zaki
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An 18-year-old man presents with a 2-day history of fever, chills, and migratory arthralgias involving the ankles, knees, elbows, and shoulders. On physical examination there are subcutaneous nodules on the volar surface of both forearms, and a grade 2/6 long systolic murmur and a third heart sound are heard at the left ventricular apex. There is no objective evidence of joint disease.
Which of the following findings indicates a definite diagnosis of acute rheumatic fever in this patient?
A) Physical findings of arthritis
B) The presence of erythema marginatum or choreoathetosis
C) An elevated erythrocyte sedimentation rate
D) A throat culture positive for group A streptococci
E) An electrocardiogram showing first-degree atrioventricular block
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Maverick
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| mahendra
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i think its D
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| Yulia
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to diagnose acute rheumatic fever you have to have 2 major jones criteria or one major and two minor.
Based on that B is the correct answer. erythema marginatum and choreoathetosis are major criteria.
migratory arthritis - one major - not enough
elevated esr - one minor - not enough
throat culture positive for strep - minor
first degree av block - certainly not enough to establish a diagnosis
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i think is D , u need to confirm that the pt has previous or recent streptoccal infection or not , if the pt didn't have the recent infection than DX of of rheumatic fever is in great doubts,
so the crucial thing in the dx is the confirmation of streptococal infection, otherwise all the criteria are full fill for dx of RF , that is S/c nodule is the major criteria and minor criteria include arthalgia and fever
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| fried water
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that's right yulia.. 2 major.. but choice B say erythema marginatum OR chorea.. aint it confusing.
Well, as far as streptocaccal infection is concerned, it precedes RF and usually culture is absent by the time RF develops and we can only rely on positive ASO titre i.e. >200 and that too is only a minor criteria.
first degree AV block.. sonds convincing, it cud be coz of carditis... but then again only 1 major.. aint enuff ? 
..well change that 'or' to 'and' hehe 
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| zaki
Forum Guru
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My dear friends, for dx of rheumatic fever u need 2 major criteria or 1 major and 2 minor + the evidence of prior streptococal infection, for eg if the pt has 2 major criteria (except chorea) and no evidence of steptococcal infection then dx of rheumatic fever is difficult to make, so u need evidence fo streptococcal infection whether or the criteria are met or not to dx the rheumatic fever.
Only chorea is one major criteria which if included in the criteria of the pt u don't need ASO titer or any other evidence to dx RF bc chorea developed late.
so the answer is ASO titer bc there is 1 major critera that is sc nodule and fever, arthalgia are the minor critera and the thing only reqd to dx RF is evidence of infection which is fulfil by elevated ASO titer as culter may be negative if presentation is late.
I Hope that will clear the confusion
let me know
waiting for your responses
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| usmledoctor1
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excellent zaki this is first time i read yulia commenting wrong but i must say she is so intelligent i m inspired by u yulia on forums
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| lucky
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i'd go with yulia and fried water.
the q says 'definitive dx' and for that +throat culture isn't enuff.
for dx u need jones criteria + a positive culture.
culture alone isn't enuff.
as fried water suggested culture may not be + by the timeRF developed.
in this q the criteria major and minor r given in seperate stems. so we can't pick 2majors and 1 minor simultaeously, so i think we have to pick a major one and that is B.
plz correct me if i'm wrong
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| lucky
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sorry i was wrong, i take my answer back.
in this particular pt. it would be a + throat culture as the jones criteria is met.
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| babu
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cany understand abt the chorea developing late------->dont need an ASO????
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| asmi
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I think babu u r right..no need for ASO if chorea already there.
And in the above Q D seems the best choice.
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| fried water
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Tricky question man!!! Yeap I agree the answer in this particular case has to be 'positive culture for strept' ... cuz this patient already has 1 Major (subcutaneous nodules) and 1 minor (migratory arthralgia) in question stem!! All he needs is an evidence of prior strept infection.. which is needed and can be in form of an elevated ASO titre or a postive strept culture.
pheeewww... makes sense! :idea:
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