحتا الصوت, وكان عرض صدره ناحية الحلمات 5 سم. أظهر الإصغاء نظماً جيبياً طبيعياً دون وجود أي نخفات, خبب, أو احتكاكات. كانت بطته قاربية من دون وجود ضخامة كبدية طحالية, كتل, او مضض. ليس لديه التهاب حشفة أو كتل خصيوية, ولم يظهر فحص المستقيم أي اعتلالات في البروستات.
بفحص الظهر لوحظ وجود جنف خفيف نحو اليمين. واكنت حركة العمود الفقري متحددة بمقدار 5 درجات بالانبساط و20 درجة بالانعطاف الأمامي. وباختبار شوبير كان التوسع من 10 -12 سم, كما كان الانحناء نحو اليمين أو اليسار متحدداً أيضاً.لم يستطع المريض لمس الأرض بأصابعه, واثناء الوقوف وظهره إلى الجدار, كان رأسه يلمس الجدار. كلا المفصلين الحرقفيين العجزيين كان ممضين, وكذلك النواتئ الشوكية للفقرات الصدرية 10-12 والقطنية 3-5.
بالفحص العصبي لم تلاحظ أي اضطرابات. ولم تكن مفاصله المحيطية متورمة أو مؤلمة . ولكن لوحظ وجود ألم في وتر أشيل الأيمن بالجس.

كتابة حرة وطرح موضوع النقاش!
Question # 1: What are the four most likely diagnoses?
A. Vertebral osteomyelitis.
B. Herniated disc.
C. Pars interarticularis stress fracture.
D. Kidney stone.
E. Spondyloarthropathy.
F. Fibromyalgia.
G. Spondylolisthesis.
H. Scoliosis.

السؤال 1: ماهي التشخيصات الأربع الأكثر احتمالاً:
1. التهاب عظم ونقي في الفقرات.
2. انفتاق القرص الفقري.
3. الكسر الانضغاطي للجزء داخل المفصلي.
4. حصية كلوية.
5. اعتلال مفصلي فقري.
6. الألم الليفي العصبي.
7. انزلاق الفقري.
8. الجنف.

المرجع

.

Fouad's picture
by
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Quote:
E. Spondyloarthropathy.

number 1

qusei


ممكن reactive arthritis

qusei

Quote:
السؤال 1: ماهي التشخيصات الأربع الأكثر احتمالاً

ضروري تكتبوا الأربعة....مشان التشخيص التفريقي يكون تمام...

Fouad's picture
Fouad
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بظن 1 و 3 و5 و7

drhanadi's picture
drhanadi
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التهاب فقار لاصق وخلص

moonberg's picture
moonberg
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1. التهاب عظم ونقي في الفقرات.
3. الكسر الانضغاطي للجزء داخل المفصلي.
5. اعتلال مفصلي فقري.
7. انزلاق الفقري.
8. الجنف.

DAM's picture
DAM


Why have you choosed osteomylitis?
I don't think it will be inclucded in the DDx with this history

Hot sauce's picture
Hot sauce
طبيب مقيم

ok ppl....thanx for partecepiate.....
the answers are 2,3,5,and 7.....
Musculoskeletal strains and sprains producing back pain usually resolve within a few days or weeks. In contrast, pain caused by vertebral body infections or tumors usually progress in severity over several months, and within six months, would have likely produced other symptoms. Therefore, vertebral osteomyelitis is an unlikely possibility.

It is unlikely that this patient’s back pain represents referred visceral pain from a kidney stone because of the duration and bilateral nature of the pain.

Fibromyalgia is a diffuse pain syndrome with prominent fatigue complaints, but this patient has localized pain and no fatigue.

Scoliosis usually does not cause severe low-back pain, and only minimal scoliosis was noted on physical examination.

In a young person, prolonged back pain suggests a serious mechanical disorder, and a thorough work-up should be initiated. Possible mechanical causes of back pain continuing for six months in a young man include herniated disc or pars interarticularis stress fracture, with or without spondylolisthesis. However, mechanical back pain typically worsens with activity, rather than being relieved by activity, as described by this patient. A herniated disc usually produces unilateral pain that does not radiate to both sides, as in this patient, although it can cause prolonged pain without radiculopathy. Posterior midline disc protrusion can usually be traced to previous trauma and may be accompanied by neurologic changes resulting from sacral plexus impingement (e.g., saddle anesthesia, sphincter changes). Such findings constitute an emergency requiring immediate neurosurgical consultation for possible decompression.

