me007
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a 48 yo man, fever, several fainting spells over the past few months.
He has not fainting spells when he is laying down, but they occur when he is standing up.
Physical examination - normal BP, when he is laying down or sitting up.
Late diast murmur is heard.
Pain in the left upper quadr worse on inspir.
spleen enlarged and tender.
right flank pain on percussion, urine dipstic positive for blood, rbc in urine sediment
which of the following is most likely diagnosis?
1. aortic stenosis
2. hypertrophic cmp
3. left atrial myxoma
4. mitral stenosis
5. pericardial effusion
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| new_n_lost
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3. left atrial myxoma <== ?? most likely
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| monam84
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wow this ones a toughy, i am torn between atrial myxoma and miral stenosis which both present and can be lead to embolization, but I would have to say the one that may be more common is mitral stenosis. Not sure though.
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| silver
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1
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| Luckyall
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MS for sure
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| Ms.Apara
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i will go with.. MS..
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| me007
Forum Guru
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how is renal symptoms related to MS?
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| Ms.Apara
Forum Senior
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possible explanation is - embolization.
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| me007
Forum Guru
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sure embolisation.
with MS?
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| Ms.Apara
Forum Senior
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wat i hav found is formation of thrombi in left atrium and systemic embolization may be the presenting complaint in otherwise asym patients with mild MS
renal invlovment is not mentioned as such..
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| Ms.Apara
Forum Senior
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so wats the ans...????? 
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| me007
Forum Guru
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c.
cardiac myxomas are mc primary cardiac tumors in adults.
symptoms include nonspecific complaints such as fever, malaise.
The tumor has ball-valve efect that causes sudden blockage of the blood flow throw mitral valve, resulting in episodic faint spells.
A diastolic murmur similar to that of MS is also present.
Peripheral embolization of tumor also occurs.
Infarctions of the spleen cause pain in the left upper quadrant
infarction of the kidney - flank pain and hematuria
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| keepgoing
Forum Guru
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yes MS--> atrial fibrilation producing blood clots in left atrium due to stasis -->emboli go to kidney/spleen
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| keepgoing
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thanks me007 this was something  , but emobil is possible in MS as well...see explanation above...ref dr goljan lect.
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| Ms.Apara
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well all these features are present in MS too.. so how u differentiate...
MS is more common thn Myxoma
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| me007
Forum Guru
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i was thinking 
that in MS they would describe LHF and RHF, and might be embolization with connection to atrial fibrillation.
if someone can find tricky q with MS as a main actor pls post
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| me007
Forum Guru
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Goljan path 2004 2nd block, #39
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| keepgoing
Forum Guru
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thanks me007..i think it was tough question and syncope could be the only def factor from MS here in this scenario..perhaps
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| arlete
Intern in 2009!!!!!
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The key to differentiate MS form atrial myxoma in this question is that the fainting spells occur when he is standing up (probably it moves the tumor in a way that it blocks the blood flow). MS blocks the flow all the time.
So it's C.
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| Ms.Apara
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Thanks..
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| new_n_lost
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Guys the Most Specific for Syncope or Presyncope is Hypertrophic Cardiomyopathy. MS shud have in UR Dx list cos the Its the only cause which cud have explian embolization but in MS u will have Systemic embolization leads to stroke, renal failure, and myocardial infarction. the Only thing which lead to me choose A Myxoma was that except a Myxoma nothing will cause a Multi Organ Infarct. the Kidney picture had RBC Cast alongwith a splenic infract pic so just choose that cause nothing else was going to explain that.
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FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| new_n_lost
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Hypertrophic Cardiomyopathy
- Syncope is a very common symptom, resulting from inadequate cardiac output upon exertion or from cardiac arrhythmia. It occurs more commonly in children and young adults with small LV chamber size and evidence of ventricular tachycardia upon ambulatory monitoring.
- Alternatively, syncope may be caused by arrhythmias, either tachycardias or bradycardias. Some patients with HCM have abnormalities in sinus node function, leading to sick sinus syndrome with alternating tachyarrhythmias and bradyarrhythmias or severe bradyarrhythmias.
- Syncope and presyncope identify patients at high risk of sudden death and warrant an urgent workup and aggressive treatment.
- Presyncope includes "graying-out” spells that occur in the erect posture and can be relieved by immediately lying down.
- They occur quite commonly and identify patients at high risk for sudden death.
- These symptoms are exacerbated by vagal stimulation. Presyncope also may occur with nonsustained atrial or ventricular tachyarrhythmias.
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FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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