Pars interarticularis fractures in young people, especially prior to their growth spurt, may result in posttraumatic spondylolisthesis and pain years later. These stress fractures between the growth centers are usually bilateral and produce bilateral pain that fluctuates in intensity. The pain may be localized or referred, but it is not limited to nerve root distribution. This “pars” fracture often cannot be seen on plain radiographs. With this patient’s history of a significant back injury as an adolescent, this possibility must be kept in mind. The findings of a “step-off” of the posterior spinous processes at the level of the listhesis (Greek, meaning “to slip”) was not noted on the exam.

The constellation of morning stiffness, nocturnal pain, and decreased pain with activity is suggestive of an inflammatory spine disease, the spondyloarthropathies. Ankylosing spondylitis and related disorders (such as psoriatic arthritis, Reiter’s syndrome, arthritis associated with inflammatory bowel disease, and reactive arthropathy) are all possible diagnoses. Ankylosing spondylitis causes low-grade inflammation and ankylosis of axial skeletal joints (the sacroiliac joints, posterior apophyseal joints) and may also involve the peripheral synovial joints.

In this patient, the history of a painful, light-sensitive, red eye is suggestive of iritis, another manifestation of spondyloarthropathy. Conjunctivitis presents with either no symptoms or just a “scratchy feeling” in the eye and no light sensitivity. Blood vessels extend over the edge of the iris; so, with conjunctival vessel engorgement, no white space is visible between the iris and cornea. With iritis and episcleritis, deeper scleral vessels are engorged and produce a redness that ends before the margin of the iris, leaving a white rim of sclera visible around the iris. Iritis is associated with eye pain and photophobia, with or without visual acuity changes

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Fouad
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next:
Question # 2: What five tests will you now order?
A. Sedimentation rate and/or C-reactive protein
B. HLA-B27
C. Lumbosacral spine x-rays with SI joint views
D. CBC
E. CT of the lumbosacral spine
F. Colonoscopy
G. Stool guaiac
H. Urinalysis

السؤال 2: مالاختبارات الخمس التي سوف تطلبها؟
1. سرعة التثفل/ البروتين الارتكاسي C.
2. مستضد HLA-B27.
3. صورة شعاعية للعمود القطني العجزي مع ظهور الالمفاصل الحرقفية العجزية.
4. تعداد كريات الدم.
5. تصوير طبقي محوري للعمود القطني العجزي.
6. تنظير كولون.
7. اختبار الدم الخفي في البراز.
8. تحليل بول.

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Fouad
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1-2-3-7

والخامس بجوز 8

moonberg's picture
moonberg
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answers are:1,3,4,7,8
The sedimentation rate and/or the CRP may be elevated in inflammatory diseases, but not in mechanical spine disorders.

Radiologic studies of the lumbosacral spine and SI joints could provide evidence of spondylitis, scoliosis, spondylolisthesis, disc space narrowing, or an unexpected vertebral body lesion.

Abnormal CBC values, which are not a feature of mechanical spine problems, should prompt further work-up for systemic disease.

A positive stool guaiac raises the possibility of inflammatory bowel disease.

WBCs in the urine are suggestive of Reiter’s syndrome, even in the absence of genitourinary symptoms or urethral discharge.

Most patients with ankylosing spondylitis are HLA-B27 positive, but the majority of HLA-B27-positive individuals don’t develop ankylosing spondylitis Approximately 5% of AS patients do not have HLA-B27, and the negativity rate is higher in the other spondyloarthropathies. Thus, the HLA-B27 test will neither rule in nor rule out spondyloarthropathy.

A CT scan is unnecessary for this patient, but would be useful to demonstrate a pars interarticularis fracture or early sacroiliitis if the LS spine and SI joints appear normal on x-ray films.

It would not be appropriate to do a colonoscopy in the absence of GI symptoms or a positive stool guaiac test indicating blood in the stool.

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Fouad
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next:
The patient’s Hgb was 14 gm%, WBC 8,000/mm3 with a normal differential, and platelets 500,000/mm3. The ESR was 40 mm/hr, CRP 4.8 mg/dl, urinalysis showed no protein or cells, and stool guaiac was negative.

Spine films were interpreted as showing indistinct margins, with large erosions in both SI joints. Vertebral body height was normal and the cortical margins were intact. There was no disc space narrowing, and alignment was normal.

كان الهيموغلوبين عند المريض 14غ/دل, الكريات البيضاء 8,000/مم مع توزع طبيعي, والصفيحات الدموية 500,000/مم. سرعة التثفل 40 مم/سا, البروتين الارتكاسي 4.8مغ/دل, تحليل البول أظهر عدم وجود بروتين أو خلايا فيه, وكان اختبار الدم الخفي في البراز سلبياً.

في صور العمود الفقري , كانت الهوامش مبهمة, مع تآكلات كبيرة في المفصلين الحرقفيين العجزيين. بقي ارتفاع جسم الفقرة طبيعياً وكانت الهوامش القشرية سليمة. لم يلحظ وجود تناقص في المسافة القرصية, وكان الاصطفاف طبيعياً.

Question # 3: What three interventions will you recommend at this time?
A. Indomethacin or other NSAID therapy .
B. Oral prednisone .
C. Urgent ophthalmology referral .
D. Lumbar–thoracic brace .
E. TENS unit .
F. Sulfasalazine .
G. Extension exercises .

السؤال 3: ما هي الإجراءات الثلاثة التي تستحسنها ؟
1. الاندوميتاسين أو أي معالجة بمضادات الالتهاب غير الستيروئيدية.
2. البريدنيزون عبر الفم.
3. إحالة عينية مستعجلة.
4. مشد قطني ظهري.
5. تحريض عصبي كهربائي تحت الجلد.
6. السلفاسالازين.
7. تدريبات بسط.

Fouad's picture
Fouad
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بظن رقم 3

drhanadi's picture
drhanadi
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answers are 1,3,7
The mainstay of treatment of the spondyloarthropathies is nonsteroidal antiinflammatory drugs. The indole derivatives such as indomethacin or tolmetin may be more effective than the other NSAIDs.

Systemic prednisone is not used for spondylitis.

If NSAIDs fail to control symptoms, sulfasalazine may be beneficial as a second-line agent, especially in patients with peripheral arthritis.

Conjunctivitis does not usually need specific treatment, but patients with uveitis should be evaluated by an ophthalmologist and treated first with topical steroids and if no response, topical ophthalmic cyclosporin A. Continued monitoring is also necessary to detect increased intraocular pressure.

A lumbar-thoracic brace is not indicated for AS patients because it further restricts expansion of the thoracic cage.

Although a TENS unit may be used to help control refractory pain, it does not contribute to maintaining normal posture or spinal flexibility.

Extension exercises are critically important for maintaining erect posture and preventing shoulder and hip dysfunction.

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Fouad
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next:
Question # 4: What three recommendations will you give the patient?
A. Instruction about daytime posture .
B. Use of a firm mattress, with small or no pillow .
C. Apply for disability .
D. Describe the benefits of snowmobiling .
E. Advise HLA-B27 typing for patient and children .
F. Physical therapy referral to develop a program of extension exercises and aerobic conditioning .

السؤال 4: ماهي الإرشادات الثلاث التي ستعطيها للمريض؟
1. إرشادات حول الوضعية خلال النهار.
2. استخدام فراش صلب مع وسادة صغيرة أو بدونها.
3. تقديم طلب للعجز(أي للعمل).
4. شرح فوائد السير على الثلج (أي القيام بالجهد).
5. النصح بتنميط الـ HLA-B27 للمريض و أطفاله.
6. الإحالة للمعالجة الفيزيائية لوضع برنامج لتمرينات البسط والتكيف الهوائي.

Fouad's picture
Fouad
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answers are :1,2,6
Our major goals are to decrease the pain and discomfort, to preserve function, and to limit deformity of the spine. As ankylosing spondylitis progresses there is a tendency for increasing thoracic kyphosis to develop, which leads to a very nonfunctional position of the spine.

Instructing the patient regarding good posture habits, sleeping supine on a very firm mattress with a very small pillow, and referral to physical therapy for an exercise program designed to increase extension through activities such as swimming are all critical for preserving function.

Patients should be cautioned against engaging in any high-impact sports such as snowmobiling or horseback riding because a rigid spine is vulnerable to fractures from compression and sudden bending.

Most patients with spondylitis will never become disabled and should not be advised to apply for disability. However, patients whose occupations require physical activity may benefit from vocational counseling and consider a career that places minimal stress on the spine and does not require normal spinal mobility.

HLA-B27 is present in approximately 5% to 8% of the white population in the United States. With over 90% of white patients with ankylosing spondylitis positive for B27, it is among the strongest disease associations known for the HLA region. However, most B27-positive individuals will never have ankylosing spondylitis. B27-positive offspring of B27-positive subjects with AS have a 10 to 20% risk of developing the disease, but HLA-B27 typing of the patient and his asymptomatic children would neither prove nor disprove the diagnosis of AS, and is therefore not needed.

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Fouad
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next:
The patient returns to your office 26 years later. He is now 47 years old and works as a dairy farmer. Although no longer troubled by back pain, back stiffness is present all the time and he walks with a rigid spine. The problem now is that he becomes short of breath after throwing four bales of hay, and he cannot lie flat on his back on his firm mattress because he is awakened by shortness of breath soon after falling asleep. He denies cough, hemoptysis, and chest pain, and never had rheumatic fever. He experiences palpitations when he is short of breath, and his legs feel “weak and heavy” at times.

The patient appears comfortable. His blood pressure is 110/50, and his pulse is 90 and slightly irregular. There is no conjunctival injection or pupillary irregularities, and retinal exam reveals no abnormalities. No cervical lymphadenopathy is present, and the thyroid is not enlarged or tender to palpation. With his head held at 30°, the neck veins are distended 2 cm above the sternal notch. Chest expansion is less than 1 cm at the nipple line. Breath sounds are clear, with moist bibasilar rales and dry rales over both apices. The apical impulse is palpable in the fifth intercostal space at the mid-clavicular line, and he has a loud S3 and a 3/6 diastolic murmur, best heard at the lower left sternal border. There is 1+ pitting edema of his lower extremities.

Examination of the spine shows no extension, flexion, or lateral bending; the Schober test remains at 10 cm with flexion. When standing with his back to the wall, his posterior occiput is 4 cm from the wall, and finger-to-floor distance is 15 cm. Peripheral joints have normal range of motion with no swelling or tenderness. There is no change in muscle strength, deep tendon reflexes, or rectal sphincter tone, and he has no saddle anesthesia.

عاد المريض للعيادة بعد 27 سنة, هو الآن في الـ 47 من العمر ويعمل كمزارع يومي. على الرغم من أنه لم يعني من ألم ظهري, اليبوسة في الظهر موجودة طوال الوقت وهو يمشي مع ظهر متصلب. المشكلة الآن أنه يعاني من قصر النفس بعد رمي 4 رزم من القش, ولا يستطيع التممد على ظهره على فراشه الصلب لأنه يستقيظ مباشرة بعد نومه بسبب قصر النفس . نفى وجود السعال, النفث الدموي, والألم الصدري, كما أنه لم يصب بحمى رثوية. يعاني المريض من خفقان عندما يصاب بقصر النفس, كما يحس بأن قدمه ضعيفة وثقيلة عند ذلك.

بدا المريض مرتاحاً. ضغطه الشرياني 110/50, ونبضه 90 مع شذوذ خفيف. لا وجود لاحتقان في الملتحمة أو تغيرات في الحدقة, ولم يبد فحص الشبكية أي تغيرات. لا وجود لضخامة عقدية في العنق, ولم تكن الدرق متضخمة أو مؤلمة بالجس. وبوضع الرأس بزاوية 30 , لوحظ أن الوريد الرقبي متوسع حتى 2 سم فوق الثلمة القصية. كان توسع الصدر أقل من 1سم على خط الحلمات. الأصوات التنفسية كانت واضحة, مع خراخر رطبة وجافة فوق السرتين. ضربة القمة كانت مجسوسة في المسافة بين الوربية الخامسةعلى الخط الناصف للترقوة, ولوحظ وجود صوت ثالث عالٍ ونفخة انبساطية شدتها 3/6, تسمع أفضل ما يمكن عند الحافة القصية السفلية اليسرى. لوحظ وجود وذمة انطباعية على الطرف السفلي.
بفحص العمود الفقري لوحظ عدم وجود انبساط, انعطاف, أو انحناء جانبي. وبقي اختبار شوبير على الـ 10 سم بعد الانعطاف. عند الوقوف والظهر للحائط, كان قذاله الخلفي عل بعد 4 سم من الجدار, وكانت مسافة اختبار الإصبع للأرض 15سم. كانت المفاصل المحيطية تمتلك مجال حركة طبيعي مع عدم وجود تورم أو مضض. لا وجود لأي تغيرات في المقوية العضلية, المنعكسات الوترية العميقة, أو الضغط في المعصرة المستقيمية, كما أنه لم يعاني من خدر سرجي.

Question # 5: Aside from his known ankylosing spondylitis, what four diagnoses should you consider?
A. Congestive heart failure .
B. Mitral valve disease .
C. Aortic valve disease .
D. Farmer’s lung .
E. Tuberculosis .
F. Interstitial fibrosis of the lung.

السؤال 5:بالإضافة لمرضه بالتهاب الفقار اللاصق, ما هي التشخيصات الأربع التي يجب أن تضعها في عين الاعتبار؟
1. قصور قلبي احتقاني.
2. اعتلال في الصمام التاجي.
3. إصابة في الصمام الأبهري.
4. رئة المزارع.
5. السل.
6. تليف خلالي في الرئة.

Fouad's picture
Fouad
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answers are :1,3,5,6
With this patient’s description of the disappearance of back pain and the persistence of stiffness throughout the day, it appears that he now has extensive spinal fusion. Physical findings of minimal chest expansion and no movement on the Schober test confirm this impression. The dyspnea on exertion and while supine, together with the S3 gallop, rales, and distended neck veins, suggest congestive heart failure. The diastolic murmur at the fifth intercostal space next to the sternum and wide pulse pressure may indicate aortic insufficiency rather than aortic stenosis, which would produce a systolic murmur, or mitral valve disease, which would produce a murmur at the apex.

The finding of exertional dyspnea in a patient with rales in the lung apices should prompt a search for tuberculosis or interstitial lung disease.Upper lobe fibrosis may occur in patients with severe AS who have marked reduction of chest wall movement, and may be complicated by secondary apical tuberculosis or aspergillosis. Farmer’s lung can produce dyspnea, but it is usually manifested by fever, chills, malaise, and cough four to eight hours after exposure to moldy hay or grain containing thermophilic actinomycetes.

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Fouad
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Question # 6: What six diagnostic tests will you do today?
A. CBC .
B. PA and lateral chest x-ray .
C. EKG .
D. PPD .
E. CT scan of the chest .
F. Echocardiogram .
G. Pulmonary function tests .
H. BUN/creatinine .

السؤال 6: ما هي الاختبارات الستة التي ستطلبها؟
1. تعداد دم.
2. صورة شعاعية امامية خلفية وجانبية للصدر.
3. تخطيط قلب كهربائي.
4. اختبار الجلد للسل.
5. تصوير طبقي محوري للصدر.
6. تصوير بالأمواج فوق الصوتية للقلب.
7. اختبارات وظائف الرئة.
8. قيم البولة والكرياتينين.

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Fouad
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1
2
3
4
7
8

i.e exclude ct, done after the initial tests.
exclude echocardiograph, done after ECG.

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dr.tabban

answers are 1,2,3,4,6,8
You should immediately obtain a PA and lateral chest x-ray and EKG. A CBC should be checked to rule-out anemia as a cause of heart failure. BUN and creatinine should be measured to eliminate renal failure, and a PPD skin test should be done to rule-out tuberculosis.

Echocardiogram should be performed to assess aortic insufficiency, measure the valve area, quantitate the amount of regurgitation, search for vegetations, and measure left ventricular function. As a late complication of AS, aortic insufficiency, cardiomegaly, and cardiac conduction defects develop in 3.5% to 8.0% of patients. Amyloidosis may develop in 8 to 10% of patients with longstanding AS and can cause cardiac failure, renal insufficiency, or nephrotic syndrome.

The patient’s complaint of heaviness in his legs could simply reflect reduced exertional capacity secondary to heart failure, but it does raise the possibility of other late complications of ankylosing spondylitis: the cauda equina syndrome or cord compression secondary to spinal fractures. These are more common in ankylosing spondylitis than in other inflammatory disorders because the rigid spine has a very limited ability to absorb even minor amounts of trauma. However, the absence of weakness, no changes in deep tendon reflexes, normal rectal sphincter tone, and no saddle anesthesia rule-out these structural complications. It is likely that his sense of reduced strength and physical stamina is due to the heart failure.

A CT scan of the chest should be done only if a mass were seen on the chest x-ray. In light of the cardiac abnormalities, pulmonary function tests are not indicated at this time.

that is the last,thanx for all.......

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Fouad
